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Case 22: Extremely Tortuous Angulated mid LAD Diagonal Bifurcation Lesion

Case Presentation

  • A 75-year-old woman with PMH HTN, HLD and NIDDM presented with new onset CCS class II angina for few weeks and stress MPI revealed moderate apical and inferior ischemia.
  • Home medication: Aspirin, Atorvastatin, Metoprolol XL, Losartan, Amlodipine, Metformin, Vitamins
  • LHC revealed 2 V CAD: 95% prox RCA, 90-95% calcified, angulated, severely tortuous mid-distal LAD with D1 bifurcation, 30-50% pLCx and LPL, LVEF 60% and Syntax score 18
  • Pt underwent PCI of pRCA one with one DES (Xience Sierra) and discharged home same day. Pt still has CCS class I angina on GDMT.
  • Planned for staged PCI of extremely tortuous angulated mid LAD/Diagonal bifurcation lesion. Likely will require angulated catheters for wire advancement.

Pre Angiogram

Case Description and Planning

PCI Strategy

  • 6F guide catheter
  • Anticipate to have difficulty wiring into the LAD, especially from the diagonal branch which may even require angulated catheters (Venture or SuperCross)
  • If it is difficult to wire into the distal LAD, would consider to place stent into the LAD first (before diagonal branch) then attempt to wire into the distal LAD
  • Provisional LAD stenting
  • Wire choice would be hydrophilic, polymer jacketed one (Fielder or Fielder FC)


  • First, we used Fielder wire to negotiate from LAD into the diagonal branch.
  • Another Fielder wire with venture catheter was advanced and attempted to redirect the wire into the distal LAD which was not successful.
  • Then we did PTCA of first LAD lesion, then reattempted to wire the LAD. However, it was unsuccessful even with venture catheter.
  • After careful consideration, we had changed our strategy to place the stent into the LAD (prior to the diagonal branch) first, then will try to wire into the distal LAD.

Discussion and First Stent Placement

Angiogram (Post First Stent)

  • Xience 3.25/18 was placed in the mid LAD.


  • After the stent placement in mid LAD, we had planned to negotiate the wire into the distal LAD using various techniques – 1) SuperCross 120 catheter with Fielder or Fielder XT-A; 2) FineCross with MiracleBros; and 3) Use of dual-lumen catheter with Fielder or Fielder XT-A.
  • First, SuperCross 120 with Fielder wire was used to negotiate into the distal LAD. After a few attempts, Fielder wire was successfully advanced into the LAD.

Discussion of Various Methods and Distal LAD Rewiring


  • Subsequently, we exchanged the Fielder wire (LAD) into 300 cm Runthrough via SuperCross microcatheter.
  • It was followed by PTCA and placement of one DES (Xience 3/15 mm) with an excellent result, confirmed by OCT.

Overview of Wiring Techniques

One vs Two Stent Strategy

Final Angiogram

Learning Points

  • Wiring into angulated artery is particularly challenging and careful pre-procedural planning is paramount in these cases.
  • Angulated catheters (SuperCross or Venture) with hydrophilic, polymer jacketed wire (i.e Fielder) is useful to negotiate angulated and tortuous artery.
  • In two sequential and angulated lesions, stenting of proximal lesion could help to negotiate the wire into the distal segment, like in this case.

Left Main DK Crush Video ID