Guidewire-Induced Pseudostenosis of the Iliac Artery During Chronic Total Occlusion Percutaneous Coronary Intervention

BACKGROUND: Guidewire-induced pseudostenosis, or the "accordion effect," can mimic true arterial occlusion during percutaneous coronary intervention, particularly in tortuous vessels. CASE SUMMARY: A 67-year-old male undergoing chronic total occlusion percutaneous coronary intervention developed apparent right external iliac artery occlusion following femoral access with a stiff guidewire. The patient remained asymptomatic and hemodynamically stable, though the femoral sheath pressure tracing was dampened. Contralateral angiography and intravascular ultrasound demonstrated a patent vessel without dissection or obstructive disease. Repositioning the stiff guidewire and allowing the floppy distal segment to track the natural tortuosity restored vessel curvature and resolved the angiographic stenosis. DISCUSSION: Mechanical straightening of tortuous arteries by stiff guidewires can produce angiographic pseudostenosis and flow disturbance. Recognition of this phenomenon prevents unnecessary intervention. TAKE-HOME MESSAGE: Suspect pseudostenosis when stenosis resolves after guidewire adjustment.