An Extended Use of the Balloon Deflection Technique for Difficult Side Branch Wiring

A 65-year-old man was admitted with non-ST-segment elevation myocardial infarction (NSTEMI). Coronary angiography showed a left dominant system with severe and diffuse left anterior descending artery (LAD) disease (Figure 1A, Video 1), necessitating percutaneous coronary intervention (PCI). LAD wiring was uneventful. Wiring of the diagonal artery for protection was difficult due to its retroflex take-off from the LAD and severe downstream disease. A Sion Black (Asahi Intecc) wire was able to select the diagonal branch but failed to negotiate across the more distal lesion despite support of a Finecross (Terumo) microcatheter (Figure 1B). Advancement of a small 1.0 mm x 5 mm compliant balloon led to wire prolapse into the LAD. With the inflation of a 3.0 mm x 15 mm non-compliant (NC) balloon in LAD (Figure 1C), the Sion Black wire was able to negotiate across the diagonal lesions (Figure 1D, Video 2). This was followed by successful stenting of the LAD, resulting in excellent final angiographic results with good side branch patency (Figure 1E, Video 3).

Wiring of angulated side branch can be challenging and requires special techniques. One of these is the use of angulated microcatheters. However, angulated microcatheters are costly and difficult to deliver to the side branch take-off if the proximal main vessel is severely diseased, as in our case. Reverse wiring is another option, but it is difficult for the ‘hairpin’ tip to negotiate downstream lesions in the side branch, as active wire control is hampered. The balloon deflection technique (BDT) was reported to select angulated side branch. Our case is the first to demonstrate BDT’s feasibility in assisting the wiring of critical downstream lesions in angulated side branches by (1) altering the wire bias away from the lesion, and (2) preventing prolapse into the distal main vessel to increase wire trackability into the side branch.

Affiliations and Disclosures

From the Division of Cardiology, Department of Medicine & Geriatrics, United Christian Hospital, Hong Kong SAR, China.

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

Address for correspondence: Siu-Fung Wong, MBChB, Department of Medicine & Geriatrics, United Christian Hospital, Hong Long SAR, China. Email: anthonywaaf1992@hotmail.com