Simplified Reverse Wire Technique using Angulated Microcatheter

History

Mr LF, an 87 years old gentleman, was admitted for an episode of acute coronary syndrome presenting with chest pain followed by brief syncope. His previous history was remarkable for hypertension, diabetes mellitus as well as 50 pack years of smoking on medical therapy.

Serial ECGs revealed dynamic T wave inversion over anterior leads while urgent echocardiogram showed satisfactory LV systolic function.

Coronary Angiogram

In view of his risk factors as well as high risk ECG features, in patient coronary angiogram was arranged. Coronary angiogram showed focal significant lesions over distal Right Coronary Artery and middle part of Left Circumflex Artery (Movie 1, Movie 2, Movie 3). Left anterior oblique view demonstrated a filling defect which was suspicious of a flap at distal Left Main Trunk (Movie 4).

Attempts were made with a workhorse wire into the LCx but unfortunately were successful after several minutes of trial. In view of failed efforts to wire the LCx artery, the suspicion of a LM flap grew even further. Instead, the LAD was wired for protection as well as to provide a way to peek into LCx with Abbott OCT (Movie 5). The OCT study demonstrated a retroflex opening of ostial left circumflex which is more obvious on the longitudinal view. In view of the clinical presentation, biochemical and ECG findings, we believe it was a dissection flap partially covering the ostium of LCx.

Reverse Wire Technique

In order to negotiate a wire through the 270 degrees angle created by LM flap and down the LCx, reverse wire technique was considered. This technique was originally described by Dr. Kawasaki (Figure 1) but nowadays this can be achieved by use of specialized microcatheters with angled tips.

Simplified Reverse Wire Technique using Angulated Microcatheter

In this case of unusual anatomy, we tried performing a reverse wire technique using an angulated microcatheter e.g. Supercross 120 (Figure 2).

We named it as “simplified reverse wire technique using angulated microcatheter” (Figure 2, Figure 3). Apart from using this angulated microcatheter, we need to make a double curve at the wire tip. The primary curved was created over distal 2-3 mm at 30-70 degree. This curve is used for side branch ostium negotiation. The second curve was made at 4-6 mm from distal tip. The diameter of this curve should be less than the diameter of vessel. This second curve was for side branch negotiation after passing through the main branch ostium (Figure 2).

Procedure

First, we put the appropriately curved wire and angulated microcatheter in main branch distal to the side branch. Then, advancing the reverse wire from distal to proximal direction of the vessel to engage the LCx ostium and proximal portion. Afterwards, the microcatheter was pulled back gently and then the wire was also withdrawn slowly until the wire jumped deeper into the LCx. Further advancement could now be done by the usual wiring technique (Figure 3, Figure 4) (Movie 6, Movie 7, Movie 8).

In this procedure, the wire chosen in this case was Asahi Fielder XT-R. After putting the wire into LCx, the procedure was completed by OCT guided DK Crush technique for LM-LAD-LCx bifurcation. Final OCT showed well opposed stents with wide opening of LCx ostium (Figure 5). Final angiographic result was excellent (Movie 9).

Conclusion

Reverse wire technique with angulated microcatheter is feasible and simpler then conventional double lumen catheter guided reverse wire technique.