Facilitated advancement of the Palmaz-Schatz stent delivery system with the use of an adjacent 0.018" stiff wire

Percutaneous Extraction of Deployed Coronary Stent During Retrieval of Jailed Buddy Wire

Retrieval of a buddy wire following coronary stenting of long, tortuous, and calcified lesions runs the risk of wire entrapment and stent deformation. We report a case of successful percutaneous extraction of a longitudinally deformed coronary stent during retrieval of jailed buddy wire from the left anterior descending artery. (Level of Difficulty: Advanced.).

Carotid Artery Stenting Using the Snake Hunt Technique for Highly Tortuous Carotid Artery Stenosis: A Technical Note

In carotid artery stenting (CAS) for highly tortuous carotid stenosis, it is often difficult to guide rigid devices such as carotid stents. There are various adjunctive techniques using a guidewire: the buddy wire technique, the sheep technique, and the stiff guide technique. We report a case in which the tortuous vessel was straightened and a stent could be inserted. A 64-year-old man with amaurosis had highly tortuous left carotid stenosis. Despite the best medical treatments, he often had transient cerebral ischemic symptoms, so we planned CAS. We could insert the first stent, but the proximal vessel was kinked by the placement of the stent. It was so tortuous that the second stent could not be inserted by adjunctive techniques. Therefore, the proximal balloon was inflated and pulled back to straighten the tortuous vessel, and then we could insert the stent. We named this technique the "snake hunt technique" because it was just like catching a snake given that the tortuous vessel was stretched. This technique could be a troubleshooting step when it is difficult to insert a stiff device such as a stent or balloon even with the use of various adjunctive techniques.

Anchor balloon, buddy wire, and wire and sheath techniques to deploy percutaneous pulmonary valves in tetralogy of fallot patients

Advances in surgical techniques in tetralogy of Fallot (TOF) patients have improved survival of these patients into adulthood. The procedure requires right ventricular outflow tract or trans-annular patch with resultant pulmonary stenosis and/or regurgitation. As such, adult patients seen with this condition may have increasing right ventricular hypertrophy and/or right ventricular dilation. Recently, the Sapien XT valve (Edwards Lifesciences, CA) was approved by the FDA for pulmonary implantation. In some cases, advancing the valve in right ventricular outflow tract is difficult. This is a case series of delivering Sapien XT valves in TOF patients with severe pulmonary regurgitation and/or stenosis, using the anchor balloon, buddy wire, and the novel, wire and sheath techniques. © 2017 Wiley Periodicals, Inc.

Degenerated Saphenous Vein Graft Intervention: Should We Target the Native Vessel instead?

Coronary interventions of degenerated saphenous vein grafts (SVGs) continue to present a management challenge. Although repeat coronary artery bypass grafting (CABG) remains a significant risk factor for operative mortality, percutaneous coronary intervention (PCI) is still associated with a high risk for periprocedural events. There is a lack of consensus on the optimal treatment strategy for patients with severe stenosis of SVGs. It is imperative to review the characteristics of native versus SVG disease, risk factors for complications after SVG intervention, procedural treatment strategies important to the decision on which therapeutic strategy to follow, and measures to mitigate the risks of periprocedural complications.

Distal balloon deflation technique: a new method to facilitate entry of balloon catheter, stent, and guiding catheter to distal lesion

We occasionally encountered difficult cases of balloon and stent delivery to the distal lesion because of narrow stent strut, severe calcification, or tortuosity of the proximal section. We describe a new technique to deliver balloon, stent, and guiding catheter to the distal lesion using a distal balloon deflation. This technique offers a potential alternative for cases in which the delivery of balloon and stent is difficult.

The "buddy-in-jail" technique-a novel method for increasing support during percutaneous coronary intervention

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.

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.

Retrograde application of the buddy wire technique

We report the case of an 85-year-old man who presented with worsening exertional dyspnoea 18 months after coronary artery bypass surgery for critical three vessel coronary artery disease. Coronary angiography revealed an anastomotic stricture between a radial artery graft and the first diagonal branch. Percutaneous coronary intervention utilizing a retrograde application of the "buddy" wire technique was then performed.

Vertebral artery origin stenting with buddy wire technique in tortuous subclavian artery

Catheterization of vessels with severe tortuosity and atherosclerotic changes may represent a technical challenge and is associated with a higher incidence of vascular complications [Putman CM, Chaloupka JC. Use of large-caliber coronary guiding catheters for neurointerventional applications. AJNR Am J Neuroradiol 1996;17:697-704]. Placement of guiding catheter to the tortuous subclavian artery in vertebral artery origin stenting procedure is such a condition with difficulties. In the presence of severe tortuosity of aortic arch and proximal subclavian artery placement of guiding catheter may be difficult and yield poor backup support. We describe a technique that uses a buddy wire to make the guiding catheter stable in its proper position and make possible to perform stenting the vertebral artery origin stenosis.

Cathétérisme triple axial renforcé des tortuosités cervico-encéphaliques

Tortuous anatomy of the cervicoencephalic vessels can cause failure in 4 to 6% of interventional procedures by slippage of the material back in the aorta, kinking or difficulty to move forward a balloon. stent or microcatheter. We report on an old patient with high vascular tortuosity, referred for embolization of a ruptured aneurysm of the left inferior cerebellar artery. Access wasn't possible until we used a "triple axial system" with a long 7F sheath, positioned in the left subclavian artery and strongly supported by a super stiff guidewire with its distal end floating freely in the vascular lumen. Inside the sheath and parallel to the guidewire, we pushed a 4F catheter till the mid-vertebral artery. The microcatheter-microguide system tracked through it, towards the aneurysm, with the backward tendency being neutralized by the increased stiffness. Our technique presents the advantage of a strong back-up support, without increased risks such as vasospasm, clotting or dissection, since the guidewire serving as a stiff rail, lies exteriorly to the navigated vessel. Efficiency of this elegant and relatively low risk solution has yet to be proved in larger series.

New method to increase a backup support of a 6 French guiding coronary catheter

A 6 Fr guiding catheter is commonly used in the percutaneous coronary intervention (PCI). However, one of the limitations of the 6 Fr guiding catheter is its weak backup support compared to a 7 or an 8 Fr guiding catheter. In this article, we present a new system for PCI called the five-in-six system. Between March 2003 and September 2003, this system was tried on eight chronic total occlusion cases. The advantage of the five-in-six system is that it increases backup support of a 6 Fr guiding catheter.

Rotaglide-facilitated stent delivery: mission accomplished

Percutaneous coronary interventions are performed with a high success rate, though failures still occur. Inability to deliver stents to the target lesion is the most common cause for failures. We present two cases using Rotaglide applied on the stents to enable delivery, showing that Rotaglide is effective in improving stent delivery.

Novel technique for stent delivery in tortuous coronary arteries: report of three cases

We present a novel technique for stent delivery across tortuous lesions. Gentle forward pressure was applied on the stent balloon while the balloon was inflated to 2-3 atm. This resulted in the balloon and stent crossing the impeding segment and settling in the target site where it was deployed with excellent angiographic outcome.

Amplatzing a 6 Fr Judkins right guiding catheter for increased success in complex right coronary artery anatomy

Stent supported angioplasty is being performed in an increasing number of patients and, with advances in device technology, more morphologically complex lesions are being treated. In such a setting, it is extremely important to deliver the device to the target lesion. We describe a new technique that allows successful stent delivery in complex right coronary anatomy using the Judkins right guiding catheter. Cathet Cardiovasc Intervent 2001;53:405-409.

Nonsurgical retrieval of embolized coronary stents

Embolization of coronary stents before deployment is a rare but challenging complication of coronary stenting. Different methods for nonsurgical stent retrieval have been suggested. There were 20 cases (0.90%) of intracoronary stent embolization among 2,211 patients who underwent implantation of 4,066 stents. Twelve of 1,147 manually crimped stents (1.04%) and eight of 2,919 premounted stents were lost (0.27%, P < 0.01) during retraction of the delivery system, because the target lesion could not be either reached or crossed. Percutaneous retrieval was successfully carried out in 10 of 14 patients (71%) in whom retrieval was attempted. In 10 patients, stent retrieval was tried with 1.5-mm low-profile angioplasty balloon catheters (success in 7/10) and in seven cases with myocardial biopsy forceps or a gooseneck snare (success in 3/7). Three patients (15%) underwent urgent coronary artery bypass surgery after failed percutaneous retrieval, but their outcomes were fatal. In two patients, stents were compressed against the vessel wall by another stent, without compromising coronary blood flow. In two patients, a stent was lost to the periphery without clinical side effects; treatment was conservative in these cases. Embolization of stents before deployment is a rare but serious complication of coronary stenting, with hazardous potential for the patient. Manual mounting of stents is associated with a significantly higher risk of stent embolization. Stent retrieval from the coronary circulation with low-profile angioplasty balloon catheters is a readily available and technically familiar approach that has a relatively high success rate.

Successful stent delivery with deep seating of 6 French guiding catheters in difficult coronary anatomy

Despite improvements in coronary stent design, delivery difficulties may still be encountered. Between April 1996 and September 1998, 945 patients underwent coronary stenting in our Institute. New 6 Fr Long Brite Tip (LBT) guiding catheters, allowing deep coronary artery intubation and increased backup support, were used in 25 (2.6%) of these patients presenting complex coronary anatomy and poor stent accessibility, electively in 3 (12%) and after stent delivery failure with multiple (2.1 +/- 1.2) standard guiding catheters in 22 (88%). Deep coronary artery intubation (>/= 20 mm) was successfully performed in 22 (88%) patients and was associated with adequate pressure recording and contrast opacification without blood flow compromise. Ten (22.7%) Palmaz-Schatz stents and 34 (77.3%) second-generation stents of various lengths were successfully delivered to different coronary vessels (RCA = 15, LAD = 9, LCx = 1) in all patients in whom deep coronary intubation was obtained. These data demonstrate that deep coronary artery cannulation with LBT catheters is feasible and safe and may markedly increase the rate of stent delivery success in very complex coronary anatomy and when standard guiding catheters have failed.

Push-pull angioplasty: ACE balloon-facilitated stent passage technique

Improvements in interventional cardiology equipment have facilitated the treatment of more complex anatomies. Bulky stent transport systems and the inflexibility of stents have remained a limitation to the delivery of stents to distal, angulated, stiff, and calcified vessels. In order to provide the strongest guide backup, some vessel straightening, and a stiff rail over which the stent apparatus could be passed, an ACE balloon was advanced past the target lesion and used to trap the distal wire by gently inflating the ACE balloon at low pressure. Traction is then placed on the ACE catheter and the angioplasty guide wire at the touey valve insertion site. This procedure facilitates easy passage of angioplasty devices through challenging anatomies. In addition to the two case reports described, this technique has been used numerous other times with consistent success. Cathet. Cardiovasc. Intervent. 48:93-95, 1999.

Bent stents: a method to facilitate delivery of the Palmaz-Schatz stent in tortuous and rigid coronary arteries

The Palmaz-Schatz stent delivery system (PS 153) and "bare" PS 204 stents are relatively high-profile, rigid devices that can be difficult to deliver to lesions beyond tortuous, irregular, or rigid proximal segments. Described herein is a method of mounting and shaping a Palmaz-Schatz stent on a low-profile balloon that provides a steerable, low-profile, and secure stent delivery system. Also described is the successful use of this method in four consecutive cases where Palmaz-Schatz stents could not be delivered to the lesion site due to severely angulated, irregular, or rigid proximal vessel segments.