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Paraggio et al. Vessel Plus 2019;3:12 I http://dx.doi.org/10.20517/2574-1209.2018.72 Page 5 of 11

A B

C D

Figure 2. “Anchoring balloon” technique example. A: Basal angiographic assessment; B: angiographic evaluation after proximal stent
implantation; C: GuideLiner delivery with distal anchoring balloon; D: final angiography after three more overlapping stents implantation

GUIDEWIRES AND MICROCATHETERS: A BAG OF TRICKS
The toolbox of CTO operators has rapidly increased over the last decade as new tools and equipments
have been developed. A complete knowledge of such equipment is now essential for every interventional
cardiologist in order to improve performance in everyday PCI.

Specialized CTO guidewires are now commonly available in every cathlab as they represent the key tool
to afford antegrade crossing of CTO lesions. Indeed, antegrade wire escalation is the most commonly
used technique to cross the lesion throughout the true vessel lumen and involves progressive utilization of
guidewires with various stiffness and/or penetrating force. Moreover, with the development of global interest
over CTO procedures, such guidewires have been extensively publicized even in international conventions
and their characteristics are now familiar to every interventional cardiologist [Table 2]. In everyday
practice, soft, tapered and polymer-jacketed wires, such as the Fielder family (Asahi Intecc, Japan), could
be very useful to cross very narrowed lesions, especially in calcified vessels. In this setting, the polymeric
coating together with the tapered tip of such guidewires may be helpful in navigating a narrow true lumen
of a tortuous calcified vessel minimizing the risk of causing a dissection. However, routine use of polymer
jacketed guidewires with higher tip weigh should be avoided in everyday practice. Beyond CTO guidewires,
a new family of workhorse wires called Sion (Sion, Sion Blue and Sion Black; Asahi Intecc, Japan),
characterized by a higher direction and torque response, have been developed and have showed such ability
in retrograde collaterals crossing. Such wires are essentially driven by a new technology called “Composite
Core”: the parallel placement of a classic wire and a twist wire linked at the distal tip determine a more
precise transmission of torque rotation. Such characteristics make Sion guidewires very useful in daily PCI
in every case of difficult distal wire positioning in tortuous and/or calcified vessels and in bifurcation PCI
when wiring or re-wiring of side branch is difficult due to a narrow angle.