Abstract Background Wiring in bifurcation PCI 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 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 mm DES with post-dilatation. Final IVUS showed optimal expansion (MSA 9 mm²). The patient was discharged same day; at three months he remained asymptomatic with 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.
Sindhi et al. (Wed,) studied this question.