S128 J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 7 , N O . 1 6 , S U P P L S , 2 0 1 6

Case Summary.� Learning from previous failure and meticulous pre-treatment plan-

ning are critical to subsequent success for challenging lesions� Reverse wire technique is a very useful tool for side branch taking >

120 degrees angulation from main vessel� PCI under general anesthesia is a good option for those who cannot

stand conscious procedure

TCTAP C-043Successful Bail Out the Catheter-induced Coronary Artery Dissection inLeft Main Coronary Artery

Hiroshi Kubota,1 Tetsuya Nomura11Nantan General Hospital, Japan

[CLINICAL INFORMATION]Patient initials or identifier number. S. MRelevant clinical history and physical exam. A-82-year-old Japanesefemale admitted to our hospital, because she had a repetitive resting

chest pain early in the morning. Her coronary risk factor was onlyhypertension. Because we suspected a coronary spastic angina, weplanned to perform a coronary angiography (CAG) and a spasmprovocation test with acetylcholine.Relevant test results prior to catheterization. The findings of her elec-trocardiography and echocardiography were normal.Relevant catheterization findings. We performed CAG with 5-Fr JR4.0/JL4.0 catheters, and there was no significant stenosis in the coronaryarteries. After CAG, we performed a spasm provocation test. Duringthe test, because of the deep-engaged catheter, spiral dissection wasoccurred from LMCA to LAD and LCX arteries.[INTERVENTIONAL MANAGEMENT]Procedural step. We immediately started a bail out PCI. Sion guidewire (GW) was advanced into the distal true lumen of the LCX artery.From the intra venous ultra sonography (IVUS) image, we confirmedthe GW tracking in the true lumen of the LCX artery. Next, Sion BlueGW crossed the LAD artery using the Crusade dual lumen micro-catheter. Because the state of cardiogenic shock persisted, we insertedan intra-aortic balloon pumping. We implanted a 3.5�18mm drugeluting stent (DES) from LMCA to LCX artery, and it was crushed witha 4.0�15mm balloon catheter. Then, we implanted a 3.5�22mm DESfrom LMCA to LAD artery. The blood flow in the LCX artery dramati-cally improved. However, because a dissection in the mid portion ofthe LAD artery remained, the blood flow in the LAD artery didn’timprove. Therefore, we implanted a 3.0�26mm DES there. Finally, weconfirmed the good blood flow without delay in both the LAD and theLCX arteries.

Case Summary. Catheter-induced coronary artery dissection is a rarecomplication. Once it occurred, it could often be fatal. Crush stentingstrategy can be performed rapidly and safely in the bail out procedurefor a coronary artery dissection involving left main bifurcation.

TCTAP C-044Reverse Wire Technique for Acute Angle Bifurcation Wiring Without Micro-Catheter Assistance

Chen Hui Tan1

1National Taiwan University Hospital, Taiwan

[CLINICAL INFORMATION]Patient initials or identifier number. 62 year-old Mr ZhangRelevant clinical history and physical exam. Current smoker, history ofhypertension and hyperlipidemia without medication control. Hereported frequent chest tightness lasting 30 mins in these 3 days with4-5 episodes daily. Sudden onset of severe chest pain occurred onafternoon while he was talking with his colleagues. The pain waslocalized at left upper chest without radiation accompanied withdiaphoresis and nausea so he went to ER.Blood pressure: 95/64 mmHg

Relevant test results prior to catheterization. ECG: V1-V2 Q waves withST-T changeElevated cardiac enzymes: CK 261 U/L, CK-MB 72 U/L, Troponin I

0.858 ng/mlEchocardiography: regional wall motion abnormalities over apical,

septal and anteroseptal area.

J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 7 , N O . 1 6 , S U P P L S , 2 0 1 6 S129

Relevant catheterization findings.LM: patentLAD: proximal 99% stenosis at Diagonal 1 bifurcation with an acute angleLCX: distal 40% stenosisRCA: patent

[INTERVENTIONAL MANAGEMENT]Procedural step.1. Guiding catheter Medtronic EBU 3.5 7F was engaged to LCA.2. Asahi Sion wire was passed to distal LAD. Asahi Fielder FC wire was

planned to pass to distal diagonal due to big vessel size (2.5mm) andlarge supply territory.

3. Crusade was used to assist acute angle diagonal wiring but due to99% stenosis of LAD, ST elevation, hypotension when Crusade wasintroduced to lesion. LAD blood flow was occluded.

4. Changed to smaller profile Excelsior micro-catheter, but still STelevation and hypotension when Excelsior reached bifurcation.

5. Thought of Simmons technique in carotid interventionwhich advancedguide wire to aortic root then reverse up to carotid artery orifice.

6. Shaped Asahi Fielder FC to a hair-pin bend, modified Simmonstechnique, advanced Fielder FC to LAD plaque distal to lesion, thenreversed to hook diagonal orifice, then guide wire was successfullypassed to distal diagonal.

7. Checked IVUS to decide stenting strategy, minimal plaque was notedat diagonal ostium, so simple stenting to LAD was decided.

8. Pre-dilatation to LAD with Sapphire 3.5*15 mm (8 atm 10 secs),plaque shifted to diagonal ostium, so balloon angioplasty to diagonalostium with Sapphire 2.5*15 mm (8 atm 10 secs).

9. Stenting to LAD with Medtronic Resolute Integrity 3.5*22 mm (12atm 10 secs).

10. The final result was good with TIMI 3 flow for both LAD and diagonalbranch.

Case Summary.1. Assistance of double lumen micro-catheter is the first choice for acute

angle bifurcation wiring.2. If without the assistance of micro-catheter, make the best use of

nearby vessel, plaque anatomy.3. Tips for successful bare wire wiring to acute angle bifurcation:

- use a hydrophilic coating workhorse wire- make a hair-pin bend tip- loop as a swan-neck shape and anchor at nearby- rotate and push forward