Dual wire technique for aortic coarctation stent placement

A young adult presented for percutaneous treatment of a narrow aortic coarctation. A very large left subclavian artery originated immediately proximal to the coarctation. In order not to exclude or jail the left subclavian artery with a stent, a double wire technique was used. From a femoral approach, two guide wires were positioned, one in the aortic arch and another in the subclavian artery. A stent crimped over a 16‐mm balloon and a 4‐Fr catheter was advanced over the two wires within a 14‐Fr long introducer sheath. The stent was successfully deployed and molded within the bifurcation by a kissing balloon technique, relieving the obstruction and leaving a guaranteed passage to the subclavian artery. The double wire technique is an elegant way to deliver a stent safely across a narrowing with guaranteed access to important side branches. © 2011 Wiley‐Liss, Inc.     

Successful percutaneous coronary intervention for complex bifurcated lesions with combination of “Reverse wire technique” and “Reverse bent wiring with the crusade catheter” novel wire manipulation technique

We encountered a case of percutaneous coronary intervention for complex bifurcated lesions in the mid portion of the left anterior descending (LAD) artery. The diagonal artery branched from the LAD artery with a markedly angulated pattern and there was severe stenosis from just proximal to this diagonal artery. The “reverse wire technique facilitated with the Crusade catheter” enabled us to cross a guidewire through to the markedly angulated diagonal side branch (SB). Next, we adopted a mini‐crushing stent strategy for this true bifurcated lesion. Thereafter, we adopted “reverse bent wiring with the Crusade catheter” for wire re‐crossing to the incarcerated side branch, and successfully completed all procedures. This technique for successful wire re‐crossing is simple but can be very effective in specific situations in practical percutaneous coronary intervention (PCI). Many PCI operators may empirically adopt this kind of wire manipulation technique. However, this case is the first report in the world describing the application of a “reverse bent wiring with the Crusade catheter” for wire re‐crossing through a double‐folded stent strut to a SB at the optimal point of the bifurcation. In this case, we made the most of the Crusade catheter. This catheter is a very useful device for multifactorial use in practical PCI. It can help us to perform complex PCI procedures successfully. © 2015 Wiley Periodicals, Inc.     

Retrieval of a subintimal fractured guide wire from the brachial artery following saphenous vein graft stenting

We present a case of a 58‐year‐old woman with diabetes mellitus with a history of angina, coronary artery bypass 24 years previously and who underwent retrieval of a fractured coronary buddy wire from the right brachial artery following attempted coronary intervention to a saphenous vein graft via the right radial route. Attempted removal of the guide wire had caused guide catheter‐induced dissection of the vein graft in addition to a distal stent edge dissection before fracture in the brachial artery. The fractured end of the buddy wire was found to be in the subintimal space and could only be retrieved by advancing the wire into the subclavian artery by means of wrapping its free portion around the guiding catheter. Its fractured end could then be snared into the guiding catheter but could only be withdrawn from behind the stented segment in the vein graft by means of a trap balloon in the guiding catheter. Successful stenting of a guide catheter‐induced dissection and distal stent edge dissection within the vein graft was then performed. This case highlights the hazards of deploying stents over buddy wires and of fractured guide wires in coronary intervention. © 2015 Wiley Periodicals, Inc.     

Successful retrieval of a broken intravascular ultrasound catheter tip in the coronary artery

We report the successful retrieval of a broken intracoronary intravascular ultrasound (IVUS) catheter tip that was mostly invisible on fluoroscopy by using a snare catheter and pulling from distal to proximal. An 80-year-old male had presented with effort-related angina for one month. A coronary angiogram revealed severe stenosis of the proximal portion of the left anterior descending artery (LAD). Percutaneous coronary intervention (PCI) was planned for the lesion. During pre-procedural IVUS examination, the IVUS catheter fractured leaving the tip of the IVUS catheter inside the LAD. An attempt was made to remove the IVUS catheter tip by engaging the free proximal end of the tip with a loop snare. This attempt failed due to the free proximal end of the IVUS catheter tip being invisible on fluoroscopy. A loop snare was instead delivered distal to the IVUS catheter tip through a microcatheter, and the IVUS wire of the catheter tip was manipulated into the loop. The loop snare was then pulled back securely catching the IVUS catheter tip. The broken IVUS catheter tip was subsequently removed. This novel technique is effective for retrieving intracoronary foreign bodies.     

Loss and retrieval of a coronary angioplasty stent balloon

A case is presented in which a breakage of the coronary stent delivery catheter occurred as retrieval of the stent balloon was attempted after stent implantation.The broken distal balloon shaft with its stuck balloon was retrieved by controlled pulling on the guiding catheter in which a new balloon was inflated, thus trapping the distal shaft. The case underscores the importance of adequate lesion assessment and preparation.     

Bifurcation stenting with a dedicated biolimus-eluting stent: X-ray visual enhancement of the final angiographic result with "StentBoost Subtract".

A 51 year-old man underwent percutaneous coronary intervention of a significant "true" bifurcation lesion involving the proximal left anterior descendens (LAD) artery and an important first diagonal branch with a dedicated bifurcation stent, which is a conical self-expandable biolimus-eluting stent with a "flared" distal part allowing for optimal scaffolding of the carina of the bifurcation, and two additional sirolimus-eluting stents, deployed with the V-stenting technique, one in the LAD and one in the diagonal branch, in overlap with the distal part of the "flared" biolimus-eluting stent. An X-ray enhancing visualization technique, "StentBoost Subtract," was used to obtain an improved visualization of the stent in relation to the corresponding vessel lumen and revealed good expansion of all the stents and good apposition to the vessel wall.     

Progression of dissection due to residual dissection after intracoronary stenting for spontaneous coronary dissection at bifurcation site of LAD and diagonal artery

A 34-year old male patient visited our hospital due to severe chest pain. Initial ECG showed ST elevation at precordial leads and all cardiac enzymes were markedly elevated. Coronary angiography showed a long, longitudinal coronary dissection with dissected flap extending from the proximal LAD to the mid segment of the vessel and proximal diagonal artery. IVUS showed dissected flap and false lumen communicating with true lumen from proximal to mid-LAD. We implanted two paclitaxel-eluting stents using crushing technique at bifurcation lesion and overlapped another paclitaxel-eluting stent at proximal LAD for full coverage of dissection. Final angiography showed good distal flow. However, despite of maximal pressure of post stent ballooning, a residual dissection was noted at proximal LAD. IVUS examination also showed encircling gap that was noted between stent and vessel wall at proximal LAD stent area. Because distal flow was good and there was no ischemic symptom and sign, the patient was discharged. Six months later from index procedure, routine follow-up angiography and IVUS examination were performed and revealed more progressed previous residual coronary dissection at proximal LAD which was extended to bifurcation site. Our case showed, although intracoronary stenting might be an attractive approach by closure of the inlet and the false lumen, complete resolution of dissection by stenting is very important for long-term prognosis.     

Successful retrieval of an entrapped guide wire between a deployed coronary stent and severely calcified vessel wall using excimer laser coronary atherectomy

We report the successful retrieval of an entrapped interventional guide wire between a newly deployed coronary stent and severely calcified vessel wall. Using a buddy wire technique, the stent was deployed at high pressure in a culprit lesion of the left anterior descending (LAD) artery. The buddy wire in the LAD artery was entrapped between the deployed stent and severely calcified vessel wall, as it was not removed before stent deployment, and could not be retrieved. Neither balloon catheters nor a microcatheter were able to be advanced behind the stent over the entrapped guide wire. Excimer laser coronary atherectomy (ELCA) was performed within the stent to modify and soften the calcification behind the deployed stent. Consequently, the entrapped guide wire was retrieved successfully and safely. This case illustrates that ELCA can be utilized to retrieve an entrapped guide wire between a deployed stent and calcified vessel wall. © 2014 Wiley Periodicals, Inc.     

Snare loop technique for removal of broken steerable PTCA wire

Two cases are described of percutaneous removal of trapped, broken steerable PTCA guidewire. One case described breakage of a guidewire inside the ascending aorta leaving a free end, which is retrieved using the snare loop technique. The second case described retrieval of an intact yet unwound wire through the guiding catheter using a snare loop wire.     

Modified crush technique with double kissing balloon inflation (sleeve technique): a novel technique for coronary bifurcation lesions.

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3-5 mm of proximal stent segment into the main vessel. At the same time, a size-matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side-branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.     

A “Simplified” culotte technique using two dedicated bifurcation stents and additional angiographic stent enhancement to treat a complex bifurcation lesion in non‐ST segment elevation myocardial infarction with poor left ventricular function

We present a case of a bifurcation lesion treated with two dedicated sirolimus eluting bifurcation stents, BiOSS Lim in the setting of non‐ST elevation myocardial infarction and poor left ventricular function. We demonstrate the feasibility of a new technique, a “simplified” culotte technique. The key differences of this new technique compared with conventional culotte are: better sizing of the stent due to the specific design of the stent with a larger proximal diameter and smaller distal diameter, direct stenting of the second stent without predilatation of the stent struts of the first deployed stent, and possibility to perform post‐dilatation directly with properly sized balloons without additional predilatation. © 2015 Wiley Periodicals, Inc.     

Modified T-stenting technique with crushing for bifurcation lesions: immediate results and 30-day outcome.

We report a new stenting technique employed in 20 consecutive patients to treat true bifurcation lesions using the Cypher stent (Cordis, Warren, NJ). Both stents are advanced at the site of the bifurcation. The proximal marker of the side-branch stent must be situated in the main branch at a distance of 4-5 mm proximal to the carina of the bifurcation and the main branch stent must cover the bifurcation as well as the protruding segment of the side-branch stent. The side-branch stent is deployed first and balloon and wire are removed. The stent deployed in the main branch completely covers and crushes the protruding segment of the side branch stent against the vessel wall of the main branch. Following main- and side-branch predilatation, stents were successfully deployed in all lesions. Final kissing balloon inflation was performed in seven patients. Two patients had in-hospital myocardial infarction and one patient underwent in-hospital re-PTCA due to a dissection distal to a stent. No other major adverse cardiac events were observed in-hospital and during 1-month clinical follow-up. Treatment of bifurcation lesions using crushing stent technique is feasible with acceptable rate of procedural complications. Angiographic follow-up is necessary to prove the advantage of this specific technique to give complete coverage of the ostium of the side branch with a drug-eluting stent.     

Use of a branch wire to anchor stents for exact placement proximal to bifurcation stents: the reverse Szabo technique.

This report describes a technique for correct positioning of a stent proximal to a bifurcation lesion treated with V-stents. A second wire passed through the first cell of a stent, the opposite end of the anchor wire technique as first described by Szabo et al, facilitated precise stent placement and eliminated erroneous positioning inside or outside the treated bifurcation lesion.     

Treatment of ostial lesions using the Szabo technique: A case series

We present a series of 13 cases of stent treatment of a variety of ostial lesions including aortoostial, subclavian‐internal mammary artery, and coronary artery bifurcation disease using the double‐wire Szabo technique. We discuss relevant technical issues using this technique as well as potential advantages and disadvantages. © 2008 Wiley‐Liss, Inc.     

A novel stenting technique for coronary artery bifurcation stenosis

A novel stenting technique, using one stent strategy, designed to treat type Medina 1,0,0 coronary bifurcation lesions, is described. The atherosclerotic plaque burden in this category of bifurcation lesions is located in the proximal segment of the main branch (MB) of a coronary bifurcation in which the side branch has a sharp angulation (T‐ or reverse‐shaped) relative to the MB. The advantages of this technique are the accurate placement of the stent tailored to cover solely the bifurcation lesion, shoving the plaque burden away from the side branch ostium during stent expansion and the ability to maintain guide wire access in the branch at highest risk of occlusion obviating the need for more cumbersome and time consuming percutaneous coronary intervention procedure. © 2009 Wiley‐Liss, Inc.     

Potential risk of provisional stenting in left main coronary artery bifurcation in multivessel‐related acute coronary syndrome

We present a case of an elderly man suffering from an acute coronary syndrome (ACS) with preshock vital signs and remarkable ST–T wave depression in leads V4–V6, and ST elevation in lead aVR. Coronary angiography showed total occlusion of the right coronary artery (RCA) and impending occlusion in the distal left main coronary artery (LMCA) with a tandem lesion in the proximal left anterior descending artery (LAD). After insertion of an intra‐aortic balloon pump both the LAD and left circumflex artery (LCX) were dilated alternatively; and cross‐over stenting in the LMCA bifurcation was subsequently performed. However, total occlusion of the LCX occurred and it caused acute hemodynamic collapse and ventricular fibrillation storm. Immediate installation of percutaneous cardio‐pulmonary support system allowed stent deployment to be performed in the RCA and subsequent reopening of the LCX that led to a return to sinus rhythm. The patient recovered almost normal left ventricular wall motion and previous activity without any neurological deficit within 2 weeks. Provisional stenting in ACS in the LMCA bifurcation with multivessel disease has a potential risk of acute hemodynamic collapse; a planned two‐stent deployment strategy may assure a higher rate of safety in such cases. © 2011 Wiley‐Liss, Inc.     

Fix and pull technique for retrieval of intracoronary unexpanded-stent entrapment

During left main (LM) bifurcation PCI using T and small protrusion (TAP) technique, after deployment of LM-left anterior descending (LAD) stent, left circumflex (LCx) stent was entangled at LM ostium with balloon and wire slippage. Ping-pong (dual) guide catheters were used to simultaneously fix the LM-LAD stent and snare the trapped stent. This technique proved effective in retrieving the lost stent and minimizing LM stent deformation.     

Retrieval of a detached partially expanded stent using the SpideRX and EnSnare devices--a first report

Stent detachment and loss from the balloon represents a dreaded complication of coronary angioplasty. Previously described techniques of stent retrieval include the distal small balloon technique, the wire braiding technique, the snare technique, the stent crush technique4 and a single report of retrieval with the PercuSurge distal embolic protection device. Partially expanded stents are potentially much more difficult to retrieve from the coronary circulation given their larger profile. We describe a new method of stent retrieval with the use of the SpideRX distal protection basket device to retrieve a partially expanded drug-eluting stent to the iliac artery and subsequent retrieval and externalization of this expanded stent and SpideRX unit in succession with an EnSnare device via a contralateral Balkin sheath.     

Intravascular ultrasound assessment of distal left main bifurcation disease: The importance of the polygon of confluence of the left main,left anterior descending,and left circumflex arteries

Background : The polygon of confluence (POC) represents the zone of confluence of the distal left main (LM), ostial left anterior descending (LAD), and ostial left circumflex (LCX) arteries. Methods : We used intravascular ultrasound (IVUS) to assess the POC pre and post‐drug‐eluting stent implantation for unprotected distal LM disease. Four segments within 82 LM bifurcation lesions were defined by longitudinal IVUS reconstruction: (1) ostial LAD, (2) POC, and (3) distal LM (DLM)—from LAD‐pullback, and (4) ostial LCX from LCX‐pullback. Results : Preprocedural minimum lumen area (MLA) and poststenting minimum stent area (MSA) within the LM were mainly located within the POC (51 and 71%). On ROC analysis, a cut‐off of the MLA within the POC of 6.1 mm² predicted significant LCX carinal stenosis (85% sensitivity, 52% specificity, AUC = 0.7, 95% CI = 0.57–0.78, P < 0.01). Poststenting MSA within the distal LM proximal to the carina (to include DLM and POC) positively correlated with the preprocedural MLA within the POC (r = 0.283, P = 0.02); it was significantly smaller in 48 lesions with a pre‐PCI MLA within the POC < 6.1 mm² versus 25 lesions with a pre‐PCI MLA ≥6.1 mm² (7.5 ± 2.1 mm² vs. 8.6 ± 2.0 mm², P = 0.04). Independent predictors for poststenting LCX carinal MLA also included preprocedural MLA within the POC (β = 0.240, 95% CI = 0.004–0.353, P = 0.04). Conclusion : The MLA within the POC was a good surrogate reflecting the overall severity of LM bifurcation disease including ostial LCX stenosis pre‐PCI and the ability to expand a stent within the distal LM as well as final ostial LCX lumen area post‐PCI. © 2011 Wiley Periodicals, Inc.     

PCI of an ostial LCX stenosis,with protection of LAD,using two guiding catheters

A 65‐year‐old male patient with unstable angina and history of hypertension, diabetes, and hyperlipidaemia was referred for coronary angiography. On the diagnostic procedure, separate ostia of LAD and LCX were found, with a significant lesion in the middle LAD and a high‐grade ostial lesion of LCX, which we considered as culprit. We decided to perform an interventional procedure on both lesions. After positioning a guiding catheter in the LCX ostium, we wanted to protect the LAD, but we could not wire both arteries because of separation between the two ostia. We decided than to engage a second guiding catheter in the LAD ostium and wire the LAD. There were no difficulties in implanting safely a stent in the LCX ostium. After that, we proceeded with a standard intervention on the LAD with stent implantation.