Challenging side-branch wiring during coronary bifurcation interventions frequently arises from difficult anatomy such as: Wide angle (>70°), or reverse angulation, eccentric plaque at the carina, calcification, projecting stent struts, and vessel tortuosity. These scenarios demand individualized wire selection and specialized techniques. Wires with superior torque control, shape retention, and enhanced tip support are favoured, as they reduce prolapse into the main vessel. Short primary curves with secondary proximal bends may improve access in sharply angulated branches. Pull-back wiring entails advancing the wire distally in the main vessel and slowly withdrawing until the side-branch ostium is engaged, with gentle rotation to facilitate entry. Polymer-jacketed hydrophilic wires, such as Sion Blue, prove useful in reverse wiring for extremely angulated branches, often supported by a dual-lumen catheter.
We report a 57-year-old diabetic male with NSTEMI and prior left anterior descending artery [LAD] stenting for ostial disease. Angiography revealed critical distal Left main coronary [LMCA] bifurcation disease (Medina 11,1), including 95% distal LMCA stenosis, 90% ostial LAD in-stent restenosis with protruding struts, and 90% ostial left circumflex artery [LCX] stenosis. Wiring the LCX was particularly challenging due to acute angulation and protruding stent struts across the ostium. Multiple wire configurations failed, and dual-lumen microcatheters were unavailable. Balloon blocking of the LAD, plaque modification, or rotational atherectomy were avoided because of the risk of ischaemia, plaque shift, or unpredictable side-branch compromise. A pierced-balloon technique served as a strict bailout strategy rather than a primary approach. Careful fluoroscopic guidance during balloon withdrawal helped prevent loss of wire position.
Prestenting Kissing-balloon inflation1 was performed given the high anatomical complexity and plaque burden, . Isolated dilation of either branch yielded unfavourable plaque shift and haemodynamic instability; simultaneous inflation of two 2.75-mm balloons at 12 atm preserved the carina.
A planned two-stent strategy was chosen due to significant LCX disease. LMCA-LCX stenting was done with a 3.5 mm × 15 mm drug-eluting stent, followed by selective rewiring and LMCA-LAD stenting with a 3.5 mm × 18 mm stent. Sequential high-pressure postdilatation, kissing-balloon inflation, and proximal optimization were performed. Puff testing2 during full balloon expansion confirmed adequate apposition. In settings where intracoronary imaging may be unavailable, a negative POT-PUFF sign reduces the risk of mother-vessel malapposition to 6.5% compared with 70.5% with a positive sign, though it may still miss focal malapposition.
In ISAR LMCA trial,3 5-year mortality was 30.2% for patients who underwent target lesion revascularization (TLR) vs. 17.3% for those without reinterventions for unprotected LMCA disease. CABG remains the preferred strategy in LMCA reinterventions [Figure 1]. For select PCI cases, stent strategy selection (DK crush vs. culotte) should be guided by bifurcation anatomy, vessel size, angulation, protruding struts, and operator expertise.
Figure 1.
Proposed algorithm for reintervention in LMCA disease.
Conclusion: We would like to highlight that difficult side-branch access requires systematic wire escalation and individualized decision-making.The pierced-balloon technique provides a cost-effective bailout option in resource-limited settings or when conventional methods fail. Careful procedural planning and optimization remain critical for successful outcomes in complex LMCA bifurcation interventions.
Contributor Information
Veena Nanjappa, DNB Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, KRS Road, Kumbarakoppal, Mysuru, Karnataka 570016, India.
R Sreedhara, DNB Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, KRS Road, Kumbarakoppal, Mysuru, Karnataka 570016, India.
K S Sadanand, DNB Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, KRS Road, Kumbarakoppal, Mysuru, Karnataka 570016, India.
Author contributions
Veena Nanjappa (Conceptualization [equal], Formal analysis [equal], Supervision [equal], Writing—original draft [equal], Writing—review & editing [equal]), R. Sreedhara (Conceptualization [equal], Formal analysis [equal], Supervision [equal], Writing—original draft [equal], Writing—review & editing [equal]), K.S. Sadanand (Conceptualization [supporting], Formal analysis [supporting], Supervision [supporting], Writing—original draft [supporting], Writing—review & editing [supporting])
Funding
No funding
Data availability
All data are incorporated into the article.
References
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Data Availability Statement
All data are incorporated into the article.