What is the recommendation for using the Whisper guidewire (percutaneous coronary intervention guidewire) in routine Percutaneous Coronary Intervention (PCI)?

Recommendations for Using Whisper Guidewire in Routine PCI

For routine percutaneous coronary intervention (PCI) procedures, a polymer-jacketed, low penetration force guidewire such as the Whisper guidewire is recommended as the first-line choice according to European Society of Cardiology guidelines. 1

Guidewire Selection Framework for PCI

Standard/Routine Lesions

• First choice: Polymer-jacketed, low penetration force guidewire (such as Whisper) 1
• Benefits: Provides good trackability and flexibility for navigating coronary anatomy
• Optimal for: Simple lesions with minimal calcification or tortuosity

Based on Lesion Complexity

1. Blunt proximal caps:

   • Escalate to intermediate penetration force polymer-jacketed guidewire 1

2. Highly calcified lesions:

   • Consider stiffer, high penetration force guidewires 1

3. Chronic Total Occlusions (CTOs):

   • For tapered proximal caps: Polymer-jacketed low penetration force wires (like Whisper)
   • For blunt proximal caps: Intermediate penetration force polymer-jacketed or composite core guidewires 2

Best Practices for Guidewire Use

Support Techniques

• Use microcatheter support: The 2019 CTO PCI guidelines strongly recommend using a microcatheter to:
  • Allow rapid guidewire switching
  • Improve precision of guidewire movements
  • Enable dynamic alteration of wire penetration force
  • Provide fluoroscopic feedback with distal tip markers 2, 1

Wire Escalation Approach

When initial wire crossing is unsuccessful, follow a structured escalation approach:

1. Start with polymer-jacketed, low penetration force, tapered guidewire
2. Escalate to intermediate penetration force wires if needed
3. Progress to high penetration force guidewires for resistant lesions
4. De-escalate to less penetrating guidewires after crossing the proximal cap 1

Special Considerations

Anatomical Challenges

• Tortuous vessels: Consider using a J-shaped or knuckled guidewire to reduce perforation risk 1
• Multiple branch vessels: Multiple guidewires may be used to occupy unintended branch vessels in complex anatomies 3

Technical Support

• Guide catheter support: Inadequate guide support accounts for 7-17% of transradial PCI failures 1
• Complex lesions: Intravascular imaging is recommended as an essential adjunct to angiography for specific lesion subsets (e.g., left main, proximal LAD, in-stent restenosis, calcified coronary arteries, chronic total occlusions) 2

Safety Precautions

• Avoid aggressive wire manipulation to prevent vessel perforation or dissection 1
• Recognize subintimal wire tracking, which occurs frequently during CTO interventions 1
• Avoid unnecessary wire changes to reduce procedure time, radiation exposure, and cost 1

Specialized Techniques When Standard Approach Fails

• Rotational atherectomy: Consider for fibrotic or heavily calcified lesions that cannot be crossed by a balloon catheter (Class IIa recommendation) 1
• Cutting balloon angioplasty: Consider for in-stent restenosis or ostial lesions in side branches (Class IIb recommendation) 1
• Laser angioplasty: Consider for fibrotic or moderately calcified lesions that cannot be crossed with conventional techniques (Class IIb recommendation) 1

The selection of appropriate guidewires like Whisper for routine PCI is a critical step that can significantly impact procedural success and patient outcomes. Following these evidence-based recommendations can help optimize PCI procedures while minimizing complications.