Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with increased procedural costs, greater complication rates, and worse outcomes compared to PCI of simple coronary lesions. Coronary bifurcation interventions account for approximately 20% of all PCIs. Nonetheless, they remain one of the most challenging lesion subsets in interventional cardiology in terms of lower procedural success rate and increased rates of long-term adverse cardiac events. Regardless of the planned strategy to approach a bifurcation lesion, the most important step is always wiring of the side branch.1 This maneuver can be challenging due to vessel diameters and tortuosity, plaque burden distribution, and side branch take-off.2 Although wiring of the side branch is usually performed without difficulty, some anatomical subsets, such as a wide bifurcation angle (>150°), present technical challenges, and guidewire crossing into the side branch can be difficult using a standard anterograde method. In these unfavorable situations, a “reversed guidewire” technique3 can be a useful trick to engage the side branch ostium and advance the wire distally, as documented in this case.
A 57-year-old man with known ischemic heart disease and previous PCI of all three coronaries was admitted to our department with unstable angina. Coronary angiography showed a progression of atherosclerotic pathology with three-vessel critical stenosis, including two bifurcation lesions in the circumflex-obtuse marginal branch (Cx-MO) and left anterior descending-diagonal (LAD-D2). (Figure 1).
The case was discussed with the heart team, but the patient refused cardiac surgery; therefore, a staged percutaneous revascularization was planned, starting from the bifurcation of the Cx-MO (the culprit lesion) treated with a double kissing crush stent technique. Five days later, we completed the revascularization in LAD vessel, anticipating the difficulties in wiring the D2 because of the take-off from the diseased main vessel, with a greater than 90° angle.4 A redo right transradial access was chosen to insert a long radial 6 French (Fr) hydrophilic sheath (PreludeEase hydrophilic sheath introducer, Merit Medical) and 6 Fr Extra Backup (EBU) Launcher 3.75 (Medtronic) guiding catheter. A workhorse guidewire was advanced in the distal part of the LAD and several attempts with different workhorse guidewires (spring coil and polymeric) were made to engage the D2 ostium from the anterograde without success.
At this point, we thought that a microcatheter-facilitated reverse wire technique could offer a valid option to cross the side branch. As suggested by in vitro evaluation5, a polymer-jacket hydrophilic guidewire (Fielder FC, Asahi Intecc) was preferred, properly shaped like a swan neck with a first sharp curve (40-50°) about 1-2 mm from the tip and a reverse rounded bend at about 3 cm (Figure 2).
A dual-lumen microcatheter (NHancer RX, IMDS) was chosen and advanced at the proximal part of guiding catheter using the short monorail rapid exchange, while the Fielder FC was proximally inserted using the over-the-wire dual-lumen microcatheter hole. The banded guidewire and dual-lumen microcatheter were inserted together into the Y-connector and advanced into the coronary artery. The radiopaque tip of the dual-lumen microcatheter was driven into the distal LAD next to the side branch orifice. We used a pull-back maneuver of the microcatheter to place the tip of the guide in front of the side branch. Consequently, the guidewire slid easily inside the side branch without damaging the vessel (Figure 3). After the successful wiring, the dual-lumen microcatheter was exchanged with a single-lumen microcatheter (Finecross, Terumo) and the polymer-jacked wire was replaced in the side branch by a workhorse guidewire. After the successful wiring, we planned a bifurcation treatment with a “keep it open” strategy for the side branch. The D2 ostium was dilated with a 2 mm x 12 mm compliant balloon, while the LAD was pre-dilated with a 3 mm x 15 mm semi-compliant balloon. A 3.0 mm x 22 mm zotarolimus-eluting stent (Resolute Onyx, Medtronic) was successfully implanted in the middle LAD. Final angiography showed an excellent angiographic result with no residual stenosis at the bifurcation level (Figure 4).
Percutaneous treatment of coronary disease involving a side branch that needs to be protected by a wire or end stented is common practice during routine angioplasty in the cath lab. However, some difficulties and complications can occur while trying to introduce the guidewire into the side branch ostium, due to stenosis and any unfavorable bifurcation angle (>90°). The “reverse wire” technique is considered an unusual but safe way to manipulate the guidewire in complex situations.4
This procedure was first developed by Kavasaki et al in 20083, but the technique has been improved over the following years with the addition of a dual-lumen microcatheter to more easily engage the narrow, angulated side branch. The NHancer RX (IMDS) offers good trackability due to its tapered, flexible, and atraumatic distal tip with radiopaque markers at the two exit ports and the presence of a shaft-torquer in the proximal part to better direct the microcatheter in front of the side branch ostium.6 The NHancer RX can be removed in a safe manner (trapping technique), also in a 6 Fr guiding catheter, avoiding the risk of advancing the polymer-jacket hydrophilic guidewire in the distal side branch and causing a perforation.
To facilitate the engagement of the side branch ostium, we chose a polymer-jacketed hydrophilic-coated guidewire. The choice of this guidewire was double-edged sword: the lubricity of the wire was an added advantage during the reversing maneuvers, but it also meant an increased risk of dissection. In order to easily engage the side branch ostium, we bend the tip of the guidewire as follows: first we make a short (1-2 mm), acute angle (30-45°) at the tip, then we add a second opposite bend at about 3 cm from the tip, choosing a rounded shape conformation (“swan-neck”), as suggested in the in vitro study.5 We think there might be more possibility to damage the plaque in advancing a dual-lumen microcatheter with a sharp curve for its “blade” shape. Table 1 summarizes the advantages and limits of a “sharp” versus a “round” curve. As suggested by Nomura et al7 and confirmed by our experience, it is always better to start with a round curve and if unsuccessful, to shift to a sharp curve.
A reverse wire technique with a dual lumen microcatheter was effective and safe for approaching the highly angulated branch of a complex bifurcated lesion. This approach permitted us to achieve complete revascularization in a three-vessel disease patient.
Disclosures: The authors report no conflicts of interest regarding the content herein.
The authors can be contacted via Alberto Cereda, MD, at firstname.lastname@example.org.
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- Nomura T, Kikai M, Hori Y, et al. Tips of the dual-lumen microcatheter-facilitated reverse wire technique in percutaneous coronary intervention for markedly angulated bifurcated lesions. Cardiovasc Interv Ther. 2018 Apr; 33(2): 146-153. doi: 10.1007/s12928-017-0462-0.