Side-branch technique for difficult guidewire placement in coronary bifurcation lesion




Abstract


Despite tremendous advances in technology and skills, percutaneous coronary intervention (PCI) of bifurcation lesion (BL) remains a particular challenge for the interventionalist. During bifurcation PCI, safe guidewire placement in the main branch (MB) and the side branch (SB) is the first step for successful procedure. However, in certain cases, the complex pattern of vessel anatomy and the mix of plaque distribution may make target vessel wiring highly challenging. Therefore, specific techniques are required for solving this problem. Hereby, we describe a new use of side-branch technique for difficult guidewire placement in BL.



Introduction


Bifurcation lesion (BL), accounting for 20% of PCI procedures, is truly technically challenging and remains a difficult lesion subset to treat . Compared with simpler lesions, BL intervention is associated with more complex procedures, lower procedural success rates, and higher clinical event rates . During the PCI procedure, the first and critical step is the safe placement of the guidewire in the main branch (MB) and the side branch (SB). However, when the bifurcation take-off angle is wide and there is severe stenosis with a large plaque distributed in the proximal MB, primary wiring becomes difficult. In previous studies, various approaches have been described to facilitate guidewire manipulations. These approaches include shaping the guidewire tip curvature, use of stiffer or hydrophilic polymer coating guidewire, the double wiring technique, and advancing a micro-catheter or balloon closer to the BL in order to increase the back-up support .


Here, we report the use of side-branch technique to solve difficult guidewire placement in BL. In this article, we review two typical cases to describe the tips and tricks useful for success in difficult target vessel access.





Technique description



Case 1 ( Fig. 1 )


A 69-year-old male with a past medical history of diabetes, hypertension and smoking was referred for cardiac catheterization after being admitted for symptoms of unstable angina and elevated bio-markers diagnostic for a non-ST-elevation myocardial infarction (NSTEMI). Coronary angiography showed a Medina classification (1, 1, 1) bifurcation lesion involving a mid left anterior descending artery (LAD) with 95% stenosis and a first diagonal branch (D 1 ) lesion with 90%, D 2 lesion with 90%. The proximal-LAD diameter was approximately 5 mm, while the diameter of the mid-LAD and D 2 was approximately 2.75 mm each. The SKS technique was chosen in this case because of the large proximal vessel.




Fig. 1


Case 1. A and B: Left coronary angiogram shows a bifurcation (White Arrow) lesion in the mid LAD. C: The attempts using a BMW and a Pilot 50 guidewire both failed to enter into the LAD. Then a 2.5*20 mm balloon was put into the D2 and inflated to 8 atm. D: After the inflation of the balloon, a BMW guidewire easily entered into the LAD. E: Two stents were deployed at LAD and D2 simultaneously. F: The final result after stenting.


Angioplasty to the bifurcation lesion in the mid-LAD was performed through the right femoral approach using a 7 French EBU3.5 guiding catheter (Launcher®, Medtronic, USA). First, a 0.014″ BMW guidewire (Abbott Laboratories, Abbott Park, USA) was maneuvered into the D 1 , with a second guidewire advanced into the D 2 . Then, a BMW guidewire was advanced into LAD. However, this attempt was unsuccessful. The guidewire always slipped away into the diagonal branch (D 1 or D 2 ). After that, it was exchanged to a Pilot 50 guidewire (Abbott Laboratories, Abbott Park, USA) with an appropriately shaped tip curvature. It failed as well. At this moment, we put a 2.5*20 mm balloon into the D 2 and inflated it to 8 atm. Then, the tip of the BMW guidewire easily entered into the LAD. There was no acute and post-procedural complication.





Technique description



Case 1 ( Fig. 1 )


A 69-year-old male with a past medical history of diabetes, hypertension and smoking was referred for cardiac catheterization after being admitted for symptoms of unstable angina and elevated bio-markers diagnostic for a non-ST-elevation myocardial infarction (NSTEMI). Coronary angiography showed a Medina classification (1, 1, 1) bifurcation lesion involving a mid left anterior descending artery (LAD) with 95% stenosis and a first diagonal branch (D 1 ) lesion with 90%, D 2 lesion with 90%. The proximal-LAD diameter was approximately 5 mm, while the diameter of the mid-LAD and D 2 was approximately 2.75 mm each. The SKS technique was chosen in this case because of the large proximal vessel.


Nov 13, 2017 | Posted by in CARDIOLOGY | Comments Off on Side-branch technique for difficult guidewire placement in coronary bifurcation lesion

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