Can whisper wire be used for routine percutaneous coronary interventions (PCIs)?

Guidewire Selection for Routine PCIs

Whisper wire can be used for routine PCIs, particularly for side-branch protection during bifurcation lesions, but it is not the optimal first-choice guidewire for most routine procedures. According to current guidelines, polymer-jacketed guidewires with low penetration force are recommended as the initial choice for standard PCIs, with subsequent escalation to intermediate and high penetration force wires as needed based on lesion characteristics 1.

Guidewire Selection Algorithm for Routine PCIs

Initial Assessment and Wire Selection

• Standard lesions: Begin with a polymer-jacketed, low penetration force guidewire 1
• Blunt proximal caps: Start with an intermediate penetration force polymer-jacketed guidewire 1
• Highly calcified lesions: Consider stiffer, high penetration force guidewires 1

Role of Whisper Wire in PCIs

• Bifurcation lesions: Whisper wire has demonstrated safety for side-branch protection during stenting and proximal optimization technique (POT) 2
• Caution: SEM examination showed significantly greater polymer shearing with Whisper wire compared to Runthrough wire, though correlation with post-stenting CK-MB release was weak 2

Specialized Equipment for Complex Lesions

Calcified Lesions

• Rotational atherectomy: Reasonable for fibrotic or heavily calcified lesions that cannot be crossed by a balloon catheter or adequately dilated before stent implantation (Class IIa, Level of Evidence: C) 3
• Avoid routine use: Rotational atherectomy should not be performed routinely for de novo lesions or in-stent restenosis (Class III: No Benefit, Level of Evidence: A) 3

Other Specialized Techniques

• Cutting balloon angioplasty: Might be considered to avoid slippage-induced coronary artery trauma during PCI for in-stent restenosis or ostial lesions in side branches (Class IIb, Level of Evidence: C) 3
• Laser angioplasty: Might be considered for fibrotic or moderately calcified lesions that cannot be crossed or dilated with conventional balloon angioplasty (Class IIb, Level of Evidence: C) 3

Best Practices for Guidewire Use

Microcatheter Use

• Always use a microcatheter for supporting the coronary guidewire and allowing rapid guidewire switching 3
• Microcatheters improve precision of guidewire movements and allow dynamic alteration of wire penetration force 3

Considerations for Special Scenarios

• SVG interventions: Embolic protection devices should be used during SVG PCI when technically feasible (Class I, Level of Evidence: B) 3
• Primary PCI: Aspiration thrombectomy is reasonable for patients undergoing primary PCI (Class IIa, Level of Evidence: B) 3

Pitfalls and Caveats

• Polymer shearing: Be aware that hydrophilic wires like Whisper can experience polymer shearing, though clinical significance appears limited 2
• Crossability challenges: Consider novel cutting balloons for calcified lesions where crossability is an issue, as they demonstrate better crossability compared to scoring balloons 4
• Wire selection escalation: Start with the least aggressive wire that can accomplish the task, and escalate as needed based on lesion resistance 1

Remember that guidewire selection should be based on lesion characteristics, and while Whisper wire has demonstrated safety in certain applications like side-branch protection, it is not universally recommended as the first-line choice for all routine PCIs.