General Principles of Wiring and Predilatation
General Principles of Wiring and Predilatation
Source: Medical News — 16th EBC consensus (EuroIntervention ,2022), 17th consensus (2023), and 18th consensus (2024). Latest updates highlight evolving strategies for bifurcation PCI
1. Guidewires
• Workhorse wire: balanced support and flexibility, safe for routine PCI (e.g., BMW, Runthrough, Sion).
• Hydrophilic wire: slippery, for crossing tight/calcified/tortuous lesions or CTOs; not safe for long-term working (risk of distal perforation, poor support).
• Wire exchange principle: always exchange hydrophilic for workhorse using a microcatheter (preferred) or OTW balloon → preserves access and prevents wire loss.
2. Wiring Tips
• Always wire MV and SBs at the start (in trifurcation: MV + all three SBs).
• Use microcatheter for tight or angulated branches, and for safe wire exchange.
• Terminology:
* Near-carina cell (distal cell, DC): the cell adjacent to the carina → correct site for rewiring.
* Outer-wall cell (proximal cell): the cell near MV outer wall → avoid.
• Guideline statement: “When rewiring the side branch, cross through the near-carina cell (DC), not the outer-wall cell.”
• This prevents wire entrapment (wire trapped between stent and vessel wall), optimizes SB ostial opening, and improves kissing balloon result.
3. Predilatation
• Always sequential, one branch at a time.
• Never simultaneous kissing during initial preparation (to preserve carina).
• Balloon size 1:1 with distal vessel.
• Start with low pressure in severe stenosis or thrombus, escalate cautiously.
• This rule applies to all techniques (Provisional, TAP, Culotte, Crush/DK-Crush, TKC).
4. Re-crossing Principles by Technique
1. Provisional stenting: re-cross through near-carina cell (DC).
2. TAP / Culotte: proximal/outer-wall recrossing may sometimes be used to achieve stent symmetry.
3. Crush / Mini-crush / DK-Crush: near-carina recrossing is mandatory after each crush step. In DK-Crush → required twice (after first and second crush).
4. Trifurcation (TKC): wire all branches, sequential predilatation, sequential SB stenting and crushing, near-carina rewiring each time, kissing after each, finish with final POT.
