PCI in the angulated or tortuous lesion

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Editors-In-Chief: C. Michael Gibson, M.D.; Alexandra Almonacid M.D.; Jeffrey J. Popma M.D. Associate Editors-in-Chief: Duane Pinto, M.D.; Brian C. Bigelow, M.D.; Sudarshan Srivats, M.D., M.P.H.[1]

Overview

Percutaneous coronary intervention (PCI) of angulated and tortuous lesions is among the most technically demanding lesion subsets because vessel curvature impairs equipment delivery and independently increases the risk of dissection, perforation, periprocedural myocardial infarction, stent underexpansion and malapposition, stent fracture, and worse long-term outcomes. Severe angulation (>90°) and moderate-to-severe tortuosity remain ACC/AHA type C features and carry a durable adverse prognostic signal even in the drug-eluting stent era, although contemporary procedural success is high. Management centers on anticipating difficult anatomy, maximizing guide support, staged escalation of delivery techniques (now led by guide extension catheters), judicious wire and stent selection, and intravascular imaging to confirm expansion and apposition at the curve. This microchapter addresses angiographic assessment, equipment and technique selection, adjunctive support strategies, atherectomy considerations, and complications specific to curved and tortuous anatomy.

Angiographic Assessment and Definitions

Angulation refers to the bend angle at the lesion itself, measured at end-diastole in the least-foreshortened projection; tortuosity refers to proximal vessel curvature that must be traversed to reach the target. In the modified ACC/AHA lesion classification, moderate angulation (>45° and <90°) is a type B feature and severe angulation (>90°) is a type C feature; excessive proximal tortuosity is likewise a type C feature.[1][2][3]

Because a curved segment foreshortens angiographically, lesion length must be measured in the most unforeshortened projection to size balloons and stents correctly. Coronary tortuosity is reported in roughly 14%–40% of angiograms and is more common in the right coronary artery, in older and hypertensive patients, and in previously revascularized vessels; it should be anticipated during pre-procedural access-site and guide selection.[4][5]

Prognostic Impact

Contemporary type C lesion procedural success is approximately 83% in registry data, though reported rates vary with lesion definition and era; the ACC/AHA class retains independent predictive value for procedural success, in-hospital complications (dissection, perforation, MI), and 30-day and 12-month mortality/MACE, even as modern equipment has somewhat attenuated its discrimination.[1] In the largest modern dataset—a pooled analysis of 6 randomized stent trials—moderate-to-severe tortuosity was associated with higher periprocedural MI and, importantly, higher 5-year target-vessel MI and ischemia-driven target-vessel revascularization after adjustment, with much of the excess revascularization occurring remote from the target lesion and a signal toward more definite stent thrombosis.[4] Proposed mechanisms include flow disturbance with reduced downstream perfusion, difficulty achieving optimal stent expansion and apposition in curved segments, and stent fracture; numerical-simulation data indicate that stenting a tortuous segment further reduces wall shear stress, reinforcing a restenosis mechanism.[4][6][7]


Guide Catheter and Access Selection

Coaxial alignment and maximal passive support are the foundation.[8][9]

  • Large-bore, supportive shapes: 7–8F guides and supportive curves (Amplatz-left or geometry-specific guides for the RCA; EBU/XB for the left system) improve backup at the cost of higher ostial/proximal guide-induced trauma.
  • A long femoral sheath straightens iliac tortuosity and improves guide support.
  • Deep/active engagement improves support but risks proximal dissection; a side-hole guide preserves perfusion but limits high-concentration intracoronary drug delivery.
  • Confirm coaxiality — for the RCA, an RAO view helps assess anteroposterior guide alignment.

Guide Extension Catheters

Guide catheter extension systems are now first-line tools for tortuosity-related delivery failure and have largely displaced many older maneuvers. They provide deep, coaxial subselective intubation that increases push and creates a smooth track past proximal tortuosity and calcification, with reported device/procedural success of roughly 93–99% in tortuous/calcified anatomy, including via radial access.[10][11][12] A contemporary cohort reported high procedural success (~96%) with guide-extension use despite enrichment for calcified, RCA, and left-main lesions.[13]

Delivery of the extension into a tortuous vessel is aided by the "inch-worm" technique (intermittent inflation/deflation of a balloon half in/half out of the extension, advancing the extension on deflation) or by an anchor balloon.[10][9] Key caveats: guide extensions can cause proximal-vessel dissection from deep insertion, pressure damping, and stent stripping or deformation on withdrawal, and carry a recognized learning curve.[14][11] A monorail extension also enables selective low-volume contrast injection, useful in chronic kidney disease.[15]

Guidewire Selection and Shaping

  • Wire shaping: severely angulated arteries often require a two-bend wire—a primary bend matching the lesion and a secondary bend matching the tortuous segment.
  • Initial crossing is best with a floppy, lubricious workhorse wire; a stiff wire in a tortuous vessel produces pseudolesions/vessel pleating (accordion effect) that mimic dissection.[4]
  • Support/exchange wires: an extra-support shaft or exchange to a stiffer wire through a microcatheter or OTW balloon after initial crossing straightens tortuosity to enable device delivery, at the cost of more wire bias and pseudolesions.
  • Wire bias is the central mechanical problem: a stiff wire straightens the vessel but forces devices against the outer curve; a softer delivery wire alongside a stiff support (buddy) wire exploits vessel straightening while minimizing device bias.[10]

Adjunctive Delivery Techniques

When a balloon or stent will not cross, escalate through a recognized sequence:[16][8][9]

  • Buddy wire: a second wire (often of different stiffness/lubricity) straightens tortuosity, reduces friction and wire bias, and stabilizes the guide; remove before stent deployment or atherectomy.
  • Anchor-balloon techniques: a side-branch anchor (small 1.5–2.0 mm balloon inflated in a proximal branch—conus/acute marginal for RCA, diagonal for LAD—to fix the guide) enhances support for uncrossable segments; a distal anchor (balloon over a buddy wire inflated distal to the lesion) provides a rail for a stiff stent through tortuous/calcified segments but is not applicable to uncrossable lesions and risks stent damage/loss or perforation with excessive force.
  • Wiggle wire shifts the direction of pushing force to step over obstructions and reduce wire bias.[10]
  • Balloon-assisted stent delivery: partial (2–3 atm) inflation of the stent balloon straightens the segment and lifts struts off the wall with constant forward pressure—a described bailout when standard methods fail.[16]
  • Respiratory maneuvers: deep inspiration (occasionally full expiration) can transiently straighten a segment.
  • Steerable/deflectable microcatheters aid wiring of extremely angulated side branches.[17]

Equipment and Stent Selection

Over-the-wire and low-profile rapid-exchange systems both have roles; OTW platforms facilitate wire exchange and can improve pushability in severe tortuosity, whereas monorail systems offer lower profile and better visualization. Prefer short, flexible, thin-strut second-generation DES on cobalt-chromium or platinum-chromium platforms for deliverability and lower fracture risk; contemporary thin-strut devices deliver far more readily than first-generation stents.[6][18] Intracoronary imaging (IVUS/OCT) should be strongly considered—RENOVATE-COMPLEX-PCI showed imaging-guided complex PCI improves outcomes—and is particularly valuable in curved vessels prone to underexpansion and malapposition.[19][6] Beyond RENOVATE-COMPLEX-PCI, meta-analyses and a 2026 lesion-level network meta-analysis confirm that imaging-guided PCI reduces cardiac death, MI, stent thrombosis, and revascularization, including in calcified-lesion subsets, with no significant difference between IVUS and OCT; the 2024 ESC Chronic Coronary Syndromes guideline endorses intracoronary imaging in complex PCI, although the ILUMIEN IV trial missed its primary target-vessel-failure endpoint while reducing stent thrombosis.[20][21][22][23][24]

Rotational Atherectomy and Calcium Modification

Rotational atherectomy is hazardous in angulated lesions, where marked angulation is considered a relative contraindication. The thresholds derive from different datasets and definitions and should not be read as a single validated cutoff: contemporary expert guidance treats angulation in excess of 45° as a relative contraindication; classic data identified a bend ≥60° as an independent predictor of both procedural failure and ischemic complications with the Rotablator; and a contemporary all-comers study confirmed acute angulation (≤90°) as an independent predictor of both clinical and procedural rotational atherectomy failure.[25][26][27] Mechanistically, burr bias to the inner curve of an angulated segment predisposes to spasm, pseudostenoses, dissection, and perforation.[28] Rotational atherectomy of highly angulated lesions should therefore generally be avoided.[25]

When plaque modification is unavoidable in curved calcified anatomy, image guidance and cautious burr sizing are advised, and intravascular lithotripsy is an increasingly used, less angulation-sensitive alternative. Meta-analyses show significantly less slow-flow/no-reflow (OR ~0.34) and coronary perforation (OR ~0.43) with intravascular lithotripsy versus rotational atherectomy, with comparable MACE, and pooled DISRUPT CAD data show serious angiographic complications in only 0.5% of intravascular lithotripsy cases.[29][30][31]

The 2021 ACC/AHA/SCAI revascularization guideline grades calcium-modification tools as follows.[32]

2021 ACC/AHA/SCAI recommendations for calcified-lesion plaque modification
Recommendation COR LOE
Rotational atherectomy for fibrotic or heavily calcified lesions before stenting to improve procedural success IIa B-R
Orbital atherectomy, laser atherectomy, balloon atherotomy (cutting/scoring), or intracoronary lithotripsy for calcified lesions before stenting IIb B-NR

Complications

  • Dissection, perforation, and abrupt closure — angulation and tortuosity independently increase these, particularly with stiff wires, aggressive guides, and atherectomy.[4][1]
  • Pseudolesions/vessel pleating from stiff-wire accordioning — distinguish from true dissection before treating.
  • Subintimal wire passage — more common in sharp bends; a 1:1 torque response, easy device advancement, absence of distal tip kinking, and distal contrast injection through a small balloon confirm intraluminal position.
  • Stent underexpansion/malapposition at the curve — a driver of restenosis and thrombosis; optimize with imaging.[6]
  • Stent fracture — angulation, tortuosity, RCA location, long/overlapping stents, and rigid closed-cell designs are risk factors; incidence ~1–8%, with 15–60% requiring revascularization, and high-grade (type III–IV) fractures strongly linked to in-stent restenosis, target-lesion revascularization, and stent thrombosis.[6][33][34]

Practical Approach

A staged, escalating strategy for delivery failure in curved/tortuous anatomy:

  1. Measure lesion length in the least-foreshortened, end-diastolic view and size stents to avoid gaps and overlap at bends.[1]
  2. Establish maximal passive support (supportive large-bore guide, long sheath, coaxiality), then escalate to a guide extension as the preferred first-line adjunct for delivery failure.[10][9]
  3. Cross with a floppy workhorse wire; escalate to a support/stiffer wire or buddy wire for delivery, accepting the trade-off of wire bias.[10][8]
  4. Reserve anchor-balloon and partial-inflation techniques for refractory delivery, mindful of stent damage and perforation risk.[8][16]
  5. Favor short, flexible, thin-strut second-generation DES; use IVUS/OCT to confirm expansion and apposition at the apex of the curve.[19][6]
  6. Approach rotational atherectomy cautiously in angulated lesions: angulation >45° is a relative contraindication, a bend ≥60° independently predicts failure and ischemic complications, and acute angulation (≤90°) predicts contemporary RA failure. Consider intravascular lithotripsy—less angulation-sensitive with lower slow/no-reflow risk—or alternative preparation when modification is needed.[25][26][27][31]
  7. Refer for CABG when severely angulated/tortuous lesions subtend large myocardial territories in multivessel disease, or when PCI is high-risk or has failed—a Heart Team decision consistent with the 2021 ACC/AHA/SCAI revascularization guideline.[32]

Common Pitfalls

  • Mistaking stiff-wire pseudolesions/accordion for dissection and treating them
  • Over-aggressive deep guide or guide-extension insertion causing proximal dissection
  • Rotational atherectomy across a bend with wire bias
  • Overreliance on an anchor balloon leading to stent stripping, loss, or perforation
  • Stent gap/overlap at a bend from foreshortened length assessment
  • Forgetting to remove the buddy wire or anchor balloon before final deployment.

Areas of Uncertainty

  • There is no uniform, validated definition of clinically significant angulation/tortuosity, limiting cross-study comparison and risk scoring.[1][27]
  • Optimal stent strategy in tortuous segments is unsettled: ultrathin struts improve deliverability and rheology but have shown greater late lumen loss in some subsets, so thinnest-is-best is not universal.[6]
  • The elective versus bailout timing of atherectomy in complex/calcified (often angulated) anatomy remains debated, with registry signals both ways and no adequately powered RCT.[35][36][32]
  • Whether routine imaging-guided optimization fully abolishes the tortuosity outcome penalty is unproven.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Theuerle J, Yudi MB, Farouque O; et al. (2018). "Utility of the ACC/AHA lesion classification as a predictor of procedural, 30-day and 12-month outcomes in the contemporary percutaneous coronary intervention era". Catheter Cardiovasc Interv. 92 (3): E227–E234. doi:10.1002/ccd.27411.
  2. ↑ Dehmer GJ, Badhwar V, Bermudez EA; et al. (2020). "2020 AHA/ACC Key Data Elements and Definitions for Coronary Revascularization". J Am Coll Cardiol. 75 (16): 1975–2088. doi:10.1016/j.jacc.2020.02.010.
  3. ↑ Harold JG, Bass TA, Bashore TM; et al. (2013). "ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures". J Am Coll Cardiol. 62 (4): 357–96. doi:10.1016/j.jacc.2013.05.002.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Konigstein M, Ben-Yehuda O, Redfors B; et al. (2021). "Impact of Coronary Artery Tortuosity on Outcomes Following Stenting: A Pooled Analysis From 6 Trials". JACC Cardiovasc Interv. 14 (9): 1009–1018. doi:10.1016/j.jcin.2020.12.027.
  5. ↑ Kahe F, Sharfaei S, Pitliya A; et al. (2020). "Coronary Artery Tortuosity: A Narrative Review". Coron Artery Dis. 31 (2): 187–192. doi:10.1097/MCA.0000000000000769.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 Giustino G, Colombo A, Camaj A; et al. (2022). "Coronary In-Stent Restenosis: JACC State-of-the-Art Review". J Am Coll Cardiol. 80 (4): 348–372. doi:10.1016/j.jacc.2022.05.017.
  7. ↑ Li Y, Fang R, Ma G; et al. (2026). "The Impact of Stenting on Hemodynamic Environment of Tortuous Coronary Artery: Results Derived From a Numerical Simulation Model". Front Bioeng Biotechnol. 14: 1789824. doi:10.3389/fbioe.2026.1789824.
  8. ↑ 8.0 8.1 8.2 8.3 Di Mario C, Ramasami N. (2008). "Techniques to enhance guide catheter support". Catheter Cardiovasc Interv. 72 (4): 505–12. doi:10.1002/ccd.21670.
  9. ↑ 9.0 9.1 9.2 9.3 Elrayes MM, Xenogiannis I, Nikolakopoulos I; et al. (2021). "An algorithmic approach to balloon-uncrossable coronary lesions". Catheter Cardiovasc Interv. 97 (6): E817–E825. doi:10.1002/ccd.29215.
  10. ↑ 10.0 10.1 10.2 10.3 10.4 10.5 McQuillan C, Jackson MWP, Brilakis ES, Egred M. (2021). "Uncrossable and undilatable lesions—A practical approach to optimizing outcomes in PCI". Catheter Cardiovasc Interv. 97 (1): 121–126. doi:10.1002/ccd.29001.
  11. ↑ 11.0 11.1 Ma J, Hou L, Qian J; et al. (2017). "The Safety and Feasibility of Guidezilla Catheter in Complex Coronary Interventions and an Observational Study". Medicine (Baltimore). 96 (40): e8172. doi:10.1097/MD.0000000000008172.
  12. ↑ Ma M, Diao KY, Liu XJ, He Y. (2018). "Early clinical experience with Guidezilla for transradial interventions in China". Sci Rep. 8 (1): 5444. doi:10.1038/s41598-018-23633-7.
  13. ↑ Itelman E, Rotholz A, Bental T; et al. (2026). "Procedural and Prognostic Implications of Guide Extension Catheter Use During Percutaneous Coronary Intervention: A Retrospective Cohort Study". Catheter Cardiovasc Interv. 107 (5): 1441–1449. doi:10.1002/ccd.70477.
  14. ↑ Waterbury TM, Sorajja P, Bell MR; et al. (2016). "Experience and complications associated with use of guide extension catheters in percutaneous coronary intervention". Catheter Cardiovasc Interv. 88 (7): 1057–1065. doi:10.1002/ccd.26329.
  15. ↑ Tunuguntla A, Daneault B, Kirtane AJ. (2012). "Novel use of the GuideLiner catheter to minimize contrast use during PCI in a patient with chronic kidney disease". Catheter Cardiovasc Interv. 80 (3): 453–5. doi:10.1002/ccd.23331.
  16. ↑ 16.0 16.1 16.2 Fernandes V, Kałuza GL, Godlewski B, Li G, Raizner AE. (2002). "Novel technique for stent delivery in tortuous coronary arteries: Report of three cases". Catheter Cardiovasc Interv. 55 (4): 485–90. doi:10.1002/ccd.10139.
  17. ↑ Chan YH, Cheng VYH, Wong CW, Lam CS. (2020). "A simplified reverse wire technique using an angulated supercross microcatheter". Catheter Cardiovasc Interv. 96 (1): E93–E97. doi:10.1002/ccd.28459.
  18. ↑ Garg S, Serruys PW. (2010). "Coronary Stents: Current Status". J Am Coll Cardiol. 56 (10 Suppl): S1–42. doi:10.1016/j.jacc.2010.06.007.
  19. ↑ 19.0 19.1 Lee JM, Choi KH, Song YB; et al. (2023). "Intravascular Imaging-Guided or Angiography-Guided Complex PCI". N Engl J Med. 388 (18): 1668–1679. doi:10.1056/NEJMoa2216607.
  20. ↑ Khan SU, Agarwal S, Arshad HB; et al. (2023). "Intravascular Imaging Guided Versus Coronary Angiography Guided Percutaneous Coronary Intervention: Systematic Review and Meta-Analysis". BMJ. 383: e077848. doi:10.1136/bmj-2023-077848.
  21. ↑ Sreenivasan J, Reddy RK, Jamil Y; et al. (2024). "Intravascular Imaging-Guided Versus Angiography-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Trials". J Am Heart Assoc. 13 (2): e031111. doi:10.1161/JAHA.123.031111.
  22. ↑ Carvalho PEP, Antunes VLJ, Bittar de Pontes V; et al. (2026). "IVUS, OCT, or Angiography as Guidance for PCI in Complex Coronary Artery Lesions: Network Meta-Analysis of Randomized Controlled Trials". JACC Cardiovasc Interv. 19 (1): 31–43. doi:10.1016/j.jcin.2025.11.021.
  23. ↑ Vrints C, Andreotti F, Koskinas KC; et al. (2024). "2024 ESC Guidelines for the Management of Chronic Coronary Syndromes". Eur Heart J. 45 (36): 3415–3537. doi:10.1093/eurheartj/ehae177.
  24. ↑ Ali ZA, Landmesser U, Maehara A; et al. (2024). "OCT-Guided vs Angiography-Guided Coronary Stent Implantation In Complex Lesions: An ILUMIEN IV Substudy". J Am Coll Cardiol. 84 (4): 368–378. doi:10.1016/j.jacc.2024.04.037.
  25. ↑ 25.0 25.1 25.2 Tomey MI, Kini AS, Sharma SK. (2014). "Current Status of Rotational Atherectomy". JACC Cardiovasc Interv. 7 (4): 345–53. doi:10.1016/j.jcin.2013.12.196.
  26. ↑ 26.0 26.1 Ellis SG, Popma JJ, Buchbinder M; et al. (1994). "Relation of Clinical Presentation, Stenosis Morphology, and Operator Technique to the Procedural Results of Rotational Atherectomy and Rotational Atherectomy-Facilitated Angioplasty". Circulation. 89 (2): 882–92. doi:10.1161/01.cir.89.2.882.
  27. ↑ 27.0 27.1 27.2 Tomasiewicz B, Kubler P, Zimoch W; et al. (2021). "Acute Angulation and Sequential Lesion Increase the Risk of Rotational Atherectomy Failure". Circ J. 85 (6): 867–876. doi:10.1253/circj.CJ-20-1222.
  28. ↑ Bersin RM, Simonton CA. (2003). "Rotational and directional coronary atherectomy". Catheter Cardiovasc Interv. 58 (4): 485–99. doi:10.1002/ccd.10459.
  29. ↑ Moghadam AS, Kakavand N, Shirmard FO; et al. (2025). "Intravascular Lithotripsy Versus Rotational Atherectomy in the Management of Calcific Coronary Lesions: A Systematic Review and Meta-Analysis". Catheter Cardiovasc Interv. 106 (2): 1142–1152. doi:10.1002/ccd.31664.
  30. ↑ Kereiakes DJ, Di Mario C, Riley RF; et al. (2021). "Intravascular Lithotripsy for Treatment of Calcified Coronary Lesions: Patient-Level Pooled Analysis of the Disrupt CAD Studies". JACC Cardiovasc Interv. 14 (12): 1337–1348. doi:10.1016/j.jcin.2021.04.015.
  31. ↑ 31.0 31.1 Riley RF, Patel MP, Abbott JD; et al. (2024). "SCAI Expert Consensus Statement on the Management of Calcified Coronary Lesions". J Soc Cardiovasc Angiogr Interv. 3 (2): 101259. doi:10.1016/j.jscai.2023.101259.
  32. ↑ 32.0 32.1 32.2 Lawton JS, Tamis-Holland JE, Bangalore S; et al. (2022). "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization". J Am Coll Cardiol. 79 (2): e21–e129. doi:10.1016/j.jacc.2021.09.006.
  33. ↑ Dangas GD, Claessen BE, Caixeta A; et al. (2010). "In-Stent Restenosis in the Drug-Eluting Stent Era". J Am Coll Cardiol. 56 (23): 1897–907. doi:10.1016/j.jacc.2010.07.028.
  34. ↑ Touma G, Fairley S, Ada C, Wong B, Khialani B. (2025). "A Contemporary Framework for the Diagnosis and Management of Stent Fracture". Catheter Cardiovasc Interv. 106 (3): 1821–1827. doi:10.1002/ccd.70009.
  35. ↑ Zubiaur J, Galeote G, Jurado-Román A; et al. (2026). "Coronary Rotational ATherectomy Elective Versus Bailout in Patients With Severely Calcified Lesions and Chronic Renal Failure: Long-Term Outcomes of CRATER Trial". Catheter Cardiovasc Interv. 107 (1): 431–438. doi:10.1002/ccd.70353.
  36. ↑ Bacmeister L, Breitbart P, Sobolewska K; et al. (2023). "Planned versus unplanned rotational atherectomy for plaque modification in severely calcified coronary lesions". Clin Res Cardiol. 112 (9): 1252–1262. doi:10.1007/s00392-023-02176-6.
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