Three-Dimensional Optical Coherence Tomography to Decide on Reverse Wire Technique in Bifurcation Interventions

A 79-year-old male with effort angina was admitted to receive optical coherence tomography (OCT)-guided percutaneous coronary intervention for restenosis of an everolimus-eluting stent implanted to the left anterior descending artery (LAD) eight years ago (Figure, A). OCT showed in-stent neoatherosclerosis of the LAD and mild to moderate stenosis at the orifices of the first and second diagonal branches (DB1 and DB2, respectively) (Figure, B & C).

We attempted to cross guidewires to DB1 and DB2 for protection. Crossing the guidewire to DB2 was easy but to DB1 was impossible with conventional wire manipulation, even with multidirectional angiography. Thus, we reviewed OCT images to check the detailed anatomy of bifurcation. Notably, a three-dimensional (3D) reconstructed OCT image revealed clearly that DB1 branching from the LAD was running backward to the proximal direction at a significant angle (Figure, D; yellow arrow). A fly-through 3D rendered OCT image in a distal to proximal direction confirmed that the orifice of DB1 was opened to proximal direction (Figure, E). Therefore, we decided to use the reverse wire technique. A polymer-jacket hydrophilic guidewire with reverse curve could be introduced easily into DB1 (Figure, F-H). Finally, a 3.0/12 mm everolimus-eluting stent was implanted without occlusion of DB1 and DB2 (Figure, I).

A 3D OCT might be helpful for intuitive comprehension of bifurcation anatomy, which would provide valuable information for lesion-specific treatment like reverse wire technique.

Affiliations and Disclosures:

From the Department of Cardiology, Juntendo University Nerima Hospital, 3-1-10, Takanodai,Nerima-ku, Tokyo 177-8521, Japan.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Seiji Koga, MD, Department of Cardiology, Juntendo University Nerima Hospital, 3-1-10, Takanodai,Nerima-ku, Tokyo 177-8521, Japan. Email:kogase@juntendo.ac.jp