Buddy wire technique: a simple technique for treating calcified lesion during percutaneous coronary intervention: a case report

The buddy wire technique, i.e., using an additional 0.014 inch coronary guidewire along with the one being used to advance balloons, stents or other devices help to accomplish otherwise challenging procedures during percutaneous coronary intervention (PCI). It improves the balloon or stent support and also provides the guiding catheter stability. It is a simple, quick, easily available and deliverable method for complex lesions during PCI. We report technical aspects of a case of a mid-left anterior descending (LAD) calcified lesion in which a buddy wire facilitated the procedural success of PCI.     

Use of a second buddy wire during percutaneous coronary interventions: a simple solution for some challenging situations

The buddy wire technique, i.e. the use of a second 0.014 inch guide wire placed alongside the one employed to advance balloons and stents inside the coronary artery during percutaneous coronary intervention (PCI), may help in a series of procedural challenges during PCI. Indeed, by improving both the stability of the guiding catheter and the support for balloon and stent, a buddy wire use is sometimes the simplest way to accomplish a successful procedure. In this paper, we discuss technical aspects of some specific circumstances frequently encountered during PCI, in which a buddy wire may be helpful. These include: 1) The reduction of balloon slippage during angioplasty for in-stent restenosis; 2) insufficient back-up of the guiding catheter; 3) stenting of lesions located in vessels with proximal tortuosities/angulations; 4) stenting of lesions distally located in the vessel; 5) facilitation in the positioning of distal protection devices; 6) stenting of a lesion distally located from a previously implanted stent or from a coronary segment with both calcification and sharp bend; 7) PCI on coronary arteries with anomalous origin. Because of its simplicity, low cost, and availability, the use of a buddy wire should be considered when dealing with the aforementioned conditions during PCI procedures.     

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.     

"Buddy wire" technique to overcome proximal coronary tortuosity during rotational atherectomy

We report a case in which rotational atherectomy was planned for the treatment of a severely calcified obstructive lesion in the middle right coronary artery. Severe proximal vessel tortuosity prevented the advancement of the Rotablator burr. We utilized the "buddy wire" technique, allowing facilitated advancement of the Rotablator and successful atherectomy and stenting. We propose this old technique as an alternative method to allow advancement of the Rotablator burr through tortuous and calcified vessels.     

Buddy wire technique for stent placement at non-aorto ostial coronary lesions

Percutaneous coronary intervention (PCI) of coronary non-aorto ostial lesions offers technical challenges not encountered with other lesion sub types. Stenting of these lesions improves acute angiographic result and lowers the rate of restenosis. However, precise stent placement at non-aorto ostial lesions is technically difficult with risk of incomplete lesion coverage or jailing of the main branch. In this report, we describe a buddy wire technique to facilitate precise stent placement at non-aorto ostial lesions.     

Buddy wire, buddy balloon or better together!

The inability to cross tortuous, calcified or previously stented segments with an angioplasty balloon or coronary stent remains one of the frequent causes of the procedural failure. Numerous techniques have been developed to facilitate stent delivery in this situation: buddy wire, balloon deflection and use of specially designed guidewires. We report a case in which an ACE(R) fixed-wire balloon dilatation catheter was used as a "buddy", combining the best properties of different techniques in one device.     

The "Proxis-Tornus" technique for a difficult-to-cross calcified saphenous vein graft lesion

Severely calcified lesions may occasionally be difficult to cross. We report a case of emergency percutaneous coronary intervention of a calcified saphenous vein graft lesion. We were unable to cross the lesion with a balloon despite using a 7 Fr guiding catheter, a buddy wire and the Tornus catheter, which was likely due to poor guide support. We describe successful crossing and treatment of the lesion by simultaneously using the Proxis proximal occlusion embolic protection device and the Tornus catheter.     

Old technique, new use: novel use of a buddy wire to deploy a detached stent

Stent dislodgement or loss in a coronary artery carries significant risks of infarction, thrombosis and requirement for emergency bypass surgery. Even with the advent of premounted stents, stent loss can occasionally occur, especially when performing intervention in calcified and tortuous anatomy. Multiple stent retrieval/stent exclusion techniques have been described to overcome this dreaded complication. We describe the first case of deploying a dislodged stent using a buddy wire technique with both wires through the center of the dislodged stent, and subsequent use of the small balloon technique to successfully deploy a dislodged stent in a heavily calcified and tortuous circumflex artery.     

Two "buddies" may be better than one: use of two buddy wires to expand an underexpanded left main coronary stent

Stent underexpansion is a catastrophic complication of stent implantation that can usually be treated with high-pressure balloon dilatation. We report a case of emergency, unprotected distal left main coronary artery stenting, in which the left main stent remained under-expanded in spite of multiple high-pressure balloon inflations, cutting balloon angioplasty, and angioplasty using one buddy wire. The stent eventually expanded after balloon angioplasty using a double buddy wire technique.     

Difficult stent delivery: Use of an aspiration catheter as a “sheath”

This is a report of a case in which stent delivery to the lesion location proved difficult because of severely calcified and tortuous proximal vasculature. Efforts to deliver a stent using a buddy wire, anchoring technique and five‐in‐seven guiding system were unsuccessful, whereas an aspiration catheter enabled stent delivery to the target lesion. This technique offers a potential alternative for cases in which some stent delivery methods are problematic. In addition, this technique may also prevent potential injury to drug‐eluting polymer during stent delivery. © 2008 Wiley‐Liss, Inc.     

Guideliner microcatheter to improve back-up support during a complex coronary stenting procedure through a tortuous left internal mammary graft

Back-up support during percutaneous coronary interventions (PCI) is one of the keys for successful intervention. Extra back-up support guiding catheters, deep intubation, buddy wires, and other more complex techniques are usually used to improve this support. Left anterior descending (LAD) artery PCI through the left internal mammary artery (LIMA) are rarely performed because many operators feel reluctant to instrument a disease-free LIMA graft risking iatrogenic complications by passing wire, balloons, and stents to the diseased distal LAD. Improving back-up support during LIMA-LAD PCIs is often challenging because in this particular setting the distance between the LAD lesion and the guiding catheter is exceedingly long. We report a case of a challenging PCI of the LAD through a patent and disease-free LIMA graft. After multiple failed attempts to cross the LAD lesion with conventional stent deployment techniques, we successfully finished the stenting procedure using the Guideliner microcatheter (Vascular Solutions) as a guiding extension through the LIMA graft. With this case, we illustrate that this microcatheter dramatically improves the back-up support, allowing stent deployment also in very difficult settings as in tortuous LIMA grafts.     

Impact of 16-slice computed tomography in percutaneous coronary intervention of chronic total occlusions.

The main reason for failure of percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) is because the calcified plaque prevents the guide wire crossing the occlusion. We aimed to identify the route, and characterize plaque components within CTO, using 16-slice computed tomography (MSCT). Twenty three angiographic CTO in 22 patients (mean age 69 +/- 5 years, 17 males) were included. All patients had undergone MSCT prior to PCI. Images were analyzed for lesion visibility and plaque characteristics of CTO. The presence and location of calcified plaque within the CTO were systematically assessed. Each lesion was classified as a noncalcified, moderately calcified, or exclusively calcified plaque. Procedural failure was defined as the inability to cross a guide wire through the occlusion. All coronary routes of CTO segment were visualized. MSCT revealed three markedly bent CTO segments (13.0%), which could not be identified by coronary angiography only. Calcified plaques were detected in 30 lesions of 19 CTO segments (82.6%), but were not detected in the other four. The majority of calcified plaque was located in the proximal lesion, or both proximal and distal lesions. Fifteen out of 30 calcified lesions (50.0%) were exclusively calcified plaques. Overall procedural success was obtained in 21 CTOs (91.3%). MSCT can accurately identify the route of the CTO segment and evaluate both distribution and amount of the calcified plaque within it. Even with the complicated and/or calcified lesions, PCI success rate was excellent under MSCT guidance. MSCT should become a useful tool in PCI of CTO.     

Ostial RCA intervention: guiding catheter challenges and use of a buddy wire to perform focused-force angioplasty on a severely calcific ostial right coronary lesion

Ostial coronary disease presents a challenge from multiple perspectives with regard to percutaneous intervention. We present a novel case of a technically challenging ostial right coronary artery calcified lesion with a bar of calcium at the aorto-ostial junction which prevented intubation with multiple guiding catheters. We describe the use of a buddy wire as a technique for focused-force angioplasty with slow incremental balloon inflation of increasing diameter for plaque modification prior to stenting in a situation where rotational atherectomy and cutting balloon angioplasty were not an option.     

Percutaneous coronary Intervention for ostial occlusion lesion of an anomalous right coronary artery

Ostial lesions present many challenges for percutaneous coronary intervention （PCI）. Coronary anomaly will further increase difficulties in performing PCI for the patient. We present such a case as ostial occlusion of an right coronary artery with high takeoff. A 77-year-old male was referred to our institution with a diagnosis of non-ST elevated acute myocardial infarction. Selective coronary angiography and nonselective ascending aortography could not identify the origin of the right coronary artery. Multi-slices computed tomography showed RCA ostial totally occluded. A successful PCI was performed and a perfect final result was achieved utilized with many tips and tricks, including buddy wtre technique and focused-force angloplasty（J Genatr Cardio12009, 6：189-192）.     

Three-dimensional optical coherence tomography reconstruction of bifurcation stenting using the Szabo anchor-wire technique

Ostial lesions present unique challenges for percutaneous coronary intervention(PCI). These lesions are often more calcified,fibrotic,rigid,and more prone to elastic recoil. Intervention on these lesions is associated with higher procedural complications and higher rates of restenosis. Ostial lesions require precise stent placement in the ostium with the absence of side branch compromise. Accurate stent placement in the ostium without side branch compromise is difficult to accomplish with angiography alone. The Szabo technique uses two coronary guidewires for the correct placement in the aorto-ostial or bifurcation lesion. One guidewire is passed through the final cell of the stent strut and acts as the anchor wire. It helps to prevent migration of the stent beyond the ostium and facilitates the precise stenting at the ostium. This technique has several advantages including less reliance on angiography,lower rates of stent malposition and lower rates of incomplete stent coverage. Potential disadvantages include stent distortion and dislodgement from stent manipulation. We describe two cases of successful PCI to bifurcation lesions using the Szabo technique and confirmation of correct placement in the ostium with optical coherence tomography.     

Potential contribution of open-cell stent design to balloon entrapment and review of techniques to recover

Balloon entrapment during coronary angioplasty is a rare but potentially disastrous complication of percutaneous coronary intervention (PCI), described during both angioplasty alone, as well as with stents. This report describes the case of an entrapped stent-balloon within an extremely calcified proximal left anterior descending artery (LAD) lesion, and reviews techniques and strategies that can be applied in similar situations. In this case, we suspect the open-cell design of the specific stent used, combined with the high radial force of the calcified lesion, led to a "pincer effect," and entanglement of the balloon material within the stent scaffolding. After exhaustion of all percutaneous options to retrieve the balloon, the patient was ultimately taken for urgent cardiac surgery for extraction of the balloon and vein patch of the LAD.     

中重度冠状动脉钙化对介入治疗即刻疗效的影响

目的观察中重度冠状动脉钙化对冠状动脉介入治疗即刻疗效的影响。方法连续收集84例冠心病患者(84处靶病变),在冠状动脉支架置入术前后,通过血管内超声分析冠状动脉斑块特征、评估支架置入情况,并收集临床资料及介入操作相关信息,根据结果分为无钙化组36例和中重度钙化组48例,所有钙化病变均给予充分预扩张,并在血管内超声指导下视情况给予后扩张处理,对比2组PCI前后临床及影像学特征。结果 PCI后中重度钙化组置入支架直径、术后最小支架直径、最小支架横截面积、即刻管腔获得及相对管腔获得均小于无钙化组(P<0.05),PCI前中重度钙化组单支病变、靶病变B1型、斑块偏心指数、远端参考外弹力膜面积及管腔面积小于无钙化组(P<0.05,P<0.01)。而2组支架对称性、膨胀指数、手术并发症、院内主要不良心血管事件发生率比较,差异无统计学意义(P>0.05);2组术前最小管腔截面积、斑块负荷、管腔面积狭窄率、重构指数、病变长度差异无统计学意义(P>0.05)。结论血管内超声指导下给予充分预扩张及非顺应性高压球囊后扩张处理后,中重度钙化仍然影响PCI术后即刻管腔获得,但最终管腔面积基本理想。     

Chronotropic impairment after surgical or percutaneous closure of atrial septal defect

The “buddy‐in‐jail” technique is a novel method for increasing support during percutaneous coronary intervention. We report two case‐based examples of successful coronary stent delivery using the jailed buddy wire technique. © 2009 Wiley‐Liss, Inc.     

Successful Expansion of an Underexpanded Stent by Rotational Atherectomy

The current routine use of intracoronary stents in percutaneous coronary intervention (PCI) has significantly reduced rates of restenosis, compared with balloon angioplasty alone. On the contrary, small post-stenting luminal dimensions due to undilatable, heavily calcified plaques have repeatedly been shown to significantly increase the rates of in-stent restenosis. Rotational atherectomy of lesions is an alternative method to facilitate PCI and prevent underexpansion of stents, when balloon angioplasty fails to successfully dilate a lesion. Stentablation, using rotational atherectomy to expand underexpanded stents deployed in heavily calcified plaques, has also been reported. We report a case via the transradial approach of rotational-atherectomy–facilitated PCI of in-stent restenosis of a severely underexpanded stent due to a heavily calcified plaque. We review the literature and suggest rotational atherectomy may have a role in treating a refractory, severely underexpanded stent caused by a heavily calcified plaque through various proposed mechanisms.     

Orbital atherectomy for severely calcified lesions: More dissections in women but similar 30‐day outcomes to men

• Calcified lesions are associated with lower rates of successful percutaneous coronary intervention (PCI), greater stent thrombosis, and increased target vessel revascularization. Women undergoing PCI are more often older than men and likely to present with severe lesion calcification.
• The ORBIT II study, for the first time compares the effect of the orbital atherectomy system (OAS) in men and women undergoing PCI for severely calcified lesions. Although the adjusted risk of severe dissections was higher in women, the incidence of in‐hospital and 30‐day outcomes was similar to men.
• Randomized comparisons of the OAS with rotational atherectomy and with stenting without atherectomy are needed to further elucidate sex‐based differences in calcified lesion PCI.