What is the initial coronary wire of choice for crossing a wire through a high thrombus burden?

Initial Coronary Wire Selection for High Thrombus Burden

For lesions with high thrombus burden, a polymer-jacketed, low penetration force, tapered guidewire such as the Fielder XT is the optimal initial choice for crossing the lesion.

Rationale for Wire Selection in High Thrombus Burden

When approaching a coronary lesion with high thrombus burden, wire selection is critical for procedural success and minimizing complications. The evidence supports a stepwise approach based on lesion characteristics:

Wire Selection Algorithm:

1. First-line choice: Polymer-jacketed, low penetration force, tapered guidewire (e.g., Fielder XT)

   • These wires provide excellent trackability through thrombus
   • Associated with higher success rates in crossing challenging lesions 1
   • Lower risk of vessel perforation compared to stiffer wires

2. If unsuccessful: Escalate to intermediate penetration force polymer-jacketed guidewire (e.g., Pilot 200)

   • The Pilot 200 has been shown to be successful in 36% of antegrade wire crossings 2
   • Provides better support while maintaining reasonable safety profile

3. For resistant thrombus: Consider high penetration force guidewires (e.g., Confianza Pro 12)

   • Reserved for cases where softer wires fail to cross
   • Used in 28% of antegrade wire escalation procedures 2

Supporting Evidence and Considerations

Contemporary multicenter registry data demonstrates that polymer-jacketed guidewires are most commonly used for crossing challenging lesions, with the Fielder XT being used in 45% of antegrade wire escalation procedures and successfully crossing in 20% of cases 2.

Research has shown that using the Fielder XT guidewire:

• Increases procedural success rates (87.8% vs 79.0% without Fielder XT)
• Reduces procedure time
• Decreases contrast volume requirements
• Lowers complication rates including post-PCI myocardial infarction (6.3% vs 10.8%) 1

Technical Considerations

Always pair the selected guidewire with appropriate support:

• Use a microcatheter (used in 81% of antegrade wire attempts) 2
• The Corsair microcatheter is most commonly used (44% of cases) 2
• Ensure coaxial guide catheter position for optimal support

Thrombus Management Considerations

While selecting the appropriate wire is crucial, it's important to note that routine aspiration thrombectomy is no longer recommended (Class III: No Benefit) based on the latest guidelines 3. The TOTAL trial showed no benefit in cardiovascular outcomes with routine aspiration thrombectomy and a small but statistically significant increased risk of stroke 3.

However, in cases of large residual thrombus burden after opening the vessel with a guidewire or balloon, selective thrombus aspiration may be considered (Class IIb) 3.

Potential Pitfalls and Caveats

1. Wire perforation risk: While polymer-jacketed wires are generally safer, maintain careful wire tip control to avoid perforation
2. Distal embolization: Advance the wire slowly to minimize the risk of thrombus dislodgement
3. No-reflow phenomenon: Be prepared for pharmacological interventions if no-reflow occurs
4. Thrombus burden assessment: Consider using the thrombus burden classification (G0-G5) to guide your approach, as large thrombus (≥2 vessel diameters) is associated with worse outcomes 4

By following this evidence-based approach to wire selection in high thrombus burden lesions, operators can optimize procedural success while minimizing complications.