When Two Is Better than One

Background Delivery of most flow diverters (FD) requires larger, and thus stiffer microcatheters (0.021–0.027in.) which can pose challenges to intracranial navigation. The concomitant use of two microwires within one microcatheter, also known as the buddy-wire technique, may be helpful for navigation and support in challenging situations. Methods We analyzed all flow diverter procedures in our prospectively collected database. We recorded all patient-related, anatomical and procedural information. We performed univariate statistics and technical descriptions. Results In total, 208 consecutive patients treated with a FD at our institution between July 2014 and August 2020 were retrospectively analyzed. In 17 patients the buddy-wire technique was used (mean age 63 years, range 31–87 years: 16 female). Aneurysms were located at the petrous, cavernous, supraophthalmic internal carotid artery, and a proximal M2 branch in 2, 7, 7 and 1 patient(s), respectively. In all cases a 0.027in. microcatheter was used for device deployment. In 14 patients with a wide-necked aneurysm the buddy-wire provided additional support to advance the microcatheter and mitigated the ledge between the aneurysm neck and the parent artery or a side branch. In two giant cavernous aneurysms treated with telescoping FDs, the buddy-wire was used to re-enter the proximal end of the foreshortened FD. Conclusion The buddy-wire is a useful technique in FD procedures to prevent herniation of the microcatheter into the aneurysm sack, in wide-necked aneurysms to mitigate the ledge effect between the aneurysm neck and the parent artery where the microcatheter tip may get stuck, or to enable re-entry into a foreshortened FD.

Crossing the Carotid Siphon: Techniques to Facilitate Distal Access in Tortuous Anatomy: 2-Dimensional Operative Video

As capabilities for endovascular treatment of intracranial vascular pathologies continue to expand, the need for access to the distal internal carotid artery with rigid support catheter systems continues to increase. One of the dominant factors limiting this access is patient anatomy, specifically vessel tortuosity. Increased tortuosity of the carotid siphon is a frequently encountered anatomic variant and may complicate endovascular procedures in adults and children.1,2 Failed attempts to navigate the carotid siphon with a distal access catheter carry a risk of vessel injury and treatment failure. For this reason, techniques that aid in supporting safe advancement of a distal access catheter across a tortuous carotid siphon are essential.3,4 In this video, we demonstrate 2 ways in which this may be accomplished. The first technique uses a larger diameter microcatheter, such as the AXS Offset catheter (Stryker, Kalamazoo, Michigan), to increase support for the distal access catheter, while the second uses a buddy wire technique to accomplish this increased support. Both of these techniques can help increase the safety of navigating a tortuous carotid siphon and increase the likelihood of successful treatment. The procedures shown were performed with the informed consent of the patients.

Pull-Through Buddy Wire Technique for Endovascular Thrombectomy in Patients with Acute Ischemic Stroke: Technical Note

Excessive tortuosity is a notable cause of failed endovascular thrombectomy for acute large-vessel occlusion stroke. Transcervical access (TCA) is a commonly proposed solution for overcoming this difficulty. However, the large-bore catheter usually used in TCA increases the risk of serious local complications. This paper presents a modified technique for TCA that uses a pull-through buddy wire (PTBW) to track a large-bore femoral guiding sheath (GS) into the carotid artery via a small carotid puncture site. The carotid puncture site can be easily managed through gentle manual compression. Two illustrative cases using this technique to deal with a large aortic arch and tortuous left common carotid artery are reported. In both cases, recanalization was achieved after successful GS placement. Using a PTBW is feasible in TCA.

Case report: Buddy wire technique to facilitate atrial septal crossing during transcatheter transseptal mitral valve implantation

Background Transcatheter mitral valve-in-valve implantation (MVIV) has emerged as a viable treatment option in patients at high risk for surgery. Occasionally, despite appropriate puncture location and adequate dilation, difficulty is encountered in advancing the transcatheter heart valve across interatrial septum. Case summary We describe a case of a 79-year-old woman with severe chronic obstructive pulmonary disease (COPD), prior surgical bioprosthetic aortic and mitral valve replacement implanted in 2007, atrial fibrillation, and Group II pulmonary hypertension who presented with progressively worsening heart failure symptoms secondary to severe bioprosthetic mitral valve stenosis and moderate-severe mitral regurgitation. Her symptoms had worsened over several months, with multiple admissions at other institutions with treatment for both COPD exacerbation and heart failure. Transoesophageal echocardiogram demonstrated preserved ejection fraction, normal functioning aortic valve, and dysfunctional mitral prosthesis with severe stenosis (mean gradient 13 mmHg) and moderate-severe regurgitation. After a multi-disciplinary heart team discussion, the patient underwent a transcatheter MVIV implantation. During the case, inability in advancing the transcatheter heart valve (THV) across interatrial septum despite adequate septal balloon pre-dilation was successfully managed with the support of a stiff ‘buddy wire’ anchored in the left upper pulmonary vein using the same septal puncture. The patient tolerated the procedure well and was discharged home. Discussion Operators should be aware of potential strategies to advance the THV when difficulty is encountered in crossing the atrial septum despite adequate septal preparation. One such strategy is the use of stiff ‘buddy wire’ for support which avoids the need for more aggressive septal dilatation.

Transcatheter closure of complex iatrogenic ventricular septal defect: a case report

Background Iatrogenic membranous ventricular septal defects (VSDs) are rare complications of cardiothoracic surgery, such as septal myectomy for hypertrophic obstructive cardiomyopathy (HOCM). Transcatheter closure is considered an appealing alternative to surgery, given the increased mortality associated with repeated surgical procedures, but reports are extremely limited. Case summary We herein report the case of a 63-year-old woman with HOCM who underwent successful percutaneous closure of an iatrogenic VSD after septal myectomy. Two percutaneous techniques are discussed, namely the ‘muscular anchoring’ and the ‘buddy wire delivery’, aimed at increasing support and providing stability to the system during percutaneous intervention. Discussion Transcatheter closure represents an attractive minimally invasive approach for the management of symptomatic iatrogenic VSDs. The new techniques described could help operators to cross tortuous and tunnelled defects and to deploy closure devices in case of complex VSD anatomy.