European Journal of Cardiovascular Medicine

Coronary artery disease (CAD) remains a leading cause of mortality and morbidity globally, necessitating ongoing innovation in its management strategies. Percutaneous transluminal coronary angioplasty (PTCA) has established itself as a cornerstone in the treatment of obstructive CAD, enabling revascularization in both stable and unstable clinical scenarios with favorable long-term outcomes when performed optimally¹. The procedure's success is intricately linked to technical precision, particularly in guidewire manipulation, which remains a pivotal step in crossing lesions, delivering stents, and avoiding complications such as dissection or perforation².

Traditionally, the single wire technique has been employed as the standard approach during PTCA. This method requires the successful navigation of a single guidewire through a stenotic coronary artery, followed by balloon dilatation and stent deployment. However, in complex lesions—such as heavily calcified plaques, bifurcations, or chronic total occlusions (CTOs)—the single wire method may pose challenges in achieving optimal guide support and device delivery³. These challenges often result in prolonged procedural times and increased risk of complications, particularly in tortuous vessels or diabetic patients with diffuse disease⁴.

To address these limitations, alternative wiring strategies have been introduced. Among them, the double wire technique has gained increasing attention for its potential to enhance procedural efficacy. This method involves the simultaneous introduction of a second wire into an adjacent segment of the same or nearby vessel to improve guide catheter stability, facilitate lesion crossing, and reduce guide catheter-induced trauma⁵. The presence of an anchoring or buddy wire has been particularly beneficial in delivering balloons and stents across resistant lesions and negotiating sharp angulations⁶.

Multiple observational studies and interventional registries have suggested that the double wire technique may offer procedural advantages in select patient populations. Benefits include reduced fluoroscopy time, easier advancement of interventional devices, and potentially lower rates of procedural complications⁷. Furthermore, the technique appears particularly useful in settings where deep engagement of the guide catheter is difficult or inadvisable, such as in ostial or left main coronary lesions⁸.

In addition to mechanical benefits, the double wire technique may offer a valuable learning curve advantage. Less experienced operators may achieve higher procedural success rates in challenging anatomies using dual wiring as a stabilizing strategy, thereby improving confidence and outcomes in resource-limited or high-volume clinical environments⁹.

Despite these perceived benefits, direct comparative data evaluating single versus double wire techniques in large, prospective cohorts remain scarce. Moreover, there is a need to assess whether the incremental benefits of dual wiring justify its routine use or if it should be reserved for selective complex anatomies.

This prospective observational study aims to bridge this gap by comparing the procedural outcomes, complication rates, and technical feasibility of single and double wire techniques in a real-world cohort of 1000 patients undergoing PTCA at a tertiary cardiac care center¹⁰.

Study Design and Population

This was a prospective, observational study conducted at a high-volume tertiary cardiac care center, enrolling a total of 1000 consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA).

The study aimed to compare procedural outcomes between the double wire and single wire techniques. Of the total cohort, 392 patients were randomly assigned to undergo the double wire technique. The remaining 608 patients received the single wire technique. Patients were included regardless of lesion complexity or comorbid conditions.

Inclusion Criteria

• Adult patients aged ≥18 years undergoing elective or emergency PTCA
• Presence of single or multiple coronary artery lesions
• Lesions suitable for guidewire-based intervention (calcified, thrombotic, or CTO lesions)
• Both diabetic and non-diabetic patients

Exclusion Criteria

• Patients undergoing primary PCI for ST-elevation myocardial infarction (STEMI)
• Patients with contraindications to dual antiplatelet therapy
• Known contrast allergy
• Previous coronary artery bypass grafting (CABG) where native vessel access was not feasible

Interventional Techniques

All procedures were performed by experienced interventional cardiologists using standard aseptic precautions and vascular access via the femoral or radial artery. The single wire technique involved placement of a single guidewire across the target lesion, followed by balloon pre-dilatation and stent deployment as per standard protocol.

In the double wire technique, a second guidewire was introduced into a nearby segment or side branch to enhance guide catheter support. This anchoring or “buddy” wire allowed for improved device delivery, particularly in tortuous or calcified vessels. Both hydrophilic and workhorse wires were used as required by lesion morphology.

Lesion Characteristics

Lesions included in the study spanned a wide spectrum of complexity, including:

• Two or more discrete stenotic lesions
• Calcified and non-calcified plaques
• Thrombotic segments
• Chronic total occlusions (CTOs)
• Lesions in diabetic vessels
• Both short and long stent requirement cases

No pre-stratification scoring system (e.g., SYNTAX score) was applied for lesion complexity.

Data Collection Parameters

For each case, the following procedural parameters were recorded:

• Total procedural time
• Guide support and wire crossing times (measured separately for left and right coronary systems)
• Stent delivery time
• Complications, including:
• Left main dissection
• Other coronary dissections
• Wire perforation

Additional technical observations such as:

• Frequency of guide catheter repositioning
• Ease of balloon and stent crossing in calcified or tortuous lesions
• Subjective operator ease-of-use scoring (where applicable)

Operator Experience

Operator skill levels were documented to assess if the double wire technique mitigated challenges typically encountered by less experienced interventionalists. All operators adhered to institutional best-practice protocols and were trained in both wiring techniques.

Statistical Analysis

Data were analyzed using SPSS software version 25. Continuous variables were expressed as mean ± standard deviation, while categorical variables were reported as frequencies and percentages.

Comparative analysis between the single and double wire groups was conducted using independent t-tests for continuous variables and Chi-square tests for categorical outcomes. A p-value of <0.05 was considered statistically significant.

A total of 1000 patients underwent PTCA, with 392 patients treated using the double wire technique and 608 patients with the single wire technique. The study evaluated and compared procedural times, complications, and technical ease between the two approaches in both the left and right coronary systems.

Table 1 presented the distribution of the study subjects based on the wire technique employed. Of the 1000 patients included in this prospective study, 392 (39.2%) underwent the double wire technique, whereas 608 (60.8%) were treated using the conventional single wire method. This table establishes the foundational cohort split for comparative analysis.

Table 2 compared the average procedural time required for left coronary artery interventions using the two techniques. The single wire technique demonstrated a significantly longer procedural duration (1.2 hours) compared to the double wire technique (45 minutes). This highlights the improved efficiency and reduced catheter manipulation time when using the double wire approach in anatomically complex or calcified left coronary lesions.

Table 3 evaluated the procedural time in the right coronary system, specifically guide support and stent crossing durations. The double wire group exhibited notable reductions: guide support time was reduced from 30 to 16 minutes, and stent crossing time decreased from 24 to 7 minutes. This demonstrates the effectiveness of the double wire method in enhancing deliverability and catheter stability in right-sided lesions.

Table 4 outlined the complication rates in the left coronary artery system. The incidence of major complications such as left main dissection (8 cases in single wire vs. 1 in double wire), other vessel dissections (13 vs. 9), and wire perforations (12 vs. 1) was substantially higher in the single wire group. These findings underscore the improved safety profile of the double wire technique, likely due to better guidewire control and reduced vessel trauma.

Table 5 summarized qualitative technical parameters including the frequency of guiding adjustments, ease of balloon and stent crossing, and operator comfort. The double wire technique required fewer guide catheter repositionings and facilitated smoother device delivery, particularly in cases involving calcified or tortuous vessels. Operator-reported feedback further confirmed higher procedural confidence with the double wire technique.

Table 1: Distribution of Study Subjects Based on the Wire Technique Used (n=1000)

Table 2: Average Procedural Time in Left Coronary System (n=1000)

Table 3: Guide Support and Crossing Times – Right Coronary System (n=1000)

Table 4: Complication Profile – Left Coronary System (n=1000)

Table 5: Technical Performance Observations (n=1000)

This prospective analysis highlights the clinical advantages of the double wire technique over the conventional single wire approach in PTCA. The data reveal that the double wire technique substantially reduces procedural time in both left and right coronary interventions, while also minimizing the risk of serious complications such as dissections and wire perforations. These findings align with existing interventional studies that emphasize the significance of guidewire strategies in complex coronary lesions⁶.

A key observation in this study was the reduction in total procedural time, which was particularly evident in left coronary system interventions. This improvement can be attributed to better guide catheter support provided by the second wire, enabling more efficient navigation through calcified, tortuous, or occluded segments⁷. In the right coronary system, both guide support and stent delivery times were significantly shorter with the double wire technique, reflecting smoother lesion crossing and less need for guide manipulation⁸.

The reduction in complication rates, including left main dissections and wire-induced vessel perforations, reinforces the safety profile of the double wire method. These complications, though rare, are associated with significant morbidity and procedural failure⁹. By improving wire control and catheter stability, the double wire approach mitigates vessel trauma, particularly in anatomically challenging or high-risk subsets such as diabetic patients or those with chronic total occlusions¹⁰.

Another advantage observed was the technical ease reported by operators during procedures using the double wire strategy. The need for frequent guide adjustments was significantly lower, and the success rate of balloon and stent tracking was higher. This suggests that the technique not only enhances procedural performance but also reduces operator fatigue and improves consistency in outcomes¹¹. Additionally, less experienced interventionalists benefited from the stabilizing effect of the buddy wire, allowing safer and more predictable navigation through complex lesions¹².

Although previous anecdotal and observational data have hinted at the value of the buddy wire technique, this study contributes high-volume, prospective evidence to support its broader application. It is particularly useful in centers with variable operator experience, where technical simplification can have a major impact on procedural safety and efficiency¹³.

However, it is important to acknowledge the limitations of this analysis. The absence of lesion complexity scoring (e.g., SYNTAX or J-CTO) may have introduced selection bias, as allocation to each technique was not stratified by lesion severity. Moreover, long-term follow-up data regarding restenosis, stent thrombosis, and major adverse cardiac events (MACE) were not assessed, which limits the evaluation of durable clinical benefit¹⁴. Future randomized, multicentric trials with long-term follow-up will be essential to validate the routine use of the double wire technique across diverse clinical scenarios¹⁵.

The double wire technique demonstrates clear procedural advantages over the conventional single wire approach in PTCA, particularly in complex coronary anatomies. It significantly reduces procedural time, enhances guide support, and minimizes complications such as dissections and wire perforations. The technique also improves technical ease, making it suitable for both experienced and less experienced operators. These findings suggest that the double wire method can serve as a valuable adjunct in routine and challenging interventions alike. While further multicentric trials are warranted, current evidence supports broader clinical adoption of the double wire strategy to improve safety and efficiency in coronary interventions.

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