Another Technique for Reverse Wiring in the Acute Bend of Left Main Coronary Artery Trifurcation

A 51-year-old man presented to the emergency department with unstable angina. Coronary angiography revealed trifurcation anatomy with significant stenoses of the distal left main (LM) and proximal left anterior descending (LAD) arteries. Moderate disease was present in the proximal ramus and left circumflex (LCx) arteries (Medina classification 1-1-0-0). Attempts at wiring LAD with double-lumen catheter and conventional reverse wire techniques failed owing to severe LM and LAD angulation and equipment prolapse to ramus and LCx vessels. To address this issue without causing trauma to adjacent vessels, a balloon-assisted reverse wiring technique using a soft tip Suoh 0.3 wire (BARWAS) was successfully applied and is presented in this article. Subsequently, 2 stents were implanted from mid-LAD to LM with intravascular ultrasound guidance. BARWAS is shown to be an effective and safe technique for navigating and addressing extremely angulated main branches in complex trifurcations such as in this LM trifurcation case.