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CASE REPORT
Year : 2022 | Volume
: 11
| Issue : 4 | Page : 107-110
Practical use of dual-lumen catheter-facilitated reverse wire technique for nonhighly angulated side branch
Issei Ota, Tetsuya Nomura, Kenshi Ono, Yu Sakaue, Keisuke Shoji, Naotoshi Wada, Natsuya Keira, Tetsuya Tatsumi
Department of Cardiovascular Medicine, Kyoto Chubu Medical Center, Kyoto, Japan
Correspondence Address:
Dr. Tetsuya Nomura
Department of Cardiovascular Medicine, Kyoto Chubu Medical Center, 25, Yagi-Ueno, Yagi-Cho, Nantan, Kyoto 629-0197
Japan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/rcm.rcm_29_22
Dual-lumen catheter (DLC)-facilitated reverse wire technique is considered a method of last resort for inserting a guidewire into a markedly angulated side branch. Moreover, this technique can be practically applied to other types of anatomical variations around the bifurcation. Case 1 was that of a 53-year-old man with a tight stenosis of the proximal left anterior descending artery at the diagonal bifurcation with angiographically apparent coronary dissection. We successfully achieved guidewire insertion into the targeted branch using the DLC-facilitated reverse wire technique. Case 2 involved a 78-year-old man with total occlusion of the mid-portion of the right coronary artery. The guidewire reentry point in the atrioventricular branch was slightly distant from the true distal end of the occlusion. We successfully used the DLC-facilitated reverse wire technique to pass a second guidewire to the posterodescending artery. Case 3 was that of an 80-year-old man whose coronary artery had an aneurysm with severe stenoses at both entry and exit of the aneurysm. We adopted the DLC-facilitated reverse wire technique and easily advanced the guidewire by matching the guidewire advancing path with the direction of the sequential conduit constituted by the coronary aneurysm and stenosis. The timing of decision-making to try the DLC-facilitated reverse wire technique is important. The lesion for which reverse wiring is suitable is usually difficult to be treated with conventional guidewire crossing. We have to promptly judge the validity of applying this technique based on the angiographic findings of targeted lesions and take immediate action to implement this procedure to reduce the procedural time and irradiation dose.
Keywords: Bifurcation, coronary aneurysm, dual-lumen catheter, nonhighly angulated side branch, reverse wire technique
In practical settings of percutaneous coronary intervention (PCI), it is sometimes difficult to introduce a guidewire to the side branch owing to anatomic variations around the bifurcation.[1] To advance a guidewire toward a highly angulated side branch without special devices, the dual-lumen catheter (DLC)-facilitated reverse wire technique was established as a method of the last resort. A typical case of bifurcated lesion with a highly angulated side branch that requires this technique during PCI is shown in [Figure 1].[2] Moreover, it is supposed that this technique can be applied not only to bifurcations with highly angulated side branches but also to other types of anatomic variations. Here, we report three cases of specific anatomic variations around the bifurcation other than the highly angulated side branch. We realized that the DLC-facilitated reverse wire technique was optimal for these cases.
Figure 1: A typical bifurcated lesion with a highly angulated side branch in which the DLC-facilitated reverse wire technique is indispensable for guidewire insertion. (a) Initial angiography. (b) Schema of the bifurcation and the guidewire position during the DLC-facilitated reverse wire technique. (c) Actual guidewire image during the DLC-facilitated reverse wire technique. (d) Final angiography showed a favorable vessel dilation and blood flow. DLC: Dual-lumen catheter Case Report Case 1
A 53-year-old man complained of effort angina. Coronary angiography revealed a tight stenosis (Medina classification [1,0,1]) of the proximal left anterior descending (LAD) artery at the first diagonal bifurcation with angiographically apparent coronary dissection [Figure 2]a and [Figure 2]b. After advancing the initial guidewire distally in the LAD artery, we attempted to pass a second guidewire into the first diagonal branch using DLC in the usual manner. However, the guidewire entered the dissected lumen regardless of the number of attempts. We then switched to the DLC-facilitated reverse wire technique using a Fielder FC guidewire (ASAHI INTECC Co., Ltd., Aichi, Japan) and successfully performed guidewire insertion to the first diagonal branch with ease [Figure 2]c. Finally, we deployed two drug-eluting stents (DESs) using a culotte stenting method and achieved adequate blood flow [Figure 2]d.
Figure 2: (Case 1) (a) Initial angiography showing a tight stenosis in the proximal LAD artery at the first diagonal bifurcation. (b) Magnified image of the targeted bifurcation. (c) Sequential images while performing the DLC-facilitated reverse wire technique. The upper right panel shows a schema of the bifurcation and the guidewire position during the DLC-facilitated reverse wire technique. (d) Final angiography demonstrating adequate vessel dilation and blood flow. LAD: Left anterior descending, DLC: Dual-lumen catheterCase 2
We performed PCI for a chronic total occlusion in the mid-portion of the right coronary artery in a 78-year-old man with silent myocardial ischemia [Figure 3]a. The distal end of the occlusion was at the bifurcation of the posterior descending artery and atrioventricular branch [Figure 3]b. We could antegradely penetrate the occlusion with a Conquest Pro guidewire (ASAHI INTECC) to the distal true lumen of the right atrioventricular branch under intravascular ultrasound guidance [Figure 3]c. However, the guidewire reentry point was slightly distant from the true distal end of the occlusion. To pass a second guidewire to the posterior descending artery, we performed the DLC-facilitated reverse wire technique from the atrioventricular branch and succeeded [Figure 3]d. Finally, we deployed a DES crossing over the atrioventricular branch and achieved adequate blood flow in both branches [Figure 3]e.
Figure 3: (Case 2) (a) PCI for chronic total occlusion in the midportion of the right coronary artery. The arrow indicates tapered entry of the occlusion. (b) The distal end of the occlusion located just at the bifurcation of the posterior descending artery and atrioventricular branch (arrow). (c) Reentry of the antegrade guidewire to the distal true lumen under the guidance of intravascular ultrasound. (d) Sequential images while performing DLC-facilitated reverse wire technique. Upper right panel shows a schema of the bifurcation and the guidewire position during the DLC-facilitated reverse wire technique. (e) Final angiography revealed adequate vessel dilation and blood flow. PCI: Percutaneous coronary intervention, DLC: Dual-lumen catheterCase 3
Coronary angiography performed in an 80-year-old man with effort angina revealed a coronary artery aneurysm in the proximal part of the major diagonal branch [Figure 4]a with severe stenoses at both entry and exit [[Figure 4]b, arrows]. We performed PCI for these lesions. First, we tried to pass a Sion guidewire (ASAHI INTECC) to the diagonal branch with a single-lumen microcatheter; however, the guidewire formed a loop in the aneurysm, and we were unable to intentionally direct the guidewire tip toward the exit of the aneurysm [Figure 4]c and [Figure 4]d. Next, we switched to a polymer jacket guidewire, but it did not work well. Therefore, we changed the approach path to the exit of the aneurysm. For this purpose, we adopted the DLC-facilitated reverse wire technique and easily advanced the guidewire through the severe stenosis at the exit of the aneurysm [Figure 4]e and [Figure 4]f. We dilated the proximal segment of the diagonal branch using a drug-coated balloon catheter and deployed a DES in the proximal LAD artery. Final angiography demonstrated good patency in both LAD artery and major diagonal branch [Figure 4]g.
Figure 4: (Case 3) (a) Initial angiography demonstrating a coronary artery aneurysm at the proximal segment of the major diagonal branch. (b) Severe stenoses at both entry and exit of the aneurysm (arrows). (c) An attempt of ordinary antegrade guidewire insertion to the diagonal branch. (d) Schema of the bifurcation and the guidewire forming a loop in the aneurysm. (e) Sequential images while performing the DLC-facilitated reverse wire technique. (f) Schema of the bifurcation and the guidewire advancement to the distal diagonal branch beyond the stenosis at the exit of the aneurysm. (g) Final angiography showed adequate vessel dilation and blood flow. DLC: Dual-lumen catheter Discussion The DLC-facilitated reverse wire technique is an essential PCI technique for all interventional cardiologists because we sometimes encounter cases, in which this technique is indispensable for procedural success. Kawasaki et al. first developed the “reversed guidewire” technique in 2008.[3] In the original method, owing to the direct insertion of the guidewire with a hairpin bend into the coronary artery without a microcatheter, extreme caution was necessary to avoid damaging the vessel. To reduce the risk of vascular injury and improve guidewire advancement, Suzuki et al. reported the reversed guidewire technique with the adjunctive use of a DLC in 2013.[4] The application of this technique for chronic total occlusion was reported by Ide et al.[5] Their method is currently considered the standard procedure for this technique. Thereafter, we reported the practical usefulness of this guidewire manipulation technique[6] and discussed some tips regarding this technique in 2018.[7]
The DLC-facilitated reverse wire technique is commonly applied for guidewire advancement to a highly angulated side branch. However, this technique can be practically applied to other types of anatomical variations around the bifurcation such as coronary dissection involvement, distal end of the total occlusion, and coronary aneurysm involvement, which we have shown in this article. In cases 1 and 2, antegrade wiring into the targeted side branch was almost impossible to perform due to the anatomical complexity of the targeted bifurcation. Under such circumstances, the DLC-facilitated reverse wire technique should be started as soon as possible by properly judging the angiographic findings. Case 3 is a very educational and unusual case in which the DLC-facilitated reverse wire technique worked well. The global prevalence of coronary artery aneurysms is 0.35%.[8] They are usually associated with coronary stenosis and a higher cardiovascular risk. Their anatomical complexity often makes guidewire control during PCI difficult. In our case, the application of the reverse wire technique resulted in a change in the guidewire advancement path toward the exit of the aneurysm. The guidewire path matched the direction of the sequential conduit constituted by the coronary aneurysm and stenosis and we succeeded in guidewire insertion into the targeted branch relatively easily, reducing the procedural time, and irradiation dose. However, applying this technique for the lesion involved with coronary aneurysm is not universally effective and we always have to consider the validity of the application.
Conversely, lesions that are optimal for the DLC-facilitated reverse wire technique are not suitable for ordinary guidewire manipulation. Therefore, it is important to judge the validity of applying this technique from the angiographic findings of targeted lesions and take immediate action to implement this procedure. However, we must keep in mind the shortcomings of the reverse wire technique. We rarely encounter a situation suitable for this guidewire manipulation technique in daily PCI practice. Persisting in performing reverse wiring for a lesion unsuitable for this technique is merely a waste of time. Second, because this procedure requires multiple guidewires and microcatheters, it costs much. Third, there is always a risk of complications. Because the part of the reversely bent curve is bulky in the vessel, close attention must be paid not to cause vascular complications, such as coronary dissection or rupture.
The DLC-facilitated reverse wire technique is an essential PCI technique that all interventional cardiologists must master. This technique can be applied not only for bifurcations with a highly angulated side branch but also for other types of anatomic variations. For such lesions, it is important to take immediate action to implement this procedure to reduce procedural time and irradiation dose.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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