Leaving Your Buddy in Jail: A Simplified Approach to the Jailed Buddy Wire Technique

Dear Editor,

The concept of jailing a buddy wire to increase support during challenging PCI has been previously described and applied.^1-3 Earlier, it was suggested to frequently retrieve and replace the buddy wire if multiple stents were necessary to avoid guidewire entrapment. Overlapping stents were not deployed. Here, we offer a simplified approach of leaving a buddy wire in a jailed position throughout the whole PCI procedure, which allows placement of multiple overlapping stents, if necessary.

Calcified and tortuous coronary arteries offer a major challenge for equipment delivery and successful PCI. A strong guide support is one of the key features to overcome these issues. Besides large guiding catheters, guide extensions, and anchor balloons, buddy wires are commonly used to increase support. Each approach offers advantages and disadvantages. Seven or 8 French guiding catheters, as well as guide extensions, offer better support but are traumatic on the other hand. Anchor balloons create strong support but may lead to dissections and thus no-reflow in the anchored vessel. A buddy wire is easy to place but gain in support is limited. There is a certain “risk” of jailing the buddy wire if not retrieved before placing a stent. On the other hand, wire jailing may offer advantages. A jailed buddy wire creates tremendous guiding catheter support similar to an anchor balloon. In addition, there is little risk of dissection, and coronary vessels are not occluded compared to an inflated anchor balloon in place. In 2007, the concept of burying or jailing a buddy wire to enhance support was introduced by Kaluski and colleagues in the Journal of Invasive Cardiology and again described in 2009 by Bagnall and Spratt.^1,2 In 2014, Dangoisse et al successfully applied the “buddy-in-jail” technique in 10 male patients with deploying a distally positioned stent, subsequently using either the jailed wire or the free wire for further proximal stenting. Of note, the same authors warn from jailing the same wire with two consecutive stents.³ This concern may be justified since entrapment of a guidewire with the impossibility of retrieval refers as a major complication in coronary interventions. However, guidewire entrapment became increasingly rare since the introduction of new generation coronary wires and thin-strut stents. The current case series originated after accidentally forgetting to retrieve the buddy wire during a challenging and time-consuming PCI and multiple stenting in a calcified and tortuous RCA. However, after placing the distal stent in segment 3, we found that delivery of longer and bulkier stents was easily possible. The buddy wire was jailed by 5 stents but could be easily retrieved at the end of the procedure. Hence, we applied the technique of “leaving your buddy in jail” in 6 other challenging PCIs. Here, we present 7 cases in which the buddy wire was left in jail during multiple and overlapping stenting in calcified and tortuous vessels.

The “leaving your buddy in jail” technique is illustrated in Supplementary Figure 1. An exemplary PCI of a tortuous and calcified RCA using the “leaving your buddy in jail” technique is shown in Figure 1. The equipment used in the 7 procedures is described in Table 1.

In all cases, using the “leaving your buddy in jail” technique, target lesions were adequately treated with very good angiographic results (TIMI III flow). Six patients had an uneventful follow-up with early hospital discharge. One patient died on severe ARDS 14 days later caused by pulmonary infection not associated with the PCI procedure. In all patients, the jailed buddy wire was easily retrievable. Of note, to decrease risk of guidewire entrapment and fracture, we did not perform post-dilatation with the jailed buddy wire in place. After removal of the buddy-wire, post-dilatation was performed, if necessary.

Strong guiding catheter support is a key requirement for successful stent delivery in complex PCI. While several approaches to overcome backup issues exist, each of them comes with advantages and disadvantages. The easy concept of jailing a buddy wire with a previously deployed stent is not new and creates backup similar to an anchor balloon. Previously, it was strongly suggested not to cage a buddy wire with 2 or more overlapping stents due to increased risk of guidewire entrapment and fracture. Furthermore, the meticulous lesion preparation, especially in calcified lesions, is of utmost importance to reduce entrapment of guidewires.³ Since we aimed to treat all 7 patients without the “leaving your buddy in jail” technique at first, we repeatedly pre-dilatated calcified lesions using non-compliant and adequately-sized balloons. We did not perform primary stenting in any of these 7 patients. We did not observe difficulties in retrieving jailed buddy wires despite being jailed with several overlapping stents. Stents and guidewires may play an important role to avoid guidewire entrapment. Contemporary coronary wires with increased flexibility and durability may be significantly easier to retrieve in comparison to older generation wires. In all 7 cases, we used an ASAHI SION blue guidewire as a buddy wire. The SION blue wire possesses a durable coil tip suited for treating multiple lesions. Furthermore, it has no polymer jacket which prevents a possible peeling during guidewire retrieval. In most of our patients, coronary stenting was performed using new generation, thin-strut and flexible Boston Scientific Synergy and SMT Supraflex Cruz stents, which possibly facilitate pulling back of the jailed guidewire. However, the jailed buddy wire was easily retrieved in 1 patient who was treated with bulkier Boston Scientific Promus stents.   

To conclude, the “leaving your buddy in jail” technique simplifies the traditional “buddy-in-jail” technique and offers advantages such as increased back-up and the possibility to place overlapping stents. The risk of guidewire entrapment may be higher although we did not observe guidewire retrieval issues in our case series. Risk of guidewire entrapment may be reduced by using durable, non-polymer coated guidewires and flexible, thin-strut stents.

Affiliations and Disclosures

From the Department of Cardiology and Angiology, University Hospital Tübingen, Germany.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted February 23, 2023.

Address for correspondence: Michal Droppa, Department of Cardiology and Angiology, University Hospital Tübingen. Address: Otfried-Müller-Straße 10, 72076, Tübingen; Germany. Email: michal.droppa@med.uni-tuebingen.de

References

1. Kaluski E, Tsai S, Milo-Cotter O. Buried wire technique: enhancing support method for complex percutaneous interventions and stenting. J Invasive Cardiol. 2007;19(4):195-196.

2. Bagnall AJ, Spratt JC. The “buddy-in-jail” technique-a novel method for increasing support during percutaneous coronary intervention. Catheter Cardiovasc Interv. 2009;74(4):564-568. doi:10.1002/ccd.22049

3. Dangoisse V, Guédès A, Schroëder E. Distal “buddy-in-jail” technique: a complementary “jail with stent” method for stent delivery. Acute Card Care. 2014;16(1):28-33. doi:10.3109/17482941.2013.869342