AA

A 64-year-old Asian man presented with acute onset severe retrosternal chest pain of three hours duration associated with profuse sweating. He was a known case of coronary artery disease and underwent CABG in 2014 (Two grafts LIMA to LAD, left radial to OM1). He is a known case of diabetes mellitus and hypertension and was on optimal medical treatment. His pulse was 60/minute and his blood pressure was 100/60 mmHg. 

The patient’s electrocardiogram revealed sinus rhythmwith inferior ST-segment elevation. Bedside echocardiogram revealed basal andmid inferior and posterior wall hypokinesia with mild mitral regurgitation. His LV ejection fraction was 45%. 

Coronary angiogram showed patent LIMA to LAD graft, Atretic left radial to OM2 graft which was the culprit vessel. RCA was non-dominant and small vessel. 

The patient was planned for LCX/OM2 bifurcation stenting with two drug-eluting stents (mini crush). The first wire was parked at distal LCX, wiring of OM2 was very difficult due to the very obtuse angle. After giving several attempts with different wires even by making a large C shape, we failed to cross the lesion. So we opted for the reverse guidewire/hairpin loop method. We used a fine cross microcatheter and fielder  FC guidewire to make a hairpin loop and directed this loop to be parked in the distal branch. We kept the orifice of the microcatheter at the origin of the branch and gently pulled back the wire(hairpin loop). While pulling back the wire, It quickly crossed the markedly angulated side branch and made our further procedure very easy. The further procedure was done by the deployment of two DES by mini crush bifurcation stenting followed by final kissing balloon inflation and proximal optimization.

Discussion/Conclusion: Wiring of markedly angled side branches can be done by1)    1)Angled microcatheter2)    2)Largeshape of the wire3)    3)Reverse/Hairpinloop guidewire4)   4)Balloondeflection We did it by reverse guidewire/hairpin loop method by using a single-lumen microcatheter.