Distal ‘buddy-in-jail’ technique: a complementary ‘Jail with stent’ method for stent delivery
A 60-year-old male, heavy smoker and hypercholesterolemic was admitted for NSTEMI. Performed by 5F right transradial access, the coronary angiogram showed severe multifocal RCA disease, with a highly calcified and tortuous vessel. The mid to distal segment was the most severely diseased. Ad hoc PCI was decided, starting with a 5F RRAD Launcher from Medtronic as guiding catheter. Buddy wiring was planned from the beginning with one SION (Asahi) as main wire and one Balance Middle Weight® (BMW) (Abbott Vascular) as the buddy wire. Starting from the distal lesion, we then proceeded with balloon debulking: 2–10, 2.75–10 and finally 3–10 balloons (Sapphire II, OrbusNeich™) were successfully advanced and inflated through all lesions. Despite this debulking and the presence of the BMW buddy wire, a bare metal stent (BMS) 3–13 (Azule™SDS, OrbusNeich™) failed to reach the target distal lesion: the stent was unable to cross the bend at the level of the residual mid RCA lesion. We then changed to a shorter and smaller BMS (2.75–09 PRO-kinetic Energy®, Biotronik), which fortunately reached the distal lesion. It was deployed at 18 atmospheres, jailing the BMW wire. This BMW wire, now in a jailed position, was used subsequently to load the same 3–13 Azule™ stent which had previously failed. We left the Sion wire as the buddy wire. The stent was successfully pushed forward and positioned at the mid RCA lesion. Before delivery, the Sion wire was removed. Before un-jailing the BMW wire, we further expanded the Azule stent with a non-compliant balloon. The final angiographic result was good.