Reverse Wire Technique Research Articles

Novel Use of Excimer Laser Coronary Angioplasty for the Preparation of the Reverse Wire Technique

Guidewire insertion into the side branches during percutaneous coronary intervention may be difficult, depending on the angle of the side branch and plaque localization. The reverse wire technique (RWT) is an effective wiring method for markedly angulated bifurcated side branches. Nonetheless, continuing the procedure may be difficult if the RWT system cannot be inserted because of severe main trunk stenosis or if the insertion of the system causes a decrease in the peripheral blood flow. In these cases, balloon pre-dilation is sometimes performed; however, this is unreliable due to the risk of side branch occlusion caused by plaque shift. By performing excimer laser coronary angioplasty (ELCA) as a preparatory procedure before RWT, it is possible to eliminate the main trunk plaque without inducing insufficiency in the side branches. We herein report three acute coronary syndrome (ACS) cases in which ELCA pretreatment was effective after failure of an attempted RWT. This method is considered a novel use of ELCA in ACS.

Practical use of dual-lumen catheter-facilitated reverse wire technique for nonhighly angulated side branch

Dual-lumen catheter (DLC)-facilitated reverse wire technique is considered a method of last resort for inserting a guidewire into a markedly angulated side branch. Moreover, this technique can be practically applied to other types of anatomical variations around the bifurcation. Case 1 was that of a 53-year-old man with a tight stenosis of the proximal left anterior descending artery at the diagonal bifurcation with angiographically apparent coronary dissection. We successfully achieved guidewire insertion into the targeted branch using the DLC-facilitated reverse wire technique. Case 2 involved a 78-year-old man with total occlusion of the mid-portion of the right coronary artery. The guidewire reentry point in the atrioventricular branch was slightly distant from the true distal end of the occlusion. We successfully used the DLC-facilitated reverse wire technique to pass a second guidewire to the posterodescending artery. Case 3 was that of an 80-year-old man whose coronary artery had an aneurysm with severe stenoses at both entry and exit of the aneurysm. We adopted the DLC-facilitated reverse wire technique and easily advanced the guidewire by matching the guidewire advancing path with the direction of the sequential conduit constituted by the coronary aneurysm and stenosis. The timing of decision-making to try the DLC-facilitated reverse wire technique is important. The lesion for which reverse wiring is suitable is usually difficult to be treated with conventional guidewire crossing. We have to promptly judge the validity of applying this technique based on the angiographic findings of targeted lesions and take immediate action to implement this procedure to reduce the procedural time and irradiation dose.

Revascularization of Coronary Artery Chronic Total Occlusion by Active Antegrade Reverse Wire Technique.

Objectives To assess the effectiveness and safety of ARW for vascular recanalization in CTO patients. Background Chronic total occlusion (CTO) of coronary artery accompanied with large branch distal to the occluded segment (<2 mm) is one of the challenges physicians are facing during the coronary intervention. In cases where the antegrade wire passed the occluded segment reaching the branch vessel, but could not access the main vessel through various adjustments, application of active antegrade reverse wire technique (ARW) could be considered. Patients and Methods. A total of 301 consecutive CTO patients who received the antegrade percutaneous coronary intervention (PCI) between December 2015 and December 2019 at our institution were included, of whom 11 were treated with ARW (10 successfully) for vascular recanalization. The applicability and safety of ARW were assessed. Results Among the 301 CTO patients who received antegrade vascular recanalization, 11 were treated with ARW. ARW was successful in 10 patients as follows: from the diagonal branch (D) to anterior descending branch (LAD) in 4 patients; from the septal branch (S) to LAD in 1 patient; from D to S and LAD in 1 patient; from the circumflex branch (LCX) to obtuse marginal branch (OM) in 1 patient; from OM to LCX in 1 patient; from a posterior descending artery (PDA) to the posterior lateral vein (PLV) in 2 patients. Yet, ARW in patient with RCAm CTO failed, while the consequent retrograde PCI succeeded. The mean J-CTO score of the 11 patients was 2.7 ± 0.65, among whom eight were accompanied with calcifications. Sion Black and Fielder XTR reverse wires were used in 9 and 2 patients, respectively. No loss of side branches or severe procedure-related complications occurred in 11 patients. Conclusion Therefore, ARW can improve procedural efficiency and should be popularized for further application.

The Effective and Safe Way to Use Crusade Microcatheter-Facilitated Reverse Wire Technique to Solve Bifurcated Lesions with Markedly Angulated Target Vessel.

Objectives We aim to present a new way to introduce reverse wire in crusade microcatheter-facilitated reverse wire technique to solve markedly angulated bifurcated lesions. Background Markedly angulated coronary bifurcation lesions are still one of the considerable challenges of treatment with percutaneous coronary intervention especially with severe proximal stenosis. Microcatheter-facilitated reverse wire technique improved the efficacy of crossing a guide wire to such an extremely angulated complex targeted vessel. However, there has been a debate regarding what kind of curve was the best to introduce reverse guide wire in this technique. Methods We analyzed 7 patients who were admitted to Fuwai Hospital and underwent antegrade wiring which failed. Crusade microcatheter-facilitated reverse wire technique with simple short tip one round curve was used successfully to solve in all 7 bifurcation lesions. We investigated the bifurcation lesion's characteristics and details of the reverse wire technique procedures. Results All 7 bifurcations exhibit both a smaller take-off angle and a larger carina angle and severe proximal significant stenosis. After having suitable size of balloon predilation, reverse wire with simple short distal one curve was delivered to distal segment of targeted vessel successfully. We performed all PCI procedures without any complications and no major adverse cardiac event was observed during hospitalization. Conclusions In solving markedly angulated bifurcated lesions, especially with severe proximal stenosis, crusade microcatheter-facilitated reverse wire technique with simple short tip one curve is an effective and safe way of wiring.

TCTAP C-066 Reverse Wire Technique for CTO Bifurcation Lesion at Distal Exit

TCTAP C-066 Reverse Wire Technique for CTO Bifurcation Lesion at Distal Exit

Hammering reverse guide wire technique for safe placement of anterior column retrograde in-tramedullary screw in pelvic and acetabular surgery

Objective To evaluate the efficacy and accuracy of hammering reverse guide wire technique for safe placement of anterior column retrograde intramedullary screw in pelvic and acetabular surgery. Methods From September 2015 to March 2018, 46 patients with pelvic or/and acetabular fracture involving the anterior column were treated with hammering reverse guide wire technique for safe placement of anterior column retrograde intramedullary screw at Department of Orthopaedics, Lishui Municipal Central Hospital. They were 28 men and 18 women, aged from 21 to 85 years (mean, 55.6 years). There were 34 pelvic ring fractures, 9 acetabular fractures and 3 combined pelvic ring and acetabular fractures. After the anterior lateral spine of pubic tuberosity was drilled by a guide pin and drill bit as the entry point, a reverse guide wire was knocked into the bone lightly by a hammer. For each retrograde intramedullary screwing into the acetabular anterior column, we recorded operation time, fluoroscopic frequency, and attempts to establish an acceptable screw pathway by the guide pin. The accuracy of screwing and the quality of fracture reduction were evaluated by imaging examination. For each patient, we recorded fracture union time and complications. Functional recovery of the pelvis and acetabulum was assessed by postoperative physical examination at the last follow-ups. Results The operation time of retrograde intramedullary screwing for the 46 patients averaged 28.9 minutes (from 16 to 55 minutes); the fluoroscopy frequency averaged 16.3 times (from 9 to 35 times); an acceptable screw pathway was established by the first attempt in 43 of the 46 patients (93.5%) and re-established after adjustment of the guide pin in the other 3. Forty patients were followed up for an average of 15.2 months(from 6 to 36 months). Postoperative CT scan and three-dimensional reconstruction showed that all the screws had been placed safely and accurately in the acetabular anterior column. Implant loosening and fracture displacement occurred in one case and lower limb thrombosis in another. No nail breakage, fracture nonunion, incision necrosis or infection, neurovascular injury or femoral head necrosis was observed. All fractures united after an average of 14.7 weeks (from 12 to 18 weeks). According to the Majeed scoring at the last follow-ups, the pelvic and acetabular function was evaluated as excellent in 29 cases, as good in 9, and as fair in 2, giving an excellent and good rate of 95.0%. Conclusion Hammering reverse guide wire technique is an effective method for safe placement of anterior column retrograde intramedullary screw in pelvic and acetabular surgery, because it can increase accuracy of screwing and reduce intraoperative radiation, operation time and incidence of complications though it is simple. Key words: Pelvis; Acetabulum; Fractures, bone; Surgical procedures, minimally invasive; Fracture fixation, internal

Usefulness of longitudinal reconstructed optical coherence tomography images for predicting the need for the reverse wire technique during coronary bifurcation interventions.

The aim is to investigate the usefulness of longitudinal reconstructed optical coherence tomography (OCT) images in selecting the reverse wire (RW) technique for inserting a guidewire into a side branch (SB). It is sometimes necessary to protect the SB with a guidewire to prevent SB complications in PCI for bifurcation lesions. The RW is a novel method for guidewire insertion into an extremely angulated SB when the standard antegrade wire (AW) approach is difficult. This retrospective study included 46 consecutive patients who underwent OCT-guided PCI in bifurcation lesions with significant SB stenosis. Patients were divided into two groups: 36 patients with successful guidewire crossing using the AW (AW group) and 10 patients with unsuccessful AW but successful RW guidewire crossing (RW group). SB angle and branch point (BP) slope, defined as the angle between the line connecting the proximal and distal BPs and the vertical, were measured using longitudinal reconstructed OCT images. The RW group had a significantly larger SB angle and higher BP slope than the AW group (108.7 ± 11.4° vs. 76.2 ± 14.9°; P < 0.0001, 128.7 ± 31.6° vs. 82.9 ± 33.6°; P = 0.0004, respectively). Receiver operating characteristic curve analysis indicated that SB angle ≥ 100° and BP slope ≥ 120° are optimal cutoff values for predicting the need for RW (area under the curve 0.97, sensitivity 90.0%, specificity 91.7%; area under the curve 0.83, sensitivity 80.0%, specificity 86.1%, respectively). Longitudinal reconstructed OCT is useful for selecting the wiring technique for bifurcation lesions.

Crusade Microcatheter-Facilitated Reverse Wire Technique for Revascularization of Bifurcation Lesions of Coronary Arteries.

This study aims to analyze the lesion characteristics of bifurcations that required reverse wire technique and the efficacy and safety of this technique in approaching branches with a highly angulated take-off. We enrolled patients in whom reverse wire technique was used after failed conventional antegrade wiring with the support of a Crusade catheter. The study endpoints were the technical success defined as succeeding in sending the reversely bent wire to the targeted branches without complications and the procedural success defined as succeeding in revascularization of the bifurcation lesions without complications. Among 158 patients with bifurcation lesions undergoing percutaneous coronary intervention using a Crusade catheter to facilitate wiring, 23 (14.6%) requiring the reverse wire technique in an attempt to access branches of the bifurcation lesions with an acutely angulated take-off were enrolled for analysis. The obtainable angle of take-off was 162.9 ± 4.7 degrees. For the parent vessel, the ostium of the targeted branch, and nontargeted branch, the minimal luminal diameters were 0.3 ± 0.5 mm, 0.4 ± 0.2 mm, and 1.8 ± 0.5 mm, respectively; the diameter stenosis were 88.8 ± 18.5%, 83.0 ± 7.3%, and 32.0 ± 14.5%, respectively. Technical and procedural success was achieved in 22 cases (96% for both). We showed in the present study that the reverse wire technique is effective and safe for approaching highly angulated branches of bifurcation lesions and consequently for complete revascularization of difficult bifurcation lesions.

TCTAP C-002 Left Main STEMI Rescued by Reverse Wire Technique Under ECMO Support

TCTAP C-002 Left Main STEMI Rescued by Reverse Wire Technique Under ECMO Support

TCTAP C-133 Reverse Wire Technique for Left Circumflex Artery After Stenting from LM to LAD Is It Feasible

### 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

TCTAP C-180 Utility of the Reverse Wire Technique in Alcohol Septal Ablation for Drug-refractory Hypertrophic Obstructive Cardiomyopathy

TCTAP C-180 Utility of the Reverse Wire Technique in Alcohol Septal Ablation for Drug-refractory Hypertrophic Obstructive Cardiomyopathy

TCTAP C-170 Performing Reverse Wire Technique for an ESRD Patient with ACS and Cardiogenic Shock to Achieve Total Revascularization of this Calcified Triple and Bifurcation CAD

### Patient initials or identifier number Hsu ### Relevant clinical history and physical exam This 69 year old gentleman has history of end stage renal disease, type 2 diabetes, peripheral artery disease with left above-knee amputation, hypertension, status colostomy due to sacral bedsore. He

Tips of the dual-lumen microcatheter-facilitated reverse wire technique in percutaneous coronary interventions for markedly angulated bifurcated lesions.

In practical settings of percutaneous coronary intervention (PCI), we sometimes encounter difficulty in introducing a guidewire (GW) to the markedly angulated side branch (SB), and the reverse wire technique is considered as a last resort to overcome such a situation. We analyzed 12 cases that underwent PCI with dual-lumen microcatheter-facilitated reverse wire technique between January 2013 and July 2016. We retrospectively investigated the lesion's characteristics and the details of the PCI procedures, and discussed tips about the use of this technique. The SB that exhibits both a smaller take-off angle and a larger carina angle is considered to be the most suitable candidate for this technique. The first step of this technique involves the delivery of the reverse wire system to the target bifurcation. However, most cases exhibit significant stenosis proximal to the bifurcation, which often hampers the delivery of the reverse wire system. Because the sharply curved reverse wire system is easier to pass the stenosis as compared to the roundly curved system, we recommend a sharp curve should be adopted for this technique. On the other hand, it is sure that device delivery is much easier on the GW with a round curve as compared to that with a sharp curve. Therefore, it is important to modify the details of this procedure on a case-by-case basis according to the lesion's characteristics.

TCTAP C-245 Usefulness of Reverse Wire Technique for Septal Branch Selection During Percutaneous Transluminal Septal Myocardial Ablation

### Patient initials or identifier number 0020248389 ### Relevant clinical history and physical exam A 73 years-old female with bronchial asthma developed dyspnea on effort (DOE) and visted a hospital. She was diagnosed with hypertrophic obstructive cardio myopathy (HOCM) and administered

Practical Usefulness of Dual Lumen Catheter-Facilitated Reverse Wire Technique for Markedly Angulated Bifurcated Lesions.

This study aimed to investigate the practical usefulness of dual lumen catheter-facilitated reverse wire technique. We sometimes encounter difficulty in introducing a guidewire to the highly angulated side branch. In those cases, the reverse wire technique is considered as a last resort to overcome the situation. Between January 2013 and June 2015, we performed the reverse wire technique for guidewire crossing into an extremely angulated side branch in consecutive seven cases with true bifurcated lesions. We retrospectively evaluated patients' backgrounds, lesion characteristics, and details of the percutaneous coronary intervention (PCI) procedures. Three interventional cardiologists with various levels of experience in coronary intervention performed this technique. A polymer-jacket hydrophilic-coated guidewire was used for the reverse wire system excluding in one case, and we adopted a sharp curve for the tip shape in all cases. After crossing the reverse wire into a highly angulated side branch, we usually deliver a flexible micro catheter over the guidewire for the purpose of guidewire exchange. We deployed a stent in the side branch in three cases. We successfully performed all PCI procedures without any complications and no major adverse cardiac event was observed during hospitalization. We could safely and effectively perform the reverse wire technique for guidewire crossing into a markedly angulated side branch. We recommend a polymer-jacket hydrophilic-coated guidewire with a sharp curve in the tip shape for this technique. All interventional cardiologists should acquire knowledge and skills regarding this guidewire manipulation technique.

TCTAP C-041 Application of Reverse Wire Technique in an Ostial Left Main Total Occlusion with Acute Coronary Syndrome

### Patient initials or identifier number LCK-20864680 ### Relevant clinical history and physical exam His coronary risk factors were smoking and age. His medical history were tongue cancer, SCC, T3N1M0 and syphilis without treatment. Physical examination showed right lower lung field rales,

Utility of the reverse wire technique in multidetector computed tomography-guided percutaneous transluminal septal myocardial ablation

Utility of the reverse wire technique in multidetector computed tomography-guided percutaneous transluminal septal myocardial ablation

Microcatheter-facilitated reverse wire technique for side branch wiring in bifurcated vessels: an in vitro evaluation

To assess when and how the microcatheter-facilitated reverse wire technique should be applied to cross the guidewire into side branches in coronary bifurcations. Three interventional cardiologists with different levels of experience performed in vitro bench testing using an originally developed coronary bifurcation simulator which had six coronary bifurcations. The bifurcation angles were 90, 105, 120, 135, 150 and 165 degrees (°). Experiment 1 was conducted to assess in what coronary bifurcation the reverse wire technique is required. Antegrade guidewire advancement was conducted with two different guidewires: the spring coil guidewire SION blue and the polymer-jacket hydrophilic guidewire Fielder FC. Experiment 2 was conducted to determine what the optimal guidewire selection and the optimal guidewire shape for the reverse wire technique would be. Assessment of the guidewire crossability into the highly angulated side branch was performed, and then the balloon crossability was assessed. A total of four guidewire types were compared in experiment 2. In experiment 1, guidewire crossing was impossible by conventional antegrade wiring when the bifurcation angle became 150° or more. In experiment 2, guidewire crossing of more than 150° of bifurcation angle was achievable independent of the guidewire types and shape. Balloon deliverability was best when using a polymer-jacket hydrophilic guidewire with a round shape 3 cm from the guidewire tip. Although the guidewire crossing into the side branch was impossible by conventional antegrade methods when the bifurcation angle became 150° or more, the guidewire crossing into such a highly angulated side branch was easily possible using the reverse wire technique. The optimal guidewire selection for the reverse wire technique is the polymer-jacket hydrophilic guidewire with a round shape 3 cm from the guidewire tip.