Bağcılar Education and Research Hospital
In a 55-year-old woman with CCS class IV angina despite optimal medical therapy, an instent critical restenosis (distal stent segment and 5 mm beyond the distal edge) just before a diseased trification in the left circumflex (Video 1). Although it seems easy to wire, antegrade wiring attempts were unsuccessful after 20 minutes of efforts with some wires and different curves and after balloon dilatation (Video 2). We had then realized that main branch is ostially highly angulated (see line, ( Figure 1) and tortuous which has been masked by superposition of two branches. To the extent possible, reversed guidewire technique was regarded as most suitable wiring method. However, a standard hairpin would have been too long both to advance first landing branch (branch in the middle of trification), which is tortuous and tapering shortly after target vessel ostium. We would also need to manipulate the wire after a possible wire advancement into the ostium of target vessel because of sequential complex lesion with another tortuosity. As a result, we applied a short hairpin to a polymer-jacketed guidewire (PT-2, Boston Scientific) approximately 1.5-2 cm hairpin and 3 mm distal curve ( Figure 2) . Without a microcatheter we achieved to advance the wire first into landing branch and then pulled back to redirect its tip into ostium of target vessel. Because of short hairpin, torquing and redirecting attempts were quite easy. After predilatation (Video 3 / Video 4), we delivered a 3.0×18 mm drug-eluting stent (Xience, Abbott) as deeply as possible ( Figure 3) and postdilated (together with previous stent) with a 3.5 NC balloon. Final angiogram was satisfactory (Video 5). The patient has 3 months of symptom-free follow-up.
Reversed guidewire technique is also called “hairpin technique”. A polymer-jacketed guidewire is bent approximately 3-5 cm from the wire tip and the knuckle is advanced through the introducer into the coronary artery. Upon withdrawal the guidewire tip enters into the angulated side branch. Reverse wire technique is used in case of highly angulated side branches to advance a guidewire through the vessel. First modification is called Advanced Reversed Guidewire Technique in which wire in 3-5 mm distal tip is only different, instead of one point of a single curve, a 30-45o smoother curve with three to four mild bending points is applied (Dr. Kato’s comment).
In our case, we modified the technique by shortening the hairpin, so-called Shortened Reversed Guidewire Technique. A shorter hairpin can be applied in special cases with a sequential lesions in which a highly angulated artery is followed with another complex situation such as tortuosity, calcification, dissection etc. or first landing zone is not suitable for a long hairpin. As far as I know, it is first definition of shortened reversed guidewire technique.