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The Effective and Safe Way to Use Crusade Microcatheter-Facilitated Reverse Wire Technique to Solve Bifurcated Lesions with Markedly Angulated Target Vessel

The Effective and Safe Way to Use Crusade Microcatheter-Facilitated Reverse Wire Technique to... Hindawi Journal of Interventional Cardiology Volume 2019, Article ID 2579526, 7 pages https://doi.org/10.1155/2019/2579526 Research Article The Effective and Safe Way to Use Crusade Microcatheter-Facilitated Reverse Wire Technique to Solve Bifurcated Lesions with Markedly Angulated Target Vessel Jingang Cui , Xiaowei Jiang , Shubin Qiao, Lijian Gao, Jiansong Yuan, Fenghuan Hu, Weixian Yang, and Runlin Gao Cardiology Department, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Correspondence should be addressed to Jingang Cui; doctorcjg@163.com Received 15 December 2018; Accepted 4 March 2019; Published 11 April 2019 Academic Editor: Andrea Rubboli Copyright © 2019 Jingang Cui et al. is Th is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. We aim to present a new way to introduce reverse wire in crusade microcatheter-facilitated reverse wire technique to solve markedly angulated bifurcated lesions. Background. Markedly angulated coronary bifurcation lesions are still one of the considerable challenges of treatment with percutaneous coronary intervention especially with severe proximal stenosis. Microcatheter-facilitated reverse wire technique improved the efficacy of crossing a guide wire to such an extremely angulated complex targeted vessel. However, there has been a debate regarding what kind of curve was the best to introduce reverse guide wire in this technique. Methods. We analyzed 7 patients who were admitted to Fuwai Hospital and underwent antegrade wiring which failed. Crusade microcatheter-facilitated reverse wire technique with simple short tip one round curve was used successfully to solve in all 7 bifurcation lesions. We investigated the bifurcation lesion’s characteristics and details of the reverse wire technique procedures. Results. All 7 bifurcations exhibit both a smaller take-off angle and a larger carina angle and severe proximal significant stenosis. Aeft r having suitable size of balloon predilation, reverse wire with simple short distal one curve was delivered to distal segment of targeted vessel successfully. We performed all PCI procedures without any complications and no major adverse cardiac event was observed during hospitalization. Conclusions. In solving markedly angulated bifurcated lesions, especially with severe proximal stenosis, crusade microcatheter-facilitated reverse wire technique with simple short tip one curve is an eeff ctive and safe way of wiring. 1. Introduction tip, and rfi st curve is a short tip one and secondary curve is an opposite longer proximal one. However, especially in Safe guidewire placement in the main vessel (MV) and in markedly angulated bifurcated lesions with tight proximal the side branch (SB) is necessary for successful percutaneous stenosis, there had been different opinions about how to coronary interventions (PCI) in bifurcated lesions. Bifurcated shape the secondary curve: sharply [1] (easier to pass the lesion with small take-off angel is an important predictive proximal stenosis segment) or roundly [2] (easier to delivery factor, and targeted vessel wiring could be particularly diffi- device through reverse wire). cult. We have experienced 7 cases of difficult vessel access The reversed guide wire technique, rfi stly reported by with severe proximal stenosis. The microcatheter-facilitated Kawasaki et al. in 2008, has been improved with utilizing the reverse wire technique without the secondary curve was support of dual lumen catheter and is a very useful guide successful to cross a guide wire to extremely angulated wire manipulation technique to cross a guide wire to such complex targeted vessel. Therefore, the present study aimed an extremely angulated complex targeted vessel. In reverse to discuss what kind of curve in reverse wire is more effective wire technique, two curves are created at the guide wire in markedly angulated bifurcation. 2 Journal of Interventional Cardiology (a) (b) (c) Figure 1: Microcatheter-facilitated reverse wire technique. (a) A short tip curve (as indicated by white arrow) which ts fi the diameter of the untargeted vessel in a retrograde. (b) Solft y folding the guide wire (as indicated by white arrow), in opposite direction of the first curve at about 3 cm away from the wire tip approach. (c) eTh reverse wire system was inserted through the hemostatic valve into guiding catheter (as indicated by white arrow). 2. Materials and Methods 2.2. Preparation of the Reverse Wire System. Acrusade catheter and eld fi er FC (Asahi Intecc) guide wire were used 2.1. Study Design and Patient Population. This is a retro- exclusively for the reverse wire technique in all 7 patients. spective study conducted at Fuwai Hospital. We enrolled 7 In aspect of guide wire shape, our method of wire shape patients in whom conventional antegrade wiring to branch had many differences from past studies [1–3]. The guide wire vessel was easily done, but wiring to target vessel had failed, was introduced into the over-the-wire lumen of the crusade and inwhomareversewiretechnique wasused inan catheter and shaped by a tip curve (0.2-0.5 cm) that tfi the attempt to approach target vessels of bifurcation lesions with diameter of the untargeted vessel and without being followed a small take-off angel. This study was approved by the Ethics byasecondaryshapecurve.Then,abendofguidewireisfixed Committee of Fuwai Hospital. All participants provided their softly with the crusade catheter in the opposite direction of written informed consent to agree with using their clinical thetip curveat 3 cm away from thetip of the guidewire in a information. retrograde approach (Figure 1). Quantitative assessments were performed using the Car- diovascular Measurement System (QAngio XA 7.2, MEDIS), a personal computer-based system, for offline quantitative 2.3. Details of the Procedure (Figure 2). The first guide wire angiographic analysis. The take-off angel indicates the angle was placed in the untargeted vessel. Before the insertion of a between the proximal untargeted vessel and targeted vessel, guide wire into the untargeted vessel with a marked angula- and the carina angle indicates the angel between the distal tion, due to the tight stenosis proximal bifurcation, we usually untargeted vessel and the targeted vessel. inflate a suitable size of balloon catheter to modify the Journal of Interventional Cardiology 3 (a) (b) 3cm (c) (d) (e) Figure 2: Diagrammatic representation of the microcatheter-facilitated reverse wire technique. (a) Due to the tight stenosis proximal bifurcation, we usually inflate a suitable size of balloon catheter to modify the plaque distribution of untargeted vessel and make reverse wire system pass the stenosis proximal easily. (b) A short tip curve was made on guidewire. (c) Solft y folding the guide wire with a smooth round curve and inserting it into the hemostatic valve. (d) After pulling back the reverse system proximal to the bifurcation lesion and some rotations, the reverse wire tip directs into the ostium of the target vessel. (e) Deliver the reverse wire down to the distal segment of target vessel. plaque distribution of untargeted vessel and make reverse ranging from minimum value to maximum value for contin- wire system pass the stenosis proximal easily. uous variables. The first guide wire in the untargeted vessel supports delivery of the crusade catheter alone with the bent wire down 3. Results to the untargeted vessel with the tip of the reversely bent wire We demonstrated the lesion’s characteristics and procedural remaining distal to the carina of the targeted vessel. outcomes and the details of the PCI procedures by analyzing After pulling the crusade microcatheter back to the parent the records and angiography lfi ms of the PCI. vessel, the reversely bent wire was pulled back slowly and manipulated gently so that the wire tip directs into the ostium of the target vessel. Some rotational guide wire is required to 3.1. Baseline Demographics and Bifurcation Lesions Charac- deliver the wire down to the distal segment of target vessel. teristics. As displayed in Table 1, there are 7 cases in which Using the balloon trapping method, the crusade catheter is conventional antegrade wiring failed after being used, and removed. the carina angles of the targeted vessel ranged from 125 to 160 degrees. All patients required the reverse wire technique 2.4. Statistical Analysis. Descriptive analysis was performed. to access target vessel of the bifurcation lesion due to an Results are presented as percentage for categorical variable, acutely angulated carina. Most of the patients were male 6 4 Journal of Interventional Cardiology Table 1: Baseline demographics and bifurcation lesions characteristics. Case Age Untargeted Targeted vessel; Proximal Medina Take-off angle Carina angle Sex number (years) vessel TIMI flow stenosis (%) classification (degrees) (degrees) Male 1 50 D LAD; II 100 1,1,1 30 150 Female 2 57 LCX LAD; III 90 1,1,0 55 125 3 Male 43 D LAD; II 100 1,1,1 45 135 Male 4 66 D LAD; II 100 1,1,1 45 135 Male 5 68 D LAD; III 90 1,1,1 25 155 Male 6 54 D LAD; II 95 1,1,0 50 130 Male 7 80 D LAD; III 90 1,1,0 20 160 D, diagonal branch; LAD, left anterior descending; LCX, left circumflex. (a) (b) (c) (d) Figure 3: LM bifurcations with markedly angulated LAD vessel and severe proximal stenosis. (a) Direction of blood flow was marked with Arabic numerals and white arrow, and the order contrast appeared was LM, LCX, to LAD. (b) The balloon (2.5mm in diameter) predilation in LM-LCX aer ft wring first guide wire in the LCX vessel. (c) The reverse wire tip (as white arrow) directs into the ostium of the LAD vessel. (d) Angiographic image obtained aer ft the PCI. (85.7%), the age range was from 43 to 80 years old, and and 2 cases (28.6%) via the femoral artery. A 6 Fr guiding all of the patients presented with angina 7 (100%). The catheter was used in 5 cases (71.4%), and a 7 Fr guiding bifurcation lesions were located in left anterior descending catheter was used in 2 cases (28.6%). Patients with severe and diagonal coronary arteries 6 (85.7%), or LAD and LCX stenosis (Figure 3) or CTO (Figure 4) of the parent vessel 1 (14.3%). The type of bifurcation according to the Medina required balloon predilatation to allow passage of the crusade classicfi ation [4] was 1,1,1 4 (57.1%) or 1,1,0 3 (42.9%). The catheter alone with the reversely bent wire after the first wire targeted vessel was the LAD in 7 (100%) patients. 3 (42.9%) arrived at distal segment of untargeted vessel. The diameter of lesions were chronic total occlusion lesions and 4 (57.1%) predilation balloon (1.5-2.5mm) used was as small as possible severe stenosis lesions involving the parent vessels proximal under the condition of passage of the reverse system. No cases to the bifurcation lesion. of vascular dissection and occlusion were noted. For the cases with successful wiring, successful revascu- larization was achieved in 5 patients using the single stent 3.2. PCI Procedural Characteristics. As described in Table 2, there were 5 cases (71.4%) approached via the radial artery technique (71.4%), 1 patient using the two stents technique Journal of Interventional Cardiology 5 ft Table 2: PCI procedural characteristics. Cases Guiding Balloon predilation TIMI flow in LAD Procedure Approach Guide wire Microcatheter Stenting strategy number catheter (Fr) (mm∗mm); location aer predilation success 1 Radial 6 Fielder FC Crusade 1.5∗15; LAD-D III Single Yes 2 Femoral 7 Fielder FC Crusade 2.5∗15; LM-LCX III Single Yes 3 Radial 6 Fielder FC Crusade 1.5∗15; LAD-D III Single Yes 4 Femoral 7 Fielder FC Crusade 1.5∗15; LAD-D III Crush Yes 5 Radial 6 Fielder FC Crusade 2.5∗15; LAD-D III Single Yes 6 6 2.0∗15; LAD-D III Single Yes Radial Fielder FC Crusade 7 Radial 6 Fielder FC Crusade 2.0∗15; LAD-D III DEB Yes TIMI, thrombolysis in myocardial infarction; DEB, drug eluting balloon. 6 Journal of Interventional Cardiology (a) (b) (c) (d) Figure 4: LAD bifurcations. (a) Markedly angulated LAD and proximal chronic total occlusion. (b) eTh balloon (1.5mm in diameter) predilation in LAD-D aer ft wring first guide wire in the diagonal vessel. (c) eTh reverse wire tip (as white arrow) direct into the ostium of the LAD vessel. (d) Angiographic image obtained aeft r reverse wire technique successful (as white asterisk). (14.3%), and 1 patient using a drug-eluting balloon (14.3%), microcatheter-facilitated reverse wire technique, owing to resulting in a procedural success rate of 100%. No cases sharp curve with advantage of being easier to pass the of vascular perforation or dissection, thromboembolism, or proximal stenosis segment and round curve being easier to other remarkable events were noted during the interventions. deliver device through reverse wire. Most cases exhibit significant stenosis proximal to the bifurcation (100% in our study), which often hampers the 4. Discussion delivery of the reverse wire system. Because the sharp The complex pattern of bifurcation coronary anatomies and curved reverse wire system is easier to pass the stenosis as the different pattern of atherosclerotic disease distribution compared to the roundly curved system, a sharp curve was may render targeted vessel wiring highly challenging. There recommended in some study [1]. In our study, even when a are several techniques which have been proposed to over- sharp curve was employed, we could not deliver the reverse come the difficulty of guide wire crossing in markedly angu- wire system beyond the legion of severe stenosis located lated bifurcated lesions [5]. The balloon occlusion technique just proximal to the bifurcation. To overcome this problem, in the target vessel can sometimes allow a much easier before the insertion of a guide wire into the untargeted vessel, introduction of the guide wire to the SB. The venture wire- a suitable size of balloon predilation to modify the plaque control catheter is the only deflectable catheter for guidewire distribution of nontargeted vessel is required, making reverse wire system passes the stenosis proximal easily. delivery in this challenging anatomy [6]. However, severe stenosis with a large plaque burden in the proxima vessel is Also past studies have demonstrated that balloon predi- angiographic predictors of difficult targeted vessel wiring [7]. lation of stenotic lesions before the insertion of a guide The reversed guide wire technique, rfi stly reported by wire into the targeted vessel with a marked angulation may Kawasaki et al.in 2008[3],is currently performedwith some help this phenomenon but carry a risk of causing a plaque modifications. And the main differences from the original or carina shift, resulting in targeted vessel occlusion [8]. technique include the facilitation of a microcatheter and In our study, the targeted vessel was target vessel, and the the different bending point. Microcatheter-facilitated reverse untargeted vessel was branch vessel; the diameter of target wire technique includes two shape curves: the rfi st is a vessel was larger than untargeted vessel. TIMI o fl w of targeted short distal and the second is an opposite proximal. To vessel was not influenced and without any vascular dissection deal with bifurcated lesions with markedly angulated and after having suitable size of balloon dilation. There are two causes which could be attributed to this phenomenon. First, severe proximal stenosis, there remains no consensus about the second shape curve: “sharp” or “round” using crusade the diameter of predilation balloon is of small size, and we Journal of Interventional Cardiology 7 dilated the severely stenotic legion proximal to the bifurca- Data Availability tion with semicompliant balloon for the purposes of lesion The data used to support the findings of this study are modification, not leading to occlusion of targeted vessel, available from the corresponding author upon request. also being able to successfully deliver the system into the untargeted vessel without causing any vascular injury or other remarkable complications. Second, the plaque distribution in Conflicts of Interest target vessel was in opposite direction of untargeted vessel The authors declare that they have no conflicts of interest. (in Figure 3(a)), and the diameter of targeted vessel was large enough to accommodate the modification of plaque aer ft predilation in untargeted vessel. On the contrary, if the References targeted vessel is branch vessel, and the untargeted vessel is main vessel, because of the shift of plaque and relatively small [1] T. Nomura, M. Kikai, Y. Hori et al., “Tips of the dual-lumen microcatheter-facilitated reverse wire technique in percuta- diameter of branch vessel, the predilation in target vessel may neous coronary interventions for markedly angulated bifur- result in the occlusion of branch vessel. We supposed that cated lesions,” Cardiovascular Intervention and eTh rapeutics , it is safe to predilate in branch vessel before target vessel vol. 33, no. 2, pp. 146–153, 2018. wiring. [2] S. Watanabe, N. Saito, B. Bao et al., “Microcatheter-facilitated We did not shape the second curve after the short tip reverse wire technique for side branch wiring in bifurcated curve, and once the wire tip curve directs into the ostium vessels: An in vitro evaluation,” EuroIntervention,vol. 9,no. 7, of the target vessel, with the help of wire tension to restore pp. 870–877, 2013. the original lineshape, wecould deliver thewire down [3] T. Kawasaki, H. Koga, and T. Serikawa, “New bifurcation to the targeted vessel distal segment smoothly and easily. guidewire technique: A reversed guidewire technique for Watanabe et al. [2] demonstrated that compared with the extremely angulated bifurcation - A case report,” Catheteriza- sharp, the round curved guide wire is definitely advantageous tion and Cardiovascular Interventions, vol.71, no. 1,pp. 73–76, for delivery after reverse wiring. But they did not compare the differences between with secondary curve and without [4] A. Medina, J. Suar ´ ez de Lezo, and M. Pan, “A new classification secondary curve in the reverse guide wire. In our study, of coronary bifurcation lesions,” Revista Espano ˜ la de Cardi- the simple one tip curved reverse wire, without secondary olog´ıa,vol.59,no. 2,p.183,2006. shaped curve, kept the tension of restoring the original line [5] F. Burzotta, M. De Vita, G. Sgueglia, D. Todaro, and C. Trani, shape, making it more easy to deliver guide wire to distal “How to solve difficult side branch access?” EuroIntervention, of targeted vessel before the tip of reverse wire engages vol. 6, Supplement 6, pp. J72–J80, 2010. with the ostium of targeted vessel during the wire pullback. [6] S.Ojeda, M.Pan, F.Mazuelos etal.,“Useof the venture This advantage would remain until the bend of reverse wire wire-control catheter for accessing side branches during provi- passes the location of bifurcation. These findings indicate that sional stenting: an option for bifurcations with an unfavorable modification on reverse wire technique is effective and safe in anatomy,” Revista Espano ˜ la de Cardiolog´ıa, vol.63, no.12, pp. overcoming challenging wiring for highly angulated targeted 1487–1491, 2010. vessel with severe proximal stenosis. [7] I. Iakovou, L. Ge, and A. Colombo, “Contemporary stent treat- ment of coronary bifurcations,” Journal of the American College Limitation. This study has some limitations. First, this is of Cardiology,vol.46,no.8,pp.1446–1455,2005. a retrospective observational analysis of a small number [8] P. Mortier, M. De Beule, G. Dubini, Y. Hikichi, Y. Murasato, and of patients without control group. Second, the majority of J. A. Ormiston, “Coronary bifurcation stenting: insights from in procedures were performed by an experienced operator, vitro and virtual bench testing,” EuroIntervention,vol.6,Supple- ment 6, pp. J53–J60, 2010. and the method may not be applicable for less experienced operators. At last, the bifurcation lesions in our study only included LAD and diagonal coronary arteries, LAD and LCX, but not right coronary artery. However, we also used simple short tip one curve to perform PCI easily and successfully in bifurcated lesions with markedly angulated obtuse marginal vessel, and without the help of predilation without proximal stenosis. We speculated that simple short tip one curve of reverse wire also could be extendedly used in other coronary artery bifurcated lesions with markedly angulated target vessel, with or without severe proximal stenosis. 5. Conclusion In solving markedly angulated bifurcated lesions, espe- cially with severe proximal stenosis, crusade microcatheter- facilitated reverse wire technique with simple short tip one curve is an eeff ctive and safe way of wiring. 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The Effective and Safe Way to Use Crusade Microcatheter-Facilitated Reverse Wire Technique to Solve Bifurcated Lesions with Markedly Angulated Target Vessel

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Hindawi Publishing Corporation
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Copyright © 2019 Jingang Cui et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2019/2579526
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Abstract

Hindawi Journal of Interventional Cardiology Volume 2019, Article ID 2579526, 7 pages https://doi.org/10.1155/2019/2579526 Research Article The Effective and Safe Way to Use Crusade Microcatheter-Facilitated Reverse Wire Technique to Solve Bifurcated Lesions with Markedly Angulated Target Vessel Jingang Cui , Xiaowei Jiang , Shubin Qiao, Lijian Gao, Jiansong Yuan, Fenghuan Hu, Weixian Yang, and Runlin Gao Cardiology Department, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China Correspondence should be addressed to Jingang Cui; doctorcjg@163.com Received 15 December 2018; Accepted 4 March 2019; Published 11 April 2019 Academic Editor: Andrea Rubboli Copyright © 2019 Jingang Cui et al. is Th is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. We aim to present a new way to introduce reverse wire in crusade microcatheter-facilitated reverse wire technique to solve markedly angulated bifurcated lesions. Background. Markedly angulated coronary bifurcation lesions are still one of the considerable challenges of treatment with percutaneous coronary intervention especially with severe proximal stenosis. Microcatheter-facilitated reverse wire technique improved the efficacy of crossing a guide wire to such an extremely angulated complex targeted vessel. However, there has been a debate regarding what kind of curve was the best to introduce reverse guide wire in this technique. Methods. We analyzed 7 patients who were admitted to Fuwai Hospital and underwent antegrade wiring which failed. Crusade microcatheter-facilitated reverse wire technique with simple short tip one round curve was used successfully to solve in all 7 bifurcation lesions. We investigated the bifurcation lesion’s characteristics and details of the reverse wire technique procedures. Results. All 7 bifurcations exhibit both a smaller take-off angle and a larger carina angle and severe proximal significant stenosis. Aeft r having suitable size of balloon predilation, reverse wire with simple short distal one curve was delivered to distal segment of targeted vessel successfully. We performed all PCI procedures without any complications and no major adverse cardiac event was observed during hospitalization. Conclusions. In solving markedly angulated bifurcated lesions, especially with severe proximal stenosis, crusade microcatheter-facilitated reverse wire technique with simple short tip one curve is an eeff ctive and safe way of wiring. 1. Introduction tip, and rfi st curve is a short tip one and secondary curve is an opposite longer proximal one. However, especially in Safe guidewire placement in the main vessel (MV) and in markedly angulated bifurcated lesions with tight proximal the side branch (SB) is necessary for successful percutaneous stenosis, there had been different opinions about how to coronary interventions (PCI) in bifurcated lesions. Bifurcated shape the secondary curve: sharply [1] (easier to pass the lesion with small take-off angel is an important predictive proximal stenosis segment) or roundly [2] (easier to delivery factor, and targeted vessel wiring could be particularly diffi- device through reverse wire). cult. We have experienced 7 cases of difficult vessel access The reversed guide wire technique, rfi stly reported by with severe proximal stenosis. The microcatheter-facilitated Kawasaki et al. in 2008, has been improved with utilizing the reverse wire technique without the secondary curve was support of dual lumen catheter and is a very useful guide successful to cross a guide wire to extremely angulated wire manipulation technique to cross a guide wire to such complex targeted vessel. Therefore, the present study aimed an extremely angulated complex targeted vessel. In reverse to discuss what kind of curve in reverse wire is more effective wire technique, two curves are created at the guide wire in markedly angulated bifurcation. 2 Journal of Interventional Cardiology (a) (b) (c) Figure 1: Microcatheter-facilitated reverse wire technique. (a) A short tip curve (as indicated by white arrow) which ts fi the diameter of the untargeted vessel in a retrograde. (b) Solft y folding the guide wire (as indicated by white arrow), in opposite direction of the first curve at about 3 cm away from the wire tip approach. (c) eTh reverse wire system was inserted through the hemostatic valve into guiding catheter (as indicated by white arrow). 2. Materials and Methods 2.2. Preparation of the Reverse Wire System. Acrusade catheter and eld fi er FC (Asahi Intecc) guide wire were used 2.1. Study Design and Patient Population. This is a retro- exclusively for the reverse wire technique in all 7 patients. spective study conducted at Fuwai Hospital. We enrolled 7 In aspect of guide wire shape, our method of wire shape patients in whom conventional antegrade wiring to branch had many differences from past studies [1–3]. The guide wire vessel was easily done, but wiring to target vessel had failed, was introduced into the over-the-wire lumen of the crusade and inwhomareversewiretechnique wasused inan catheter and shaped by a tip curve (0.2-0.5 cm) that tfi the attempt to approach target vessels of bifurcation lesions with diameter of the untargeted vessel and without being followed a small take-off angel. This study was approved by the Ethics byasecondaryshapecurve.Then,abendofguidewireisfixed Committee of Fuwai Hospital. All participants provided their softly with the crusade catheter in the opposite direction of written informed consent to agree with using their clinical thetip curveat 3 cm away from thetip of the guidewire in a information. retrograde approach (Figure 1). Quantitative assessments were performed using the Car- diovascular Measurement System (QAngio XA 7.2, MEDIS), a personal computer-based system, for offline quantitative 2.3. Details of the Procedure (Figure 2). The first guide wire angiographic analysis. The take-off angel indicates the angle was placed in the untargeted vessel. Before the insertion of a between the proximal untargeted vessel and targeted vessel, guide wire into the untargeted vessel with a marked angula- and the carina angle indicates the angel between the distal tion, due to the tight stenosis proximal bifurcation, we usually untargeted vessel and the targeted vessel. inflate a suitable size of balloon catheter to modify the Journal of Interventional Cardiology 3 (a) (b) 3cm (c) (d) (e) Figure 2: Diagrammatic representation of the microcatheter-facilitated reverse wire technique. (a) Due to the tight stenosis proximal bifurcation, we usually inflate a suitable size of balloon catheter to modify the plaque distribution of untargeted vessel and make reverse wire system pass the stenosis proximal easily. (b) A short tip curve was made on guidewire. (c) Solft y folding the guide wire with a smooth round curve and inserting it into the hemostatic valve. (d) After pulling back the reverse system proximal to the bifurcation lesion and some rotations, the reverse wire tip directs into the ostium of the target vessel. (e) Deliver the reverse wire down to the distal segment of target vessel. plaque distribution of untargeted vessel and make reverse ranging from minimum value to maximum value for contin- wire system pass the stenosis proximal easily. uous variables. The first guide wire in the untargeted vessel supports delivery of the crusade catheter alone with the bent wire down 3. Results to the untargeted vessel with the tip of the reversely bent wire We demonstrated the lesion’s characteristics and procedural remaining distal to the carina of the targeted vessel. outcomes and the details of the PCI procedures by analyzing After pulling the crusade microcatheter back to the parent the records and angiography lfi ms of the PCI. vessel, the reversely bent wire was pulled back slowly and manipulated gently so that the wire tip directs into the ostium of the target vessel. Some rotational guide wire is required to 3.1. Baseline Demographics and Bifurcation Lesions Charac- deliver the wire down to the distal segment of target vessel. teristics. As displayed in Table 1, there are 7 cases in which Using the balloon trapping method, the crusade catheter is conventional antegrade wiring failed after being used, and removed. the carina angles of the targeted vessel ranged from 125 to 160 degrees. All patients required the reverse wire technique 2.4. Statistical Analysis. Descriptive analysis was performed. to access target vessel of the bifurcation lesion due to an Results are presented as percentage for categorical variable, acutely angulated carina. Most of the patients were male 6 4 Journal of Interventional Cardiology Table 1: Baseline demographics and bifurcation lesions characteristics. Case Age Untargeted Targeted vessel; Proximal Medina Take-off angle Carina angle Sex number (years) vessel TIMI flow stenosis (%) classification (degrees) (degrees) Male 1 50 D LAD; II 100 1,1,1 30 150 Female 2 57 LCX LAD; III 90 1,1,0 55 125 3 Male 43 D LAD; II 100 1,1,1 45 135 Male 4 66 D LAD; II 100 1,1,1 45 135 Male 5 68 D LAD; III 90 1,1,1 25 155 Male 6 54 D LAD; II 95 1,1,0 50 130 Male 7 80 D LAD; III 90 1,1,0 20 160 D, diagonal branch; LAD, left anterior descending; LCX, left circumflex. (a) (b) (c) (d) Figure 3: LM bifurcations with markedly angulated LAD vessel and severe proximal stenosis. (a) Direction of blood flow was marked with Arabic numerals and white arrow, and the order contrast appeared was LM, LCX, to LAD. (b) The balloon (2.5mm in diameter) predilation in LM-LCX aer ft wring first guide wire in the LCX vessel. (c) The reverse wire tip (as white arrow) directs into the ostium of the LAD vessel. (d) Angiographic image obtained aer ft the PCI. (85.7%), the age range was from 43 to 80 years old, and and 2 cases (28.6%) via the femoral artery. A 6 Fr guiding all of the patients presented with angina 7 (100%). The catheter was used in 5 cases (71.4%), and a 7 Fr guiding bifurcation lesions were located in left anterior descending catheter was used in 2 cases (28.6%). Patients with severe and diagonal coronary arteries 6 (85.7%), or LAD and LCX stenosis (Figure 3) or CTO (Figure 4) of the parent vessel 1 (14.3%). The type of bifurcation according to the Medina required balloon predilatation to allow passage of the crusade classicfi ation [4] was 1,1,1 4 (57.1%) or 1,1,0 3 (42.9%). The catheter alone with the reversely bent wire after the first wire targeted vessel was the LAD in 7 (100%) patients. 3 (42.9%) arrived at distal segment of untargeted vessel. The diameter of lesions were chronic total occlusion lesions and 4 (57.1%) predilation balloon (1.5-2.5mm) used was as small as possible severe stenosis lesions involving the parent vessels proximal under the condition of passage of the reverse system. No cases to the bifurcation lesion. of vascular dissection and occlusion were noted. For the cases with successful wiring, successful revascu- larization was achieved in 5 patients using the single stent 3.2. PCI Procedural Characteristics. As described in Table 2, there were 5 cases (71.4%) approached via the radial artery technique (71.4%), 1 patient using the two stents technique Journal of Interventional Cardiology 5 ft Table 2: PCI procedural characteristics. Cases Guiding Balloon predilation TIMI flow in LAD Procedure Approach Guide wire Microcatheter Stenting strategy number catheter (Fr) (mm∗mm); location aer predilation success 1 Radial 6 Fielder FC Crusade 1.5∗15; LAD-D III Single Yes 2 Femoral 7 Fielder FC Crusade 2.5∗15; LM-LCX III Single Yes 3 Radial 6 Fielder FC Crusade 1.5∗15; LAD-D III Single Yes 4 Femoral 7 Fielder FC Crusade 1.5∗15; LAD-D III Crush Yes 5 Radial 6 Fielder FC Crusade 2.5∗15; LAD-D III Single Yes 6 6 2.0∗15; LAD-D III Single Yes Radial Fielder FC Crusade 7 Radial 6 Fielder FC Crusade 2.0∗15; LAD-D III DEB Yes TIMI, thrombolysis in myocardial infarction; DEB, drug eluting balloon. 6 Journal of Interventional Cardiology (a) (b) (c) (d) Figure 4: LAD bifurcations. (a) Markedly angulated LAD and proximal chronic total occlusion. (b) eTh balloon (1.5mm in diameter) predilation in LAD-D aer ft wring first guide wire in the diagonal vessel. (c) eTh reverse wire tip (as white arrow) direct into the ostium of the LAD vessel. (d) Angiographic image obtained aeft r reverse wire technique successful (as white asterisk). (14.3%), and 1 patient using a drug-eluting balloon (14.3%), microcatheter-facilitated reverse wire technique, owing to resulting in a procedural success rate of 100%. No cases sharp curve with advantage of being easier to pass the of vascular perforation or dissection, thromboembolism, or proximal stenosis segment and round curve being easier to other remarkable events were noted during the interventions. deliver device through reverse wire. Most cases exhibit significant stenosis proximal to the bifurcation (100% in our study), which often hampers the 4. Discussion delivery of the reverse wire system. Because the sharp The complex pattern of bifurcation coronary anatomies and curved reverse wire system is easier to pass the stenosis as the different pattern of atherosclerotic disease distribution compared to the roundly curved system, a sharp curve was may render targeted vessel wiring highly challenging. There recommended in some study [1]. In our study, even when a are several techniques which have been proposed to over- sharp curve was employed, we could not deliver the reverse come the difficulty of guide wire crossing in markedly angu- wire system beyond the legion of severe stenosis located lated bifurcated lesions [5]. The balloon occlusion technique just proximal to the bifurcation. To overcome this problem, in the target vessel can sometimes allow a much easier before the insertion of a guide wire into the untargeted vessel, introduction of the guide wire to the SB. The venture wire- a suitable size of balloon predilation to modify the plaque control catheter is the only deflectable catheter for guidewire distribution of nontargeted vessel is required, making reverse wire system passes the stenosis proximal easily. delivery in this challenging anatomy [6]. However, severe stenosis with a large plaque burden in the proxima vessel is Also past studies have demonstrated that balloon predi- angiographic predictors of difficult targeted vessel wiring [7]. lation of stenotic lesions before the insertion of a guide The reversed guide wire technique, rfi stly reported by wire into the targeted vessel with a marked angulation may Kawasaki et al.in 2008[3],is currently performedwith some help this phenomenon but carry a risk of causing a plaque modifications. And the main differences from the original or carina shift, resulting in targeted vessel occlusion [8]. technique include the facilitation of a microcatheter and In our study, the targeted vessel was target vessel, and the the different bending point. Microcatheter-facilitated reverse untargeted vessel was branch vessel; the diameter of target wire technique includes two shape curves: the rfi st is a vessel was larger than untargeted vessel. TIMI o fl w of targeted short distal and the second is an opposite proximal. To vessel was not influenced and without any vascular dissection deal with bifurcated lesions with markedly angulated and after having suitable size of balloon dilation. There are two causes which could be attributed to this phenomenon. First, severe proximal stenosis, there remains no consensus about the second shape curve: “sharp” or “round” using crusade the diameter of predilation balloon is of small size, and we Journal of Interventional Cardiology 7 dilated the severely stenotic legion proximal to the bifurca- Data Availability tion with semicompliant balloon for the purposes of lesion The data used to support the findings of this study are modification, not leading to occlusion of targeted vessel, available from the corresponding author upon request. also being able to successfully deliver the system into the untargeted vessel without causing any vascular injury or other remarkable complications. Second, the plaque distribution in Conflicts of Interest target vessel was in opposite direction of untargeted vessel The authors declare that they have no conflicts of interest. (in Figure 3(a)), and the diameter of targeted vessel was large enough to accommodate the modification of plaque aer ft predilation in untargeted vessel. On the contrary, if the References targeted vessel is branch vessel, and the untargeted vessel is main vessel, because of the shift of plaque and relatively small [1] T. Nomura, M. Kikai, Y. Hori et al., “Tips of the dual-lumen microcatheter-facilitated reverse wire technique in percuta- diameter of branch vessel, the predilation in target vessel may neous coronary interventions for markedly angulated bifur- result in the occlusion of branch vessel. We supposed that cated lesions,” Cardiovascular Intervention and eTh rapeutics , it is safe to predilate in branch vessel before target vessel vol. 33, no. 2, pp. 146–153, 2018. wiring. [2] S. Watanabe, N. Saito, B. Bao et al., “Microcatheter-facilitated We did not shape the second curve after the short tip reverse wire technique for side branch wiring in bifurcated curve, and once the wire tip curve directs into the ostium vessels: An in vitro evaluation,” EuroIntervention,vol. 9,no. 7, of the target vessel, with the help of wire tension to restore pp. 870–877, 2013. the original lineshape, wecould deliver thewire down [3] T. Kawasaki, H. Koga, and T. Serikawa, “New bifurcation to the targeted vessel distal segment smoothly and easily. guidewire technique: A reversed guidewire technique for Watanabe et al. [2] demonstrated that compared with the extremely angulated bifurcation - A case report,” Catheteriza- sharp, the round curved guide wire is definitely advantageous tion and Cardiovascular Interventions, vol.71, no. 1,pp. 73–76, for delivery after reverse wiring. But they did not compare the differences between with secondary curve and without [4] A. Medina, J. Suar ´ ez de Lezo, and M. Pan, “A new classification secondary curve in the reverse guide wire. In our study, of coronary bifurcation lesions,” Revista Espano ˜ la de Cardi- the simple one tip curved reverse wire, without secondary olog´ıa,vol.59,no. 2,p.183,2006. shaped curve, kept the tension of restoring the original line [5] F. Burzotta, M. De Vita, G. Sgueglia, D. Todaro, and C. Trani, shape, making it more easy to deliver guide wire to distal “How to solve difficult side branch access?” EuroIntervention, of targeted vessel before the tip of reverse wire engages vol. 6, Supplement 6, pp. J72–J80, 2010. with the ostium of targeted vessel during the wire pullback. [6] S.Ojeda, M.Pan, F.Mazuelos etal.,“Useof the venture This advantage would remain until the bend of reverse wire wire-control catheter for accessing side branches during provi- passes the location of bifurcation. These findings indicate that sional stenting: an option for bifurcations with an unfavorable modification on reverse wire technique is effective and safe in anatomy,” Revista Espano ˜ la de Cardiolog´ıa, vol.63, no.12, pp. overcoming challenging wiring for highly angulated targeted 1487–1491, 2010. vessel with severe proximal stenosis. [7] I. Iakovou, L. Ge, and A. Colombo, “Contemporary stent treat- ment of coronary bifurcations,” Journal of the American College Limitation. This study has some limitations. First, this is of Cardiology,vol.46,no.8,pp.1446–1455,2005. a retrospective observational analysis of a small number [8] P. Mortier, M. De Beule, G. Dubini, Y. Hikichi, Y. Murasato, and of patients without control group. Second, the majority of J. A. Ormiston, “Coronary bifurcation stenting: insights from in procedures were performed by an experienced operator, vitro and virtual bench testing,” EuroIntervention,vol.6,Supple- ment 6, pp. J53–J60, 2010. and the method may not be applicable for less experienced operators. At last, the bifurcation lesions in our study only included LAD and diagonal coronary arteries, LAD and LCX, but not right coronary artery. However, we also used simple short tip one curve to perform PCI easily and successfully in bifurcated lesions with markedly angulated obtuse marginal vessel, and without the help of predilation without proximal stenosis. We speculated that simple short tip one curve of reverse wire also could be extendedly used in other coronary artery bifurcated lesions with markedly angulated target vessel, with or without severe proximal stenosis. 5. Conclusion In solving markedly angulated bifurcated lesions, espe- cially with severe proximal stenosis, crusade microcatheter- facilitated reverse wire technique with simple short tip one curve is an eeff ctive and safe way of wiring. 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