Complex Case

Effective Use of the Balloon-Deflection Technique for Severely Angulated Bifurcation Lesions: A Case Report

Hiroaki Kohno, MD*, Shozo Sueda, MD*, Shigeru Nakamura, MD, PhD§
Hiroaki Kohno, MD*, Shozo Sueda, MD*, Shigeru Nakamura, MD, PhD§

ABSTRACT: We successfully treated a patient with a severely angulated bifurcation lesion using the balloon deflection technique. For this technique, we advanced a coronary guidewire across a severely angulated bifurcation lesion by deflecting the guidewire off of the proximal portion of a coronary balloon that was advanced into a small, adjacent septal vessel. Excluding the coronary angioplasty balloon, no additional devices or specialized wires were needed to perform this maneuver. Using specialized coronary guidewires and/or creating a special curve at the tip of the coronary guidewire was not necessary. This technique is therefore available to all interventional cardiologists. In summary, the balloon deflection technique can be a useful method in order to advance a coronary guidewire across a highly angulated bifurcation lesion.

J INVASIVE CARDIOL 2010;22:E141–E143

Key words: ventricular assist device, thrombus, coronary intervention
Severely angulated bifurcation lesions can be a challenge to cross with conventional coronary guidewires, thus leading to procedural failures and a higher risk of complications.1,2 We present the case of a patient with a highly angulated bifurcation lesion that was successfully treated using a balloon-deflection technique. Case Report. A 70-year-old male with chronic atrial fibrillation and hypertension was admitted with a cerebral infarction in 1998. During hospitalization, he suffered an acute myocardial infarction and percutaneous coronary intervention (PCI) of the proximal left anterior descending (LAD) artery was performed with a 2.5 x 18 mm bare-metal stent placement (AVE GFX, Medtronic, Inc. Minneapolis, Minnesota). The patient was asymptomatic, but surveillance coronary angiography 7 months after the initial procedure showed in-stent restenosis. Because a guidewire could not be passed across the mid LAD, we dilated the proximal LAD with a 2.5 x 20 mm Taraga balloon (St Jude Medical, Inc. St Paul, Minnesota). Given the presence of extensive right-to-left collaterals, medical therapy was recommended. The patient was subsequently admitted to the hospital for elective treatment of an abdominal aortic aneurysm. Repeat coronary angiography (Figure 1) showed severe stenosis of the mid LAD. Viability was seen within the anterior wall on thallium-201 single-photon emission computed tomography, and therefore a repeat attempt at PCI was pursued. A severe lesion at a highly angulated segment of the LAD was present (Figure 1). Multiple guidewires (Suoh, Asahi Intecc, Seto, Aichi, Japan; Runthrough NS, Terumo Co., Tokyo, Japan; Fielder FC, Asahi Intecc) were used to cross the area of stenosis without success. With engagement of each of these wires into the lesion, there was prolapse of the wire into the adjacent septal branch (Figure 2A). The procedure was thus aborted. Three months following the procedure, the patient electively returned to the cardiac catheterization laboratory for a repeat attempt at PCI. Using a 7 French (Fr) XB 3.5 Guide catheter with side holes (Cordis Corp., Miami Lakes, Florida) the left main ostium was engaged. In an attempt to prevent guidewire prolapse, a 2.5 x 15 mm Firestar balloon (Cordis) was advanced over a Suoh guidewire into the proximal portion of the adjacent septal branch. A second guidewire, an X-treme (Asahi Intecc), was advanced proximal to the lesion within a Finecross MG microcatheter (Terumo). After inflation of the balloon within the ostium of the adjacent septal branch, the X-treme guidewire was advanced. The guidewire contacted the proximal portion of the inflated balloon and was deflected into the vessel lumen distal to the stenosis (Figure 2B). The guidewire was then easily advanced into the distal LAD (Figure 3A). The lesion was predilated and a 3.0 x 23 mm Cypher stent (Cordis) was placed. Kissing-balloon angioplasty was performed using a 2.5 mm balloon in the septal branch. Final angiography showed good dilatation of the mid LAD and at the ostium of the adjacent septal branch (Figure 3B). Discussion There are several methods and devices that can be used to manipulate coronary guidewires across angulated bifurcation lesions. These include the deflectable-tip guidewire3,4 called Steer-It (Cordis)5 and the Venture catheter (St Jude Medical).6 However, these devices are costly and are not widely available. A reverse guidewire technique for extremely angulated lesions has been reported.7 This involves placing a hairpin bend on a hydrophilic-coated guidewire approximately 5 cm distal to the guidewire tip. When the guidewire tip engages the orifice of the angulated side branch, it can be advanced into the branch by pulling back the guidewire. This technique, however, can result in vessel dissection and wire entrapment from the hairpin bend that is placed on the wire. In the current case, we were able to cross the angulated segment using a balloon-deflection technique. With this technique, specific devices and manipulations are not required. The technique is simple and can be performed relatively easily by interventional cardiologists. In summary, the balloon-deflection technique is a simple and useful method to advance guidewires across extremely angulated lesions.

Editorial Comment

This complex case illustrates an innovative technique of wire deflection for angulated lesions near a sidebranch. Clearly, hydrophilic wires should be tried for this purpose and extreme care should be exercised not to advance the wire subintimally. Frequent contrast puffs should be done to see the wire advancement. If available, the Venture wire control catheter (St. Jude Medical, Minnetonka, Minnesota) still remains the easy device to use for these angulated lesions with very high procedural success rates. — Samin K. Sharma, MD
References
1. Wilensky RL, Selzer F, Johnston J, et al. Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry). Am J Cardiol 2002;90:216–221. 2. Ellis SG, Topol EJ. Results of percutaneous transluminal coronary angioplasty of high-risk angulated stenoses. Am J Cardiol 1990;66:932–937. 3. Myler RK, Tobis JM, Cumberland DC, Hidalgo B. A new flexible and deflectable tip guidewire for coronary angioplasty and other invasive and interventional procedures. J Invasive Cardiol 1992;4:393–397. 4. Tishler S, Popma J, Schwartz L. Coronary angioplasty of a posterolateral branch with severe proximal vessel tortuosity. Cathet Cardiovasc Diagn 1997;41:426–429. 5. Barlis P, Tanigawa J, Di Mario C. Successful crossing of an angulated lesion using a new deflectable-tip guidewire (Steer-IT). J Invasive Cardiol 2007;19:E154–E155. 6. McClure SJ, Wahr DW, Webb JG. Venture wire control catheter. Catheter Cardiovasc Interv 2005;66:346–350. 7. 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;71:73–76.

________________________________________________________________________ From the 1Department of Cardiology, Ehime Prefectural Niihama Hospital, Niihama, Ehime, Japan, and 2the Cardiovascular Center, Kyoto Katsura Hospital, Kyoto, Japan. The authors report no conflicts of interest regarding the content herein. Manuscript submitted October 20, 2009, provisional acceptance given November 25, 2009, final version accepted December 16, 2009. Address for correspondence: Hiroaki Kohno, MD, Department of Cardiology, Ehime Prefectural Niihama Hospital, 3-1-1 Hongo, Niihama, Ehime 792-0042, Japan. E-mail: hkohno0925@yahoo.co.jp