Appropriate selection and manipulation of equipment is critical to successful percutaneous coronary intervention (PCI) outcomes and low complication rates. The guidewire is the first piece of interventional equipment to contact the lesion to be treated. Proper intraluminal advancement of the guidewire through the lesion and into the distal vessel allows the coronary guidewire to serve as the backbone for the safe delivery of diagnostic and therapeutic devices while maintaining secure and safe access to the vessel lumen. Although the current standard 0.014-inch wires are suitable for the majority of interventions, operator familiarity and facility with guidewire selection and manipulation are still paramount. The advent of specialty guidewires, such as those designed for chronic total occlusions (CTOs), has furthered our ability to successfully treat more complex lesions, but the use of these wires requires an understanding of specific wire performance features and the possible complications that can result from their use. Given the wide variety of guidewires that are available, knowledge of their design, materials and structure aids the operator in understanding unique differences in performance and ultimately in making the proper selection for an individual patient or lesion.
In this chapter, we will review specific characteristics of coronary guidewires including their construction and properties that favor different clinical situations. In order to optimize guidewire selection, we have developed a general classification scheme based on wire performance features. We will discuss techniques for guidewire manipulation in selected subsets of coronary lesions with the caveat that minimal comparative literature is available. As with other aspects of interventional cardiology, there are multiple guidewires that can be used for each lesion, and operator selection may change with experience or as technologic advances are made.
HISTORY OF THE GUIDEWIRE
More than 30 years have passed since the introduction of a catheter system allowing an independently movable, flexible-tipped guidewire for coronary intervention. Unlike the initial balloon catheters with fixed-wire tips, the 2 component balloons and independent, steerable guidewire systems greatly enhanced coronary artery and lesion accessibility.1-3 Guidewires are designed to allow the tip to be shaped or curved so that the wire could be purposefully directed into the desired artery and across the target lesion using rotation and advancement. The independent catheter–guidewire system also brought increased safety with the ability to exchange devices without recrossing the coronary lesion.4,5
The first guidewire for angioplasty, available from 1979 to 1982, was a 0.018-inch standard wire (Cook Group Inc.). This wire had a safety wire at its tip— a precursor to the shaping ribbon—that allowed it to be shaped but resulted in added tip stiff ness. The next wire to be developed (ACS) was a standard wire that replaced the safety wire with a metal ribbon. This change made the tip more flexible while retaining the ability for shaping. Further advances included construction of a floppier wire, which lacked a shaping ribbon, ...