Author + information
Patient initials or identifier number
69 years old male, Mr. Yang
Relevant clinical history and physical exam
A 69 years-old male, history of hypertension, dyslipidemia under medical control.
He diagnosed with coronary artery disease with triple vessel disease since 2014, in which the right coronary artery was total occlusion and underwent successful coronary intervention. The proximal circumflex fixed on the same time.
He presented to our hospital under the impression of unstable angina.
Physical examination showed alert consciousness, no S3
Relevant test results prior to catheterization
Echocardiogram showed preserved left ventricle function and mild mitral regurgitation.
No stress done under the impression of unstable angina and marked dyspnea at Fc III to IV activity.
Relevant catheterization findings
Coronary angioram showed left main distal critical stenosis, and left circumflex critical stenosis. There's some plaque over LAD proximal portion. The angulation was big between left main and left circumflex artery.
Initially, we tried transradial approach, and pass a floopy wire to left anterior descending artery to protect it. Then we tried to pass another wire to left circumflex. However, the angulation between left main and left circumflex made it not easy. Later we consider reverse wire technique to pass wire to left circumflex. Initially, the Crusade catheter also cannot pass left main distal lesion, later we do 2.0 balloon dilatation, to facilitate passage of Crusade catheter, but only at very low pressure to avoid jail of left circumflex artery. The reverse wire pass to left circumflex smoothly. At that time, we think promising to succeed procedure. However, we use Crusade catheter in a 6F guide. And we failed to remove the Crusade micro catheter even using Nando technique or extension wire. Later, we shift to femoral approach and then use 7F guide, trying pass wire to Lcx by reverse wire technique. But due to looping wire character of reverse wire, the plaque in left anterior descending artery were damaged, leading to decreased flow to LAD. Chest pain, cold sweating developed. We stenting left main to left anterior descending without hesitate. The vital signs stabilized after stenting from left main to left anterior descending artery. But, is it possible to do reverse wire on a stent? After serial attempt, we successfully pass a floopy wire to Lcx and do TAP technique in left main bifurcation with final TIMI III flow.
For angulated bifurcation, reverse wire technique was a feasible choice, however, if there's plaque after target bifurcation, we should be very cautious due to loop character of reverse wire, which may damage the plaque and lead to decreased flow causing catastrophic effect. We had better use 7F guide to reverse wire technique due to bigger profile of Crusade double lumen catheter as compared with finecross microcatheter.