Slender Bi-Radial Ping-Pong Technique for Complete Revascularisation of Concomitant CTO and Non-LM Bifurcation Lesions: A Report of Two Cases.

The "ping-pong" technique entails the use of two different guide catheters to alternately engage the same coronary artery during percutaneous coronary intervention (PCI). Bi-arterial vascular access for dual injection is the standard of care in contemporary chronic total occlusion (CTO) PCI. Two-stent bifurcation PCI strategies require a minimum of 6 French (F) guide catheter. In this report, we describe two cases where dual access initially made for CTO PCI was leveraged for subsequent bifurcation PCI in the same setting, by means of two 5F Judkin's Left (JL) guides in a transradial "slender" double-guiding catheter "ping-pong" strategy. In both cases, two 5F JL guides were initially navigated via bi-radial access for antegrade and retrograde injection from left anterior descending artery (LAD) and right coronary artery (RCA) respectively, to facilitate PCI to CTO of LAD. After successful crossing of the LAD CTO lesions, we took advantage of the two 5F JL guides already present via this dual access created for CTO PCI, to adopt the novel use of the "ping-pong" guide technique in order to perform bifurcation PCI by two-stent strategy. In the first case, PCI of the left circumflex (LCx)/obtuse marginal (OM) bifurcation was performed by the DK-Culotte technique with two JL 5F guides used to alternately engage the left main (LM) coronary artery, with wiring and passage of equipment to the LCx and OM done via separate "ping-pong" guides engaging the LM. In the second case, LAD/Diagonal bifurcation PCI was performed by T and protrusion (TAP) technique in a similar slender fashion via "ping-pong" guides. This approach has limited indications. As described in our case report, the CTO lesion was relatively less complex, the LM was not diseased and importantly, narrow radial artery diameters of the patients precluded the use of larger 6F guide transradially. Advantages of this ping-pong technique in bifurcation PCI include the avoidance of wire wrap, accommodation and easy delivery of multiple hardware, and the non-necessity of changing multiple guides, thus reducing radial artery spasm, particularity among those with narrower radial artery diameters.