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A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion
G Model
JCCASE-1125; No. of Pages 3 Journal of Cardiology Cases xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion Taku Kasahara (MD), Kenichi Sakakura (MD)*, Shin-ichi Momomura (MD), Hideo Fujita (MD FJCC) Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 June 2019 Received in revised form 1 August 2019 Accepted 2 September 2019
A reverse guidewire technique along with double lumen catheter has become a standard technique for extremely angulated bifurcation lesions. A-72-year-old male underwent coronary angiography, which revealed a severe stenosis of the left anterior descending artery with an extremely angulated diagonal branch. We introduced the Crusade (Kaneka, Osaka, Japan) accompanied with the reversed guidewire to the lesion, but the Crusade with the reversed guidewire could not cross the lesion. We kept the Crusade at the just proximal to the stenosis, and advanced the only reversed guidewire to the lesion. The reversed guidewire successfully crossed the lesion, and then we pulled back the reversed guidewire to lead the reversed guidewire’s tip into the diagonal branch retrogradely. In this modified reverse guidewire technique, the Crusade does not need to cross the lesion, but needs to bring the reversed guidewire at the just proximal of the lesion. Because the profile of the reversed guidewire alone is smaller than that of the Crusade accompanied with the reversed guidewire, the reversed guidewire alone has greater chance to cross the severe stenosis. Our modification may increase the success rate of the reverse guidewire technique, and expand the indication of this technique. © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Keywords: Reverse guidewire technique Double lumen catheter Bifurcation Percutaneous coronary intervention
Introduction A reverse guidewire technique, which was originally reported by Kawasaki et al. in 2008 [1], has become a standard technique for extremely angulated bifurcation lesions. Because it is difficult to advance the reversed guidewire beyond the target lesion, double lumen catheters such as Crusade (Kaneka, Osaka, Japan) are frequently used [2,3]. However, if there is a severe stenosis just proximal of the bifurcation lesion, it may be difficult to cross the double lumen catheter accompanied with a reversed guidewire beyond the bifurcation lesion, because the profile of the double lumen catheter accompanied with a reversed guidewire is
* Corresponding author at: Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama, 330-8503 Japan. E-mail address: [email protected] (K. Sakakura).
much larger than the double lumen catheter or the reversed guidewire alone. In this case report, we show the novel modification of the reverse guidewire technique for the lesion which the double lumen catheter accompanied with a reversed guidewire could not cross. Case report A-72-year-old male who suffered from effort angina underwent coronary angiography, which revealed a severe stenosis of the proximal segment of the left anterior descending artery with an extremely angulated diagonal branch (Fig. 1A,B). We performed an elective percutaneous coronary intervention to the bifurcation lesion. A 7Fr Mach 1 CLS 3.5SH guiding catheter (Boston Scientific, Natick, MA, USA) was inserted via the left radial artery. A conventional guidewire (Sion blue, Asahi Intech, Nagoya, Japan) was advanced beyond the lesion. Because the diagonal
https://doi.org/10.1016/j.jccase.2019.09.005 1878-5409/© 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kasahara T, et al. A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion. J Cardiol Cases (2019), https://doi.org/10.1016/j.jccase.2019.09.005
G Model
JCCASE-1125; No. of Pages 3 T. Kasahara et al. / Journal of Cardiology Cases xxx (2019) xxx–xxx
2
Fig. 1.
(A,B) Severe stenosis with extremely angulated diagonal branches. (C,D) The Crusade accompanied with the reversed guidewire could not cross the lesion. The guide catheter was pushed back (arrow). (E–H) The only reversed guidewire crossed the lesion. (I,J) The reversed guidewire advanced into the diagonal branch retrogradely. (K) Stenting with jailed guidewires. (J) The final result.
branch was extremely angulated, we planned the reverse guidewire technique with the Crusade. Before the reverse guidewire technique, we advanced the Crusade without a reversed guidewire beyond the lesion as a bougie to the lesion. Then, we introduced the Crusade accompanied with the reversed guidewire (Sion black, Asahi Intech) to the lesion, but the crusade with the reversed guidewire could not cross the lesion because of the strong resistance (Fig. 1C,D). We kept the Crusade at just proximal to the stenosis, and advanced the only reversed guidewire to pass the stenotic lesion in the left descending artery (Fig. 1E–H). The reversed guidewire successfully crossed the lesion, and then we pulled back the reversed guidewire to lead the reversed guidewire’s tip into the diagonal branch retrogradely (Fig. 1I,J). After we protected two diagonal branches, we deployed a 2.5 28 mm everolimus-eluting stent (Synergy, Boston Scientific) to the lesion (Fig. 1K), and obtained a favorable result (Fig. 1L). Discussion In this modified reverse guidewire technique, the double lumen catheter does not need to cross the lesion, but needs to bring the reversed guidewire to just proximal of the lesion. Because the profile of the reversed guidewire alone is smaller than that of the double lumen catheter accompanied with the reversed guidewire, the reversed guidewire alone has greater chance to cross the severe stenosis. Our modification may increase the success rate of the reverse guidewire technique, and expand the indication of this technique. We should mention the risk of this modified reverse guidewire technique. If we advance the reversed guidewire alone to the severe stenosis, the reversed guidewire may make an injury to the lesion. Therefore, it would be important to advance the double
lumen catheter alone beyond the lesion as a bougie to the lesion, before advancing the reversed guidewire alone. After a bougie by the double lumen catheter, the risk of injury by the reversed guidewire would be minimized. If the double lumen catheter alone could not cross the lesion, we should perform small balloon dilation rather than the modified reverse guidewire technique. Moreover, if the double lumen catheter alone could not cross due to the severely calcified stenosis, rotational atherectomy should be considered rather than the small balloon dilatation, because of the lower risk of plaque shift in rotational atherectomy. If we perform small balloon dilatation before the reverse guidewire technique, the double lumen catheter accompanied with the reversed guidewire might cross the lesion, which allows us to perform the conventional reverse guidewire technique. However, if we perform small balloon dilatation before acquiring the side branch, there would be a risk of plaque shift, which may obstruct the side branch. Therefore, it is a dilemma whether we should try balloon dilatation before acquiring the side branch. Our modified reverse guidewire technique can provide an option before performing balloon dilatation in such a difficult situation, although feasibility and safety of this technique should be confirmed in future studies.
Disclosures Dr Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline, Kaneka, and NIPRO; he has served as a proctor for Rotablator for Boston Scientific; and he has served as a consultant for Abbott Vascular and Boston Scientific. Prof. Fujita has served as a consultant for Mehergen Group Holdings, Inc. Other authors declare no conflict of interest.
Please cite this article in press as: Kasahara T, et al. A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion. J Cardiol Cases (2019), https://doi.org/10.1016/j.jccase.2019.09.005
G Model
JCCASE-1125; No. of Pages 3 T. Kasahara et al. / Journal of Cardiology Cases xxx (2019) xxx–xxx
Acknowledgments The authors acknowledge all staff in the catheter laboratory in Saitama Medical Center, Jichi Medical University for their technical support in this study.
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[2] Nomura T, Kikai M, Hori Y, Yoshioka K, Kubota H, Miyawaki D, et al. Tips of the dual-lumen microcatheter-facilitated reverse wire technique in percutaneous coronary interventions for markedly angulated bifurcated lesions. Cardiovasc Interv Ther 2018;33:146–53. [3] Lee HF, Chou SH, Tung YC, Lin CP, Ko YS, Chang CJ. Crusade microcatheterfacilitated reverse wire technique for revascularization of bifurcation lesions of coronary arteries. Acta Cardiol Sin 2018;34:31–6.
References [1] Kawasaki T, Koga H, Serikawa T. New bifurcation guidewire technique: a reversed guidewire technique for extremely angulated bifurcation—a case report. Catheter Cardiovasc Interv 2008;71:73–6.
Please cite this article in press as: Kasahara T, et al. A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion. J Cardiol Cases (2019), https://doi.org/10.1016/j.jccase.2019.09.005
JCCASE-1125; No. of Pages 3 Journal of Cardiology Cases xxx (2019) xxx–xxx
Contents lists available at ScienceDirect
Journal of Cardiology Cases journal homepage: www.elsevier.com/locate/jccase
Case Report
A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion Taku Kasahara (MD), Kenichi Sakakura (MD)*, Shin-ichi Momomura (MD), Hideo Fujita (MD FJCC) Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama City, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 June 2019 Received in revised form 1 August 2019 Accepted 2 September 2019
A reverse guidewire technique along with double lumen catheter has become a standard technique for extremely angulated bifurcation lesions. A-72-year-old male underwent coronary angiography, which revealed a severe stenosis of the left anterior descending artery with an extremely angulated diagonal branch. We introduced the Crusade (Kaneka, Osaka, Japan) accompanied with the reversed guidewire to the lesion, but the Crusade with the reversed guidewire could not cross the lesion. We kept the Crusade at the just proximal to the stenosis, and advanced the only reversed guidewire to the lesion. The reversed guidewire successfully crossed the lesion, and then we pulled back the reversed guidewire to lead the reversed guidewire’s tip into the diagonal branch retrogradely. In this modified reverse guidewire technique, the Crusade does not need to cross the lesion, but needs to bring the reversed guidewire at the just proximal of the lesion. Because the profile of the reversed guidewire alone is smaller than that of the Crusade accompanied with the reversed guidewire, the reversed guidewire alone has greater chance to cross the severe stenosis. Our modification may increase the success rate of the reverse guidewire technique, and expand the indication of this technique.
Keywords: Reverse guidewire technique Double lumen catheter Bifurcation Percutaneous coronary intervention
Introduction A reverse guidewire technique, which was originally reported by Kawasaki et al. in 2008 [1], has become a standard technique for extremely angulated bifurcation lesions. Because it is difficult to advance the reversed guidewire beyond the target lesion, double lumen catheters such as Crusade (Kaneka, Osaka, Japan) are frequently used [2,3]. However, if there is a severe stenosis just proximal of the bifurcation lesion, it may be difficult to cross the double lumen catheter accompanied with a reversed guidewire beyond the bifurcation lesion, because the profile of the double lumen catheter accompanied with a reversed guidewire is
* Corresponding author at: Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma, Omiya, Saitama, 330-8503 Japan. E-mail address: [email protected] (K. Sakakura).
much larger than the double lumen catheter or the reversed guidewire alone. In this case report, we show the novel modification of the reverse guidewire technique for the lesion which the double lumen catheter accompanied with a reversed guidewire could not cross. Case report A-72-year-old male who suffered from effort angina underwent coronary angiography, which revealed a severe stenosis of the proximal segment of the left anterior descending artery with an extremely angulated diagonal branch (Fig. 1A,B). We performed an elective percutaneous coronary intervention to the bifurcation lesion. A 7Fr Mach 1 CLS 3.5SH guiding catheter (Boston Scientific, Natick, MA, USA) was inserted via the left radial artery. A conventional guidewire (Sion blue, Asahi Intech, Nagoya, Japan) was advanced beyond the lesion. Because the diagonal
https://doi.org/10.1016/j.jccase.2019.09.005 1878-5409/© 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kasahara T, et al. A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion. J Cardiol Cases (2019), https://doi.org/10.1016/j.jccase.2019.09.005
G Model
JCCASE-1125; No. of Pages 3 T. Kasahara et al. / Journal of Cardiology Cases xxx (2019) xxx–xxx
2
Fig. 1.
(A,B) Severe stenosis with extremely angulated diagonal branches. (C,D) The Crusade accompanied with the reversed guidewire could not cross the lesion. The guide catheter was pushed back (arrow). (E–H) The only reversed guidewire crossed the lesion. (I,J) The reversed guidewire advanced into the diagonal branch retrogradely. (K) Stenting with jailed guidewires. (J) The final result.
branch was extremely angulated, we planned the reverse guidewire technique with the Crusade. Before the reverse guidewire technique, we advanced the Crusade without a reversed guidewire beyond the lesion as a bougie to the lesion. Then, we introduced the Crusade accompanied with the reversed guidewire (Sion black, Asahi Intech) to the lesion, but the crusade with the reversed guidewire could not cross the lesion because of the strong resistance (Fig. 1C,D). We kept the Crusade at just proximal to the stenosis, and advanced the only reversed guidewire to pass the stenotic lesion in the left descending artery (Fig. 1E–H). The reversed guidewire successfully crossed the lesion, and then we pulled back the reversed guidewire to lead the reversed guidewire’s tip into the diagonal branch retrogradely (Fig. 1I,J). After we protected two diagonal branches, we deployed a 2.5 28 mm everolimus-eluting stent (Synergy, Boston Scientific) to the lesion (Fig. 1K), and obtained a favorable result (Fig. 1L). Discussion In this modified reverse guidewire technique, the double lumen catheter does not need to cross the lesion, but needs to bring the reversed guidewire to just proximal of the lesion. Because the profile of the reversed guidewire alone is smaller than that of the double lumen catheter accompanied with the reversed guidewire, the reversed guidewire alone has greater chance to cross the severe stenosis. Our modification may increase the success rate of the reverse guidewire technique, and expand the indication of this technique. We should mention the risk of this modified reverse guidewire technique. If we advance the reversed guidewire alone to the severe stenosis, the reversed guidewire may make an injury to the lesion. Therefore, it would be important to advance the double
lumen catheter alone beyond the lesion as a bougie to the lesion, before advancing the reversed guidewire alone. After a bougie by the double lumen catheter, the risk of injury by the reversed guidewire would be minimized. If the double lumen catheter alone could not cross the lesion, we should perform small balloon dilation rather than the modified reverse guidewire technique. Moreover, if the double lumen catheter alone could not cross due to the severely calcified stenosis, rotational atherectomy should be considered rather than the small balloon dilatation, because of the lower risk of plaque shift in rotational atherectomy. If we perform small balloon dilatation before the reverse guidewire technique, the double lumen catheter accompanied with the reversed guidewire might cross the lesion, which allows us to perform the conventional reverse guidewire technique. However, if we perform small balloon dilatation before acquiring the side branch, there would be a risk of plaque shift, which may obstruct the side branch. Therefore, it is a dilemma whether we should try balloon dilatation before acquiring the side branch. Our modified reverse guidewire technique can provide an option before performing balloon dilatation in such a difficult situation, although feasibility and safety of this technique should be confirmed in future studies.
Disclosures Dr Sakakura has received speaking honoraria from Abbott Vascular, Boston Scientific, Medtronic Cardiovascular, Terumo, OrbusNeich, Japan Lifeline, Kaneka, and NIPRO; he has served as a proctor for Rotablator for Boston Scientific; and he has served as a consultant for Abbott Vascular and Boston Scientific. Prof. Fujita has served as a consultant for Mehergen Group Holdings, Inc. Other authors declare no conflict of interest.
Please cite this article in press as: Kasahara T, et al. A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion. J Cardiol Cases (2019), https://doi.org/10.1016/j.jccase.2019.09.005
G Model
JCCASE-1125; No. of Pages 3 T. Kasahara et al. / Journal of Cardiology Cases xxx (2019) xxx–xxx
Acknowledgments The authors acknowledge all staff in the catheter laboratory in Saitama Medical Center, Jichi Medical University for their technical support in this study.
3
[2] Nomura T, Kikai M, Hori Y, Yoshioka K, Kubota H, Miyawaki D, et al. Tips of the dual-lumen microcatheter-facilitated reverse wire technique in percutaneous coronary interventions for markedly angulated bifurcated lesions. Cardiovasc Interv Ther 2018;33:146–53. [3] Lee HF, Chou SH, Tung YC, Lin CP, Ko YS, Chang CJ. Crusade microcatheterfacilitated reverse wire technique for revascularization of bifurcation lesions of coronary arteries. Acta Cardiol Sin 2018;34:31–6.
References [1] Kawasaki T, Koga H, Serikawa T. New bifurcation guidewire technique: a reversed guidewire technique for extremely angulated bifurcation—a case report. Catheter Cardiovasc Interv 2008;71:73–6.
Please cite this article in press as: Kasahara T, et al. A modified reverse guidewire technique for a Crusade-uncrossable bifurcation lesion. J Cardiol Cases (2019), https://doi.org/10.1016/j.jccase.2019.09.005