Ask the Expert: The Wholey Wire
Can you tell us about your practice and work as founder and medical director of the Baptist Cardiac & Vascular Institute?
I founded Baptist Cardiac & Vascular Institute in October 1987, as one of the first multi-disciplinary centers for integrating cardiac and vascular care. We ultimately built a working model where cardiology, cardiac surgery, vascular surgery, interventional radiology and other disciplines surrounding cardiovascular care came together to deliver integrated care around what is actually now called “patient-centered” care. During the course of creating this model, we ultimately developed a physical plant that is actually a ‘hospital within a hospital.’ The Institute is a freestanding building that’s attached to the Baptist Hospital of Miami, and is part of Baptist Health South Florida, a very large, multi-hospital, multiple-facility healthcare system. The Institute has 100 inpatient beds and 30 outpatient beds in addition to its operating rooms and 11 interventional suites.
We are involved with clinical research in a broad range of areas, including critical limb ischemia, endovascular treatment of occlusions of the superficial femoral artery (SFA) and iliac arteries, so we are participating in related stent and drug trials. We are also involved in clinical trials regarding aneurysm therapy of the thoracic and abdominal aorta. Since the Institute is an integrated care facility, we have been very active with coronary stent trials and more recently, structural heart disease research. The interventional neuro program is integrated with us as well, so we are doing stroke and intracranial stenting research. We are involved in some medical trials comparing medical therapy to endovascular therapy, and a couple of pivotal trials. We are participating in several NIH trials as well.
Let’s talk about your guidewire usage. Is there a guidewire you favor for complex or tortuous anatomy?
One of the most common guidewires we use for dealing with tortuous and complex anatomy is the Wholey wire. It’s been around for a number of years and allows us the steerability and the torquability necessary for negotiation of the wire around the tortuous anatomy. It also provides us with the stiffness to act as a reliable rail for catheter exchanges and catheter tracking. It’s my wire of choice for antegrade puncture access into the common femoral artery and for any procedure where I anticipate complex anatomy from an access point of view.
What is unique and useful about the design of the Wholey wire?
The Wholey wire is unique because it brings 1:1 torqueability. It has the ability to get predictable directional control. This wire has a very atraumatic tip, which means that if you bump into plaque, or have to pull back and turn away from plaque, the risk of dissection is nil compared to some other wires, where you may have a lot of steerability, but there is a risk of dissection because of the sharp edge or the very tip of the wire. On occasion, we actually shape a sort of mild hockey stick curve, although this wire does come in shapes. I believe they make a “J,” but we generally shape it, which gives us not just the resistance to obstruction, but the ability to steer our way around complex plaque. The other nice thing is the transition from the floppy part of the wire to the stiffer part of the wire is very gradual. This very nice transition allows catheters to track better over a sturdy ‘rail.’
How do your fellows feel about using the Wholey wire?
Our fellows find this a very easy wire to use. They very rapidly get the feel of using the wire; in fact, one of the things that I happen to like about the wire is that the tactile sensation you get at the back end of the wire when you meet resistance. With some wires, particularly hydrophilic-coated guidewires, you actually don’t have any tactile sensation. With the Wholey wire, you get very subtle transmission of what’s going on at the tip of the wire at the back end that is in your fingertips. I think that fellows like that very much when they first try it and they get adapted to it very quickly.
Are there any economic aspects that can be affected by guidewire choice?
There are some cost issues on the positive and the negative side. Obviously, if you pick the right wire you are going to be successful more often. On antegrade punctures, I always like to use a Wholey wire to start the case. This allows easy direction into the SFA and great support for sheath introduction. For straightforward diagnostic angiography, we would probably use a less expensive wire first, but if we have advanced information like a CTA or an MRA that shows tortuosity, something that we know is complex, then we generally will go with a Wholey wire.
You mentioned “picking the right wire.” Could you elaborate?
Diagnostic angiography these days is almost gone. We very rarely do a diagnostic angiogram as a ‘stand alone’ study. Patients always come with either an MRA or a CTA. Angiography is done at the time of the intervention and this is very different from how it used to be in the past. The bottom line is that today, when we approach a patient for an angiogram, we already know their anatomy. If you take advantage of that by picking the right wire for the right anatomy, you are going to save money by avoiding the trial-and-error part, the sort of flying blind, when you do angiography. Using the diagnostic information from a CTA or a MRA allows us to determine that if a patient has a tortuous iliac artery, something that is going to involve some manipulation, then it makes sense to use a Wholey wire. If you can get the wire up into the abdominal aorta, you not only save on the first wire, which may not necessarily go, but you also avoid the cost of having to take a diagnostic catheter and steer your way up the circulation until you get the catheter that you want.
There hasn’t been a lot of change in guidewire technology until the past few years. What’s your sense of how interventionalists are reacting?
I’m not sure that I could generalize. I know that in general, wire selection and wire usage is part of the art of intervention and we spend a lot of time teaching our fellows about the subtle differences between guidewires and careful guidewire selection. It’s not necessarily something that enters its way into publications, but it is part of the word-of-mouth, one-to-one training that goes on as we train fellows and colleagues.
The Wholey wire has been around for a long time. Have you always used it?
Yes, it has the comfort of an old shoe, so to speak. It’s very predictable and reliable, it has a high performance record. It’s manufactured extremely well. I will continue to use it for many, many years.
If you are an interventionalist who hasn’t tried the Wholey wire, you definitely should try it and see if it would fit into your armamentarium. It’s become an extremely valuable part of the practice of a very large group of interventionalists, both cardiologists and radiologists, here at the Institute. It’s a very significant workhorse wire.
Dr. Katzen can be contacted at firstname.lastname@example.org