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Case Report
Buddy Wire, Buddy Balloon or Better Together!
December 2007
ABSTRACT: 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™ fixed-wire balloon dilatation catheter was used as a “buddy”, combining the best properties of different techniques in one device.
J INVASIVE CARDIOL 2007;19:E363–E365
Despite numerous advances in the field of interventional cardiology in recent decades, 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. A second “buddy” angioplasty wire is commonly used in this challenging situation1 in order to provide the guiding catheter stability, straighten the tortuous segment of the artery and deflect the stent delivery system away from the calcified area. However, in some cases, despite using one or even several buddy wires, delivery of the stent to the desired area of the artery is still impossible. Here we describe a simple and inexpensive method of using an ACE™ fixed-wire balloon dilatation catheter (Boston Scientific Corp., Natick, Massachusetts) as a “buddy” for stent delivery in a patient with complex vessel anatomy.
Case Report. A 68-year-old male with a history of hypertension, dyslipidemia and chronic renal failure was admitted with acute inferior myocardial infarction 14 hours from the onset of chest pain. The patient was asymptomatic at admission and was treated medically with aspirin, clopidogrel, heparin, atorvastatin and metoprolol. However, 2 days later, the patient underwent cardiac catheterization due to post myocardial infarction angina. The catheterization was performed via the right femoral approach. The culprit lesion was a 90% stenosis in the tortuous and extremely calcified mid-right coronary artery (RCA) (Figure 1). The patient was given 5,000 Units of heparin. The ostium of the RCA was engaged with a 7 Fr JR4 guiding catheter (Cordis Corp., Miami Lakes, Florida). The lesion was crossed with a Balanced Middleweight Universal (BMW) guidewire (Guidant Corp., Indianapolis, Indiana); however, it was impossible to cross the lesion with the 2 x 15 mm and 1.5 x 15 mm Monorail Maverick™ 2 balloons (Boston Scientific). In such cases, we use the ACE balloon dilatation catheter which has a very low crossing profile due to its fixed-wire design (Figure 2). In this case, the 2 x 20 mm ACE balloon easily crossed the lesion and was inflated at 12 atm (Figure 3). Subsequently, the lesion was dilated with the 3.5 x 15 mm DuraStar noncompliant balloon (Cordis) at 20 atm. To our surprise, despite the vessel’s large diameter and optimal predilatation, it was impossible to pass the 4.5 x 18 mm Driver stent (Medtronic Inc., Minneapolis, Minnesota) to the lesion site. The Balanced Heavyweight guidewire (Guidant) was advanced through the lesion and was used as the buddy wire; however, the stent could not be delivered with moderate manipulation whether it was mounted on a BMW or a Balanced Heavyweight wire. Therefore, the BMW was withdrawn and the 2 x 20 mm ACE balloon was inserted into the RCA and parked in the postero-lateral branch (Figure 4). Using the shaft of the ACE balloon as a “buddy”, the 4.5 x 18 mm Driver stent was easily delivered to the lesion site, the ACE balloon was withdrawn and the stent was deployed at 20 atm with an excellent angiographic result (Figure 5). The post procedural course was uneventful and the patient was discharged home 2 days later.
Discussion. The case presented here illustrates a rather frustrating and familiar scenario to the interventional cardiologist: a tortuous calcified vessel without angiographically severe stenosis that effectively precludes delivery of the stent to the desired position. Besides obtaining maximum support from the guiding catheter, choosing a guidewire that provides maximal support and using the most “deliverable” third-generation stent, several special techniques have been developed to overcome this challenging situation. These include the use of one or more buddy wires,1 balloon deflection technique,2 inflated buddy balloon technique,3 use of the Wiggle Wire with sinusoidal design4 and others. All these methods share the same principle: to deflect the stent delivery system away from the calcified plaque while maintaining the guiding catheter’s stability.
The ACE fixed-wire balloon dilatation catheter has a unique design featuring a core wire to the distal tip to provide steerability. This makes its thin (1.8 Fr) shaft an excellent “buddy”, combining the best properties of a buddy wire and a buddy balloon in one device. It is steerable and has excellent torque response to facilitate its delivery to the distal segments of the artery in the most difficult anatomies, providing an anchor for the guiding catheter. Of note, a gentle inflation of the balloon will make its anchor properties even better, although this was not needed in this case. The shaft of the ACE balloon is stiff enough to straighten the tortuous segments of the artery and to act like a “shoe horn” for the stent delivery system. Due to the absence of an inner lumen for the angioplasty wire, the ACE balloon has a very low crossing profile and can be used for both predilatation and, subsequently, to facilitate the delivery of the stent to the lesion, acting as a “buddy wire balloon”. This relatively simple technique also potentially reduces the risk of coronary artery dissection related to deep intubation of the guiding catheter that might otherwise be necessary.
In conclusion, we describe here a simple, inexpensive and reliable technique for easy passage of stents or other angioplasty devices through tortuous, calcified or previously stented segments of coronary arteries. References 1. Burzotta F, Trani C, Mazzari MA, et al. Use of a second buddy wire during percutaneous coronary interventions: A simple solution for some challenging situations. J Invasive Cardiol 2005;17:171–174. 2. Abernethy WB 3rd, Choo JK, Oesterle SN, Jang IK. Balloon deflection technique: A method to facilitate entry of a balloon catheter into a deployed stent. Catheter Cardiovasc Interv 2000;51:312–313. 3. Dana A, Barbeau GR. The use of multiple “buddies” during transradial angioplasty in a complex calcified coronary tree. Catheter Cardiovasc Interv 2006;67:396–399. 4. Simons AJ, Caputo RP, Gaimbartolomei A. Successful placement of a stent in a previously treated un-stentable vessel segment, made possible by the ACS Hi-Torque Wiggle Wire: A case report. J Invasive Cardiol 2004;16:28; Discussion 29–30.
Despite numerous advances in the field of interventional cardiology in recent decades, 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. A second “buddy” angioplasty wire is commonly used in this challenging situation1 in order to provide the guiding catheter stability, straighten the tortuous segment of the artery and deflect the stent delivery system away from the calcified area. However, in some cases, despite using one or even several buddy wires, delivery of the stent to the desired area of the artery is still impossible. Here we describe a simple and inexpensive method of using an ACE™ fixed-wire balloon dilatation catheter (Boston Scientific Corp., Natick, Massachusetts) as a “buddy” for stent delivery in a patient with complex vessel anatomy.
Case Report. A 68-year-old male with a history of hypertension, dyslipidemia and chronic renal failure was admitted with acute inferior myocardial infarction 14 hours from the onset of chest pain. The patient was asymptomatic at admission and was treated medically with aspirin, clopidogrel, heparin, atorvastatin and metoprolol. However, 2 days later, the patient underwent cardiac catheterization due to post myocardial infarction angina. The catheterization was performed via the right femoral approach. The culprit lesion was a 90% stenosis in the tortuous and extremely calcified mid-right coronary artery (RCA) (Figure 1). The patient was given 5,000 Units of heparin. The ostium of the RCA was engaged with a 7 Fr JR4 guiding catheter (Cordis Corp., Miami Lakes, Florida). The lesion was crossed with a Balanced Middleweight Universal (BMW) guidewire (Guidant Corp., Indianapolis, Indiana); however, it was impossible to cross the lesion with the 2 x 15 mm and 1.5 x 15 mm Monorail Maverick™ 2 balloons (Boston Scientific). In such cases, we use the ACE balloon dilatation catheter which has a very low crossing profile due to its fixed-wire design (Figure 2). In this case, the 2 x 20 mm ACE balloon easily crossed the lesion and was inflated at 12 atm (Figure 3). Subsequently, the lesion was dilated with the 3.5 x 15 mm DuraStar noncompliant balloon (Cordis) at 20 atm. To our surprise, despite the vessel’s large diameter and optimal predilatation, it was impossible to pass the 4.5 x 18 mm Driver stent (Medtronic Inc., Minneapolis, Minnesota) to the lesion site. The Balanced Heavyweight guidewire (Guidant) was advanced through the lesion and was used as the buddy wire; however, the stent could not be delivered with moderate manipulation whether it was mounted on a BMW or a Balanced Heavyweight wire. Therefore, the BMW was withdrawn and the 2 x 20 mm ACE balloon was inserted into the RCA and parked in the postero-lateral branch (Figure 4). Using the shaft of the ACE balloon as a “buddy”, the 4.5 x 18 mm Driver stent was easily delivered to the lesion site, the ACE balloon was withdrawn and the stent was deployed at 20 atm with an excellent angiographic result (Figure 5). The post procedural course was uneventful and the patient was discharged home 2 days later.
Discussion. The case presented here illustrates a rather frustrating and familiar scenario to the interventional cardiologist: a tortuous calcified vessel without angiographically severe stenosis that effectively precludes delivery of the stent to the desired position. Besides obtaining maximum support from the guiding catheter, choosing a guidewire that provides maximal support and using the most “deliverable” third-generation stent, several special techniques have been developed to overcome this challenging situation. These include the use of one or more buddy wires,1 balloon deflection technique,2 inflated buddy balloon technique,3 use of the Wiggle Wire with sinusoidal design4 and others. All these methods share the same principle: to deflect the stent delivery system away from the calcified plaque while maintaining the guiding catheter’s stability.
The ACE fixed-wire balloon dilatation catheter has a unique design featuring a core wire to the distal tip to provide steerability. This makes its thin (1.8 Fr) shaft an excellent “buddy”, combining the best properties of a buddy wire and a buddy balloon in one device. It is steerable and has excellent torque response to facilitate its delivery to the distal segments of the artery in the most difficult anatomies, providing an anchor for the guiding catheter. Of note, a gentle inflation of the balloon will make its anchor properties even better, although this was not needed in this case. The shaft of the ACE balloon is stiff enough to straighten the tortuous segments of the artery and to act like a “shoe horn” for the stent delivery system. Due to the absence of an inner lumen for the angioplasty wire, the ACE balloon has a very low crossing profile and can be used for both predilatation and, subsequently, to facilitate the delivery of the stent to the lesion, acting as a “buddy wire balloon”. This relatively simple technique also potentially reduces the risk of coronary artery dissection related to deep intubation of the guiding catheter that might otherwise be necessary.
In conclusion, we describe here a simple, inexpensive and reliable technique for easy passage of stents or other angioplasty devices through tortuous, calcified or previously stented segments of coronary arteries. References 1. Burzotta F, Trani C, Mazzari MA, et al. Use of a second buddy wire during percutaneous coronary interventions: A simple solution for some challenging situations. J Invasive Cardiol 2005;17:171–174. 2. Abernethy WB 3rd, Choo JK, Oesterle SN, Jang IK. Balloon deflection technique: A method to facilitate entry of a balloon catheter into a deployed stent. Catheter Cardiovasc Interv 2000;51:312–313. 3. Dana A, Barbeau GR. The use of multiple “buddies” during transradial angioplasty in a complex calcified coronary tree. Catheter Cardiovasc Interv 2006;67:396–399. 4. Simons AJ, Caputo RP, Gaimbartolomei A. Successful placement of a stent in a previously treated un-stentable vessel segment, made possible by the ACS Hi-Torque Wiggle Wire: A case report. J Invasive Cardiol 2004;16:28; Discussion 29–30.
