Use of the Wholey Wire

Can you tell us about the cath labs at Texas Health Presbyterian Hospital Dallas? We have 4 labs, and do all types of coronary and peripheral endovascular procedures. We also work on structural heart disease, such as patent foramen ovale (PFO) closures and atrial septal defect (ASD) closures. We also do a fair number of endovascular abdominal aortic aneurysm (AAA) repairs. Our peripheral interventional volume is proportionally high compared to other centers and numbers in the thousands every year. Texas Health Presbyterian is a leading center in its use of specific interventional devices and we have proctored hundreds of physicians within the last few years. What is your guidewire selection process? For general access, we tend to use the standard J tip wire that comes in the sheath packet. I do like to have other guide wires available for access, just in case. When physicians come to our center in order to be proctored on peripheral interventions, I do make a point of mentioning the importance of access and of having a Wholey wire (Covidien, Mansfield, MA) in the lab. Many peripheral disease patients will have calcified, small common femoral and the iliac arteries, and it is important to be careful with access. You don’t ever want to assume anything with the J wire. If you keep on pushing, you can go subintimal or create a dissection. If I am having trouble with the initial J wire, then I will always pull back and make sure that there is plenty of blood flow coming back. I then take a Wholey wire and make sure that I can get it all the way into the aorta in order to be certain that, first, I am intraluminal, and second, that the patient doesn’t have an occluded common iliac. It is easy to be fooled. You take the wire there, you think it’s open, you put the sheath in, and then you realize that the iliac is occluded. I always like to see the wire all the way into the aorta before I put in the sheath. Even some technologists who may not be as familiar with the Wholey wire have been impressed with this method use for gaining access, especially if they come into our lab from another lab. For access problems, I don’t use any other wire. Many people like to use the Glidewire (Terumo Medical, Somerset, NJ), but it’s a hydrophilic wire and shouldn’t be used for access, because as you are pulling the wire back, it can get ensnared with the Cook needle (Cook Medical, Bloomington, IN) at the tip. Most of the time, the Wholey wire will get me to where I need to be. Sometimes I will use the Wholey wire as my guide wire for intervention, although now with the smaller-gauge wires, I do use a lot of .018” and .014” wires. I will use an .025” wire, like the Wholey wire, if I am doing iliac interventions. One neat thing about the Wholey wire is that it has a lock extension, which can be used if you need to do something over the wire. I use the Wholey wire to get across a tight iliac lesion and then use it as my working guide wire during an intervention. I also use it in endovascular grafts for aortic aneurysm repair, which I do percutaneously. When you look at the body of an AAA graft, it will have a big, rounded tube on top, and it will have two legs. One leg is short and cut off so an extension can be added to the contra lateral limb that goes into the other iliac artery. When you deploy the main body with the gate, to put the other extension on, you need to engage the gate and be able to get the wire through. I use the Wholey wire, because it is torqueable and maneuverable. How long have you been using the Wholey wire? At least 6 or 7 years. The Wholey wire has been around for at least 10 years or more. I have always been a big fan of the wire. What have you seen as guide wire knowledge is passed down from one generation of interventionalists to the next? We find that people learn from their training programs, mentors, and attendings, and tend to keep to what they have learned. People hold onto their techniques. Sometimes it’s for the good, and sometimes it’s for the bad, because I think sometimes physicians come out with a wrong technique and continue with it. I see varying types of skills and experience levels as I proctor physicians. As far as specific equipment, everyone comes out of training with some biases. So if you don’t have an open mind about trying new things, yes, I do think you could be in the trap of using the same thing all the time. However, most interventionists, if they get a good representative showing the benefits of a new device or new wire, will give it a try. Most physicians are willing to try, but I think sometimes they don’t give it enough “try” to get a full understanding of how a specific device or wire is advantageous. What is the reaction when you recommend the Wholey wire? I think that most people have at least seen it or have used it in the past. For some physicians, it takes a little longer for them to understand the benefits of a device or wire, but some intuitively, almost immediately, say, “Oh, it’s going to be helpful.” I think the fact that the Wholey wire has been around for so long means that most people are familiar with it. You mentioned technologist reactions to your use of the wire. Are they encouraged to share that information with other physicians and make suggestions? Yes, absolutely. Good, experienced techs will make some suggestions, and I want them to make those suggestions. Especially when physicians are struggling. As a technologist, you don’t want the physicians to get in trouble if they don’t need to. Techs can be helpful to think through some things with the physician, along with helping them technically. I think it would be very good to suggest use of the Wholey wire, if they are comfortable and have seen plenty of cases where it would help the physician out. Are there any economic considerations with Wholey wire use? It might be an added cost, because everybody uses the standard J wire, and you have to pull this off the shelf. But the wire itself is not very expensive. If it can prevent you from getting a subintimal dissection, which means fixing it or having the patient go to surgery, I think it is well worth the use of the wire. If you can use the Wholey wire to gain access so that it cuts down on radiation and procedural time, and/or allows you to complete the procedure, it’s worth it. Dr. Park can be contacted at jc007001@aol.com, or at CIVA, 7150 Greenville, Ste 500, Dallas, TX 75230, tel. (214) 369-3613. Disclosure: Dr. Park reports that he is a paid consultant and receives honorarium for proctoring physicians and speaking engagements from the following companies: Gore Medical Inc, Cardiovascular Systems Inc, Cordis Corporation, Medical Media Communications, ev3, Inc., and Custom Medical. He also reports that he has research funding from ev3, CSI, Abbott Vascular, Boston Scientific, and Atrium Medical.

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