Live IVUS-guided wiring in percutaneous coronary intervention: a case report

Abstract Background Wiring in bifurcation percutaneous coronary intervention can be limited by severe angulation, adverse plaque biasing, and ostial ambiguity. Real-time intravascular ultrasound (RT-IVUS) guidance can augment wire manipulation when standard techniques fail. Case summary A 49-year-old man with exertional angina had a critical lesion left anterior descending (LAD)-2nd diagonal bifurcation lesion (Medina 1,1,0) with TIMI 2 flow. Standard wiring (acutely angled wires, dual lumen, and angled microcatheters) repeatedly biased into the diagonal. Under RT-IVUS, the wire was redirected into the true lumen of mid-LAD, enabling lesion crossing, pre-dilatation, and implantation of a 3.5 × 26 mm2 DES with post-dilatation. Final IVUS showed optimal expansion (MSA 9 mm2). The patient was discharged same day; at 3 months, he remained asymptomatic with a patent stent. Conclusion RT-IVUS can overcome wiring failure in complex bifurcations by providing live intravascular guidance augmenting wire passage into true lumen, supporting safe, efficient revascularization.