Knuckle wire technique in percutaneous coronary intervention of chronic total occlusion

Abstract

In percutaneous coronary intervention, the knuckle wire technique is one of the approaches to cross the long and ambiguous course of the occluded segment. However, this technique is generally used as a last alternative, when all other techniques fail. Although knuckle wiring expedites chronic total occlusion crossing, it can also complicate the percutaneous coronary intervention strategy irreversibly. Therefore, understanding the various aspects of the knuckle wire technique is a prerequisite in a chronic total occlusion setting. The authors herein intend to describe in detail the knuckle wire technique and its safe and effective approach in various chronic total occlusion wiring strategies, while befitting to the scope of a mainstream interventionist. BASE balloon-assisted subintimal entry CART controlled antegrade and retrograde tracking CTO chronic total occlusion IVUS intravascular ultrasound PCI percutaneous coronary intervention STAR subintimal tracking and re-entry

Extrastent Plaque Modification With Knuckle Wire for Resistant Stent Underexpansion

“…This technique should be the last resort as it has the intrinsic risk of coronary perforation and subintimal hematoma compromising the distal true lumen. 6…”

Coronary Chronic Total Occlusion Revascularization: When, Who and How?

“…In case of tortuosity that makes the vessel course uncertain, or in case of severe calcifications, the operator can advance the wire into the subintimal space [41][42][43]. Using the "knuckle technique" it is possible to navigate in subintimal space with a hydrophilic wire with a J-loop configuration to allow a blunt dissection between the anatomical planes of the vessel using the principle of differential longitudinal and tangential resistance [45] and then re-enter in the true lumen with a dedicated device (i.e., Stingray balloon, dual lumen microcatheters [DLMC]).…”