The Crooked Buddy Technique: Use of a Wiggle Wire‚Ñ¢ Alongside an Extra Support Wire to Improve Device Deliverability

ABSTRACT: The buddy wire is a useful technique for difficult-to-cross lesions that are typically identified by poor guide support, vessel tortuosity, calcification and/or prior stent placement. We present 5 cases of percutaneous coronary interventional success involving difficult-to-cross lesions using the “crooked buddy” technique, a unique combination of the Wiggle guidewire as the rail and an extra support guidewire as the buddy wire. From our experience, we recommend that when difficult-to-cross lesions are identified, moving quickly to the crooked buddy technique may avoid unnecessary equipment, contrast and procedure time.

J INVASIVE CARDIOL 2010;22:377–381

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The buddy wire, a second 0.014 inch coronary artery guidewire placed alongside the working wire, can aid in the delivery of balloons and stents through calcified and/or tortuous vessels.¹ This well-known technique helps to straighten the artery and improve guide catheter support. Two standby wires often used in difficult cases are the Wiggle wire™ (Abbott Vascular, Santa Clara, California) and the Grand Slam™ wire (Abbott Vascular). The Iron Man wire (Abbott Vascular) was another commonly used support wire that is no longer available and in our laboratory has been replaced by the Grand Slam wire. The Wiggle Wire has a series of corrugations or bends near the tip that help deflect the leading edge of a balloon or stent away from potential obstructions in the vessel wall such as calcified plaque or the struts of previously placed stents. On the other hand, the Grand Slam wire is an extra-support wire that is often effective in difficult cases where there is poor guide support and/or a tortuous vessel. In this series we report 5 cases in which the buddy wire technique was successfully employed using a combination of the Wiggle wire and the Grand Slam or Iron Man wire when other techniques were ineffective. A similar series of cases using the Wiggle wire in combination with various extra-support wires as the buddy wire has been previously reported from another institution in abstract form.²Case 1. A 69-year-old male with a history of dyslipidemia and hypertension presented with an acute inferior ST-elevation myocardial infarction. The dominant, shepherd’s crook right coronary artery (RCA) was heavily calcified and ectatic with a high-grade stenosis in the mid RCA just distal to the takeoff of an acute marginal (Figure 1A) with intermittent thrombolysis in myocardial infarction (TIMI) 1 flow (American College of Cardiology/American Heart Association classification type C lesion).³ Initial attempts to deliver a balloon or microcatheter using a 6 French (Fr) JR4 guide (Cordis Corp., Miami Lakes, Florida) followed by an AL-1 guide (Cordis) were unsuccessful. We sized up to a 7 Fr AL-2 guide (Cordis) and were subsequently able to place a Whisper wire™ (Abbott Vascular) into the distal RCA. Rotational atherectomy was considered at this point, however, given the proximal tortuosity and likely presence of thrombus, we decided against this. After serial inflations with up to a 3.5 x 15 mm Maverick balloon (Boston Scientific Corp., Natick, Massachusetts), we were unable to deliver a 4.0 x 24 mm Driver stent (Medtronic, Inc., Minneapolis, Minnesota). Subsequent attempts to deliver the stent with an Ironman wire by itself as the rail, and then with a S’port wire as the rail and an Iron Man wire as the buddy wire, were unsuccessful. Ultimately, we used the Ironman wire as the buddy wire and a Wiggle wire as the rail to successfully deliver and deploy a 4.0 x 24 mm Driver stent. The stent was then posted with a 4.5 mm Quantum Maverick balloon (Boston Scientific) to high pressure, and final angiography demonstrated 10% residual stenosis, TIMI II flow and occlusion of the right ventricular branch (Figure 1B). Case 2. An 81-year-old male with a history of hypertension, hyperlipidemia, diabetes, renal insufficiency, as well as coronary artery disease status post prior coronary artery bypass grafting, and ischemic cardiomyopathy with an ejection fraction of 26% and New York Heart Association class III heart failure was referred for percutaneous coronary intervention (PCI). He had been found on prior angiography to have a high-grade stenosis at the anastamosis of a saphenous vein graft (SVG) to the distal left anterior descending (LAD) (type C lesion) (Figure 2A). The distal limb of the LAD was chronically occluded and prior nuclear stress testing showed the apex to be infarcted and the territory supplied by the retrograde limb to be ischemic. Initial attempts to deliver a balloon through a 6 Fr hockey-stick guide (Cordis) using various individual wires including a Thunder wire (Medtronic) and an Iron Man wire were unsuccessful. We swapped out the guide catheter for a 6 Fr AL-1 guide (Cordis) and again crossed the lesion into the retrograde limb of the LAD with a Pilot 50 (Abbott Vascular), which was exchanged for a Wiggle wire through a Transit catheter (Cordis). We then successfully delivered and inflated a 3.0 x 15 mm Voyager balloon (Abbott Vascular) at nominal pressures with resultant haziness suspicious for a non flow-limiting dissection. Following this, we were unable to deliver a 3.0 x 12 mm Driver stent using the Wiggle wire. Repeated attempts were made using a Pilot 50 wire, a Whisper wire and a Prowater wire (Abbott Vascular), each without success. Based on previous experience with the “crooked buddy” technique, we swapped out the AL-1 guide for a 6 Fr AL-2 guide and set up a buddy wire using the Wiggle wire as the rail and an Iron Man as the buddy wire. With this combination, we were able to deliver (Figures 2B and C) and deploy a 3.0 x 12 mm Driver stent. Final angiography was performed with a JR4 diagnostic catheter, revealing an adequate result with Case 3. An 85-year-old male with a history of hypertension, hyperlipidemia and prior coronary artery bypass surgery 13 years prior presented to the emergency room with chest pain and was found to have suffered a non-ST-elevation myocardial infarction. Angiography revealed an acute occlusion of his SVG to LAD and he subsequently underwent PCI through the protected left main into the LAD with an excellent angiographic result. There was also a significant stenosis of a heavily calcified RCA (type C lesion) (Figure 3A). Using a 6 Fr JR 4 Guide, the RCA lesion was successfully crossed with a S’port wire. A 2.5 x 20 mm Sprinter balloon (Medtronic) could not be delivered, therefore the guide was exchanged for a 6 Fr AL-1 guide. The S’port wire was placed distally and a 2.5 mm x 20 mm Sprinter balloon was successfully delivered and inflated. Next, we were unable to successfully deliver a 2.5 x 14 mm Endeavor stent (Medtronic). The S’port wire was exchanged for a Wiggle wire, but we were still unable to deliver the stent. A second wire, a Whisper wire, was placed across the lesion and was exchanged through a Quick-Cross catheter (Spectranetics Corp., Colorado Springs, Colorado) for a Grand Slam wire. Using the Wiggle wire as the rail and the Grand Slam as the buddy (Figure 3B), we were successful in delivering tandem 2.5 x 14 mm, 3.0 x 18 mm and 3.5 x 18 mm Endeavor stents to the RCA. The proximal stents were posted with a 4.0 x 8 mm Quantum Maverick balloon and the distal stent was posted with a 3.0 x 8 mm Quantum Maverick balloon, achieving an excellent angiographic result (Figure 3C). Case 4. A 63-year-old male with a history of coronary artery disease status post prior CABG and PCI presented to the emergency room with chest pain. On angiography, it was noted that the SVG to obtuse marginal (OM) was degenerated and had a high-grade stenosis in the mid segment of the graft. The SVG to OM was stented, with an excellent angiographic result. There was also in-stent restenosis of the left circumflex artery (LCx) (type B2 lesion) that supplied a significant amount of myocardium that was not perfused by the SVG-to-OM graft. A 3.75 EBU guide (Medtronic) was used to engage the left main. A Pilot 50 was placed across the lesion and was exchanged for a Wiggle Wire through a 3.0 x 20 mm Sprinter balloon. The Sprinter balloon was then used to predilate the lesion. Subsequent attempts to deliver a 3.5 x 28 mm Xience stent (Abbott Vascular) were unsuccessful. A S’port wire was then advanced across the lesion as a buddy wire. Using the Wiggle wire as the rail and the S’port wire as the buddy, unsuccessful attempts were made to deliver the stent. The S’port wire was then exchanged for a Grand Slam wire. Again, using the Wiggle wire as the rail and the Grand Slam as the buddy, tandem 3.5 x 28 mm and a 3.5 x 23 mm Xience stents were delivered through the previously placed stents and deployed at nominal pressure. The stents were posted with a Quantum Maverick 3.5 x 15 mm balloon. Case 5. A 68-year-old male presented with an ST-elevation myocardial infarction involving the distal RCA, which was successfully stented without difficulty. He also was noted to have a high-grade lesion of a branching diagonal. The patient returned for staged PCI of the calcified diagonal lesion (Figure 4A). A 3.75 EBU guide (Medtronic) was used to engage the left main. After predilatation with an Apex balloon (Boston Scientific) over a S’port wire, we were unable to deliver a 2.0 x 8 mm Mini-Vision stent (Abbott Vascular). The S’port wire was exchanged for a Wiggle wire, and after repeat percutaneous transluminal coronary angioplasty with the Apex balloon, subsequent attempts to deliver the stent were also unsuccessful. With the Wiggle left in place, a S’port wire was used to recross the lesion and was then exchanged for a Grand Slam wire. We initially used the Grand Slam wire as the rail and the Wiggle wire as the buddy wire, but were unable to deliver the stent. Next, using the Wiggle as the rail and the Grand Slam as the buddy, we were successful in delivering and deploying the stent. Because of a dissection at the distal stent edge, a 2.25 x 8 mm Micro Driver stent (Medtronic) was placed distally, in tandem, to the Mini-Vision stent (Figure 4B).

Discussion

With further advances in technology, knowledge and experience, PCI is successfully used in difficult and complex lesions. Despite the availability of modern low profile and tractable balloons and stents, delivery of devices to tortuous vessels with or without calcium remains challenging, especially when guide support is suboptimal.⁴ In these cases, usually changing guide shapes or using a larger diameter guide⁵ provides adequate support. Deep seating the guide catheter may also lead to success.⁶ Other methods include the use of rotational atherectomy for calcified lesions, multiple shorter stents and the application of Rotaglide™ (Boston Scientific, Natick, Massachusetts) directly to the stent prior to insertion⁷ or a lubricant delivered by intracoronary injection.⁸ When these techniques cannot be employed or are ineffective, several other creative techniques have been described to improve guide support such as inflating a PTCA balloon in a side branch to “anchor” the guide,⁹ or, in the case of vein grafts, using a Proxis device both for embolic protection and as an anchoring mechanism.¹⁰ Also, using multiple “telescoping” guides^11–13 improves support. In addition to these creative techniques, the use of one or more^14,15 buddy wires in an antegrade or retrograde fashion¹⁶ remains an effective method by which guide support is improved and devices can be successfully delivered. In addition to improving guide support, the buddy wire may also be effective by bouncing the stent off of superficial calcium, thereby facilitating delivery. The use of a buddy balloon works in a similar fashion.^17–19 We feel that the keys to success in these cases presented were the differing characteristics of the two wires selected for use with the buddy-wire technique. The Hi-Torque Wiggle Wire™, a 0.014" diameter straight-tip spring coil non-hydrophilic guidewire, has unique construction with a series of corrugations or bends near the distal end which aids in stent delivery in tortuous vessels where transmission of push may be poor.²⁰ This is accomplished by applying traction on the Wiggle wire to pull one of the bends into the tip of the balloon or stent, allowing the angle of the device tip in relation to the vessel to be altered. The result is the ability of the device to step over the calcium or stent struts that may be impeding progression of the device. Alternatively, the Grand Slam wire is an extra-support wire whose rigidity is used to augment guide support and to straighten tortuous vessels to allow better transmission of forces with pushing of balloons or stents. This wire tends to retain its shape rather than conform to the contours of a tortuous vessel. One potential negative result of this feature of extra-support wires is that the wire may induce a pseudostenosis or a pleating artifact on a tortuous vessel which, in fact, may impede stent delivery.²¹ In our experience from this series, we found that the characteristics of the Grand Slam wire were complementary to the Wiggle wire and that the combination aided device delivery. This was demonstrated nicely during the following unsuccessful attempts: 1) using a S’port wire as the working wire and Iron Man wire as the buddy (case 1); 2) using a Wiggle wire as the working wire and a S’port wire as the buddy (case 4); and 3) using the Grand Slam wire as the working wire and the Wiggle wire as the buddy (case 5). The cases presented here required a relatively large amount of equipment, contrast volume and procedure time (data not shown). Much of the extra equipment and time were used trying other equipment and techniques that failed. Subsequent to these initial 5 cases, we have performed 3 cases (all successful) in which we were quicker to use the “crooked buddy” technique when it was apparent that device delivery would be challenging.

Conclusion

We present here a series of five difficult cases in which some of the standard techniques mentioned above to aid in device delivery were ineffective. By using a Wiggle wire as the rail and the supportive Iron Man/Grand Slam wire as the buddy, we were able to improve guide support and deliverability, resulting in successful procedures. The combination of a Wiggle wire with a supportive wire such as the Grand Slam refines the buddy-wire technique by both providing better guide support and directing the balloon or stent away from potential obstruction(s) in the vessel wall such as calcium or previously placed stents. Once a difficult lesion is identified in which delivery of a balloon and/or stent to a lesion is unsuccessful secondary to vessel tortuosity, calcification and/or prior stent placement, moving quickly to the “crooked buddy” technique may avoid unnecessary equipment, contrast and procedure time.

References

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From *Scott and White, Temple, Texas and §Mayo Clinic Arizona, Phoenix, Arizona. Disclosures: D. Fortuin reports receiving speaker honoraria from Abbott Vascular, as well as payments to his institution for educational programs from Boston Scientific, Medtronic, and Merck. Manuscript submitted January 22, 2010, provisional acceptance given February 1, 2010, final version accepted February 8, 2010. Address for correspondence: F. David Fortuin, MD, Mayo Clinic, Cardiology, 5777 E. Mayo Blvd., Phoenix, AZ 85054. E-mail: fortuin.david@mayo.edu