How to easily load equipment onto small gauge guidewire?

Frequency of the problem:
Expert level:

Summary

Given the small gauge of contemporary cath lab endovascular wires, loading equipment onto these small wires can become a rate-limiting step for operators with visual acuity issues or tremulousness. If routinely incorporated into the cath lab workflow,  this method may help some operators overcome this problem.

The problem

Loading equipment onto guidewires is an essential step in everyday cath lab procedures. Facility with this step becomes very important, especially during emergency procedures in hemodynamically unstable patients. Tremulousness, as well as visual acuity problems, can prolong this step and ultimately lead to delay in the delivery of emergency endovascular therapies.

Principal idea

A standard syringe is readily available in contemporary cath labs and can serve the additional purpose of aligning the end of guidewires with their respective equipment to facilitate delivery.

Material needed

Standard syringe with “cross” plunger design.

Method step-by-step using 0.014 coronary wire and 0.014 coronary stent delivery system.

1. Pull the syringe plunger to maximum capacity without pulling it out of its barrel.
2. Hold the barrel of the syringe in your wire hand (left hand) as shown in figure 1, ensuring that one of the four plunger grooves is facing your thumb.
   
   

   Figure 1

   

   Figure 1

3. While maintaining orientation of the barrel, use your index finger to pin the barrel against your 2^nd, 3^rd and 4^th fingers. This will free your thumb and index finger to handle the wire end (figures 2 and 3).
   

   Figure 2

   

   Figure 2

   

   Figure 3

   

   Figure 3

4. Grasp the 0.014 wire 3-5 cm from its end, as shown in figure 4.
   
   

   Figure 4

   

   Figure 4

5. Angle the 0.014 wire 15-30 degrees with the plunger axis with the end of the wire, resting gently on the inner corner of the plunger groove (figure 5). If the wire is not coaxial with the plunger groove, use your other hand to align the wire with the groove by rotating the plunger (video 1).
   

   Figure 5

   

   Figure 5

   Video 1
6. With your right hand, grasp the equipment (microcatheter, PTCA balloon, stent delivery system, etc.) 3-5 cm from its loading end (figure 6).
   
   

   Figure 6

   

   Figure 6

7. With your equipment tip, gently touch the plunger inner corner 1-2 cm from the wire end and slide it towards the wire to engage the wire (figure 7).
8. Drop the syringe and continue to feed the equipment over the wire in standard fashion.
   See video 2 for the entire routine. Alternatively, this can be done by resting the syringe on a flat surface and following steps 4-8 (video 3).
   Video 2

   Video 3
   This requires a motion-free, flat surface that is near the end of the guidewire. In practice, this may not be feasible.

Reviewed by Christoph Naber