Predictors of failure in the reverse wire technique for complex coronary bifurcation lesions

The reverse wire technique (RWT), with a guidewire shaped in a swan-neck configuration, is used to address challenging side branch (SB) wiring in complex coronary bifurcation lesions (CBLs). However, its success is not guaranteed.

This study aimed to identify factors associated with RWT failure and to assess the feasibility of the balloon blocking technique (BBT) in the distal main vessel (MV) as an alternative.

Thirty-two consecutive complex CBLs with difficult SB wiring were retrospectively analysed. Patients were divided into two groups: those with successful RWT (RWT-S, n=17) and those who underwent BBT, either after RWT failure or as a primary approach (RWT-F/BBT, n=15). Risk factors for RWT failure were examined.

The success rate of SB wiring with BBT was 80%. RTW-F/BBT was associated with less involvement of the left anterior descending artery (40% vs 71%), smaller-diameter MV stent implantation (2.8±0.5 mm vs 3.2±0.5 mm), wider bifurcation angle (BA) between the distal MV and middle SB (BA-β: 51.6±29.8° vs 36.4±18.6°), and smaller minimum lumen diameter (MLD) in the distal MV (1.72±0.68 mm vs 2.14±0.58 mm). SB calcification (33% vs 0%; p=0.01), severe bending in the distal MV (53% vs 12%; p=0.02) and severe bending in the SB (73% vs 24%; p=0.01) were more common in the RTW-F/BBT group. A receiver operating characteristic curve analysis showed that a combination of preprocedural BA-β >34.1°, distal MV MLD <1.77 mm, and SB calcification had good discrimination ability for predicting RWT failure (area under the curve 0.85, 95% confidence interval: 0.71-0.98).

RWT is challenging in complex CBLs with calcification, significant tortuosity, and small vessels. BBT offers a viable alternative in these cases.