How to Wire a Complex Coronary Trifurcation: A Novel Guidewire Contrast Surfing Technique

Case Report

A 61-year-old male presented with severe typical angina pectoris at rest. Prior to admission, the patient had been experiencing new onset angina of effort. Past history included hypertension and remote tobacco use. His vital signs revealed a blood pressure of 140/85 mmHg, heart rate of 77 beats per minute, and respiratory rate of 16 breaths per minute. Physical exam was unremarkable. The patient’s electrocardiogram demonstrated normal sinus rhythm, left axis deviation, nonspecific intraventricular conduction delay, and nonspecific ST changes. Initial troponin level was elevated at 2.42 ng/mL and peaked at 5.33 ng/mL (normal 0.00-0.02 ng/mL). The complete blood count and basic metabolic panel were within normal limits. Echocardiography showed preserved left ventricular systolic function with ejection fraction 65%, and mild anterior and lateral hypokinesis. The patient was treated with aspirin, nitrate, intravenous heparin, beta blocker and statin, and early invasive strategy for non ST-elevation myocardial infarction was instituted. 

Angiography revealed the left anterior descending artery (LAD) had a 95% proximal tubular stenosis extending across a complex, early bifurcating first diagonal branch (D1) with 99% stenosis and TIMI-2 angiographic flow in the distal LAD. A severe bend was present in the LAD of nearly 180 degrees at the D1 take-off, which was bifurcating at its ostium, with plaque involving the trifurcation (Figure 1A). The D1 had a 95% ostial and proximal stenosis, and its inferior branch had an ostial 70-80% stenosis. No significant coronary disease was found elsewhere.

An Extra Backup (EBU) 4.0 6 French (Fr) guiding catheter (Medtronic) was used for percutaneous intervention (PCI). A Balanced Middleweight guidewire (BMW) (Abbott Vascular) could not be negotiated into the distal LAD and would end up in the diagonal branches, due to the very unfavorable bend in the LAD at this location (Figure 1B). Different tip curves of the BMW, Prowater (Asahi Intecc), and Whisper (Abbott Vascular) guidewires were tried. A single guidewire versus 2 or 3 guidewires in different combinations, with their tips into one or both diagonal branches, were tried unsuccessfully (Figure 1C).

At this point, all guidewires were removed, and a Whisper guidewire was reintroduced and placed just proximally to the severe LAD bend, past the diagonals’ take-off as in Figure 1C (except that there was no wire in the D1). The Whisper guidewire tip was directed towards the distal LAD, and a high rate and pressure (6cc/second, 900 psi) contrast injection was done with an automatic injector device (ACIST), with the introducer needle in the Tuohy Borst adapter, allowing the wire to move freely. The Whisper wire was taken by the contrast stream into the distal LAD, ending up in a septal branch distally to the stenosis (Figure 1D), from where it was renegotiated into the apical LAD in a classical fashion. In fact, the wire “surfed” the contrast wave without the operator pushing it. The rest of the case was uneventful, consisting of balloon pre-dilation of the LAD, stenting of the main vessel with a drug-eluting 3.0 mm x 23 mm stent, and balloon angioplasty of the side branch with a good result (Figure 1E). The patient was discharged home after two days, following an uncomplicated hospitalization, and remained angina free.

Discussion

Unfavorable coronary anatomy, especially involving bifurcations, can preclude guidewire passage even when there is flow distal to the stenosis.¹ There are various approaches to deal with the difficulty of placing a guidewire, including shaping of the wire tip, use of intracoronary probing or tracking catheters (including tip bend catheters), application of stiffer or hydrophilic polymer coating guidewires, use of a balloon catheter near the wire tip, the double wiring technique, distal placement of perfusion balloon and use of multiple .014-inch coronary guidewires.^2-7 Additionally, an undersized, uninflated, and distally placed balloon catheter can be used for reverse wire technique.^1,8,9

In our case, complicating factors were the severe stenosis proximal to the trifurcation and the problematic bend in the LAD, as well as the patient’s acute clinical presentation. Guidewire crossing of the proximal part of the lesion was causing angina and ST elevations. An injection of 10 cc total contrast dye was used each time (this corresponds to approximately 2 seconds per injection). Due to the short surfing time, no prolonged injections were involved. Therefore, no acute ischemic evidence was noted during the surfing. The presence of flow in the distal LAD enabled the “contrast surfing” technique, which appears relatively safe despite the loss of the operator’s finger control of the guidewire. The ACIST automated contrast injector device provided versatility in balancing the risk of high pressure, high rate, and high volume of contrast injection (dissection) versus the benefit of generating a “perfect wave” that would take the hydrophilic guidewire delicately across the bend to the distal vessel. This technique is not advised for routine use. We recommend this approach only with significant wiring problems.

References 

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6. Stankovic G, Lefevre T, Chieffo A, et al. Consensus from the 7th European Bifurcation Club meeting. EuroIntervention. 2013 May 20; 9(1): 36-45. doi: 10.4244/EIJV9I1A7.
7. Burzotta F, De Vita M, Sgueglia G, et al. How to solve difficult side branch access? EuroIntervention. 2010 Dec; 6 Suppl J: J72-J80. doi: 10.4244/EIJV6SUPJA12.
8. Lee AY, Huang CL, Chang MC, Chen TJ. Successful use of a balloon catheter to facilitate guidewire placement in an occluded coronary artery with extreme angulations. Exp Clin Cardiol. 2010 Spring; 15(1): e16-e17.
9. He X, Gao B, Liu Y, et al. Side-branch technique for difficult guidewire placement in coronary bifurcation lesion. Cardiovasc Revasc Med. 2016 Jan-Feb; 17(1): 59-62. doi: 10.1016/j.carrev.2015.03.005.

¹Professor of Medicine, Sanford Cardiovascular Institute, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota; ²Medical Student, Poznan University of Medical Sciences, Poland; ³Cardiovascular Disease Fellow, Sanford Heart Hospital, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota

Disclosure: The authors report no conflicts of interest regarding the content herein. 

The authors can be contacted via Maheedhar Gedela, MD, at maheedhar.gedela@sanfordhealth.org.