Distal ‘buddy-in-jail’ technique: a complementary ‘Jail with stent’ method for stent delivery

Figures & data

Figure 1. Diagram of the ‘stent jail’ technique: A. Proximal stenting using the jailed wire. B. Proximal stenting using the non-jailed wire.

Table I. Clinical and procedural characteristics.

Case	1	2	3	4	5	6	7	8	9	10
Age (years)	80	64	85	69	81	60	70	82	66	39
Clinical picture	Severe angina	Unstable angina	Unstable Angina	Recurrent angina	Chronic angina	NSTEMI	NTEMI	Recurrent angina	Dyspnea	Recurrent angina
Co- morbidity	Severe aortic stenosis, PVD	(–)	LIMA graft to CX art.	CABG surgery, on dialysis	COPD CRF	(–)	Severe COPD	85% OM2	COPD, 100% RCA	Smoker hyperlipemia
Diabetes	y			y
Vascular access	Left TRA	R TRA	Left TRA	R TRA	R TRA	R TRA	R TRA	R TRA	R TRA	Left TRA
Target vessel	RCA	RCA	LAD art.	RCA	RCA	RCA	LAD art.	LAD art.	CX art.	RCA
Target lesions (% stenosis)	50% prox 85% mid	70% prox to mid, 90% mid	85% mid, 70% × 2 distal	75% prox 70% mid	70% prox to mid, 70 + 85% mid to distal, 85% PDa	60% prox 75% prox to mid 90% distal	90% mid 85% mid to distal	60, 90 and 75% distal LAD art, 90% apical	70% mid Cx 90% distal Cx (OM3)	60% mid, 75% mid to distal
Calcified Vx	+++	+++	+++	++	++	++	+++	++	++	+
Tortuosity	+++ Shepherd's crook	++	+	±	+	++	+++	+	+	++
Guiding catheter	5F ‘VDL’ Sherpa NX	6F ‘VDR’ Heartrail II	5F EBU Launcher	5F RRAD Launcher	5F RRAD Launcher	5F RRAD Launcher	6F VODA RunWay	5F EBU Launcher	5F VDL 14 Sherpa NX	5F VDL 12 Sherpa NX
Guidewire	Pilot 50^®	Pilot 50^®	Asahi Sion	Asahi Sion	Asahi Sion	Asahi Sion	Asahi Sion	Pilot 50^®	Asahi Sion	Asahi Sion
Buddy wire	Choice Floppy	Pilot 150^®	BMW^®	Asahi Sion	Asahi Sion	BMW^®	Asahi Sion	Asahi Sion	BMW^®	BMW^®
Balloon's sizespre-stenting	2–153.5–15	2–10,2.5–203.5–20 4–20	2.5–15	2.5–20	2–15	2–102.75–103–10	2–102.5–122.5–08	1.2–082–12	1.5–102.5–153–15	2.5–10
Distal stent type/size	BMS 4–15	BMS 4–15	BMS 3–13	DES 2.75–24	DES 2.25–15	DES 2.75–09	BMS 2.5–09	DES 2–08	BMS 3–09	DES 3.5–30
Prox stent type/size	BMS 4–18	BMS 4.5–15	BMS 3–26	DES 3–18	DES 3–28 BMS 3.5–13	BMS 3–18	BMS 2.5–13 BMS 3–13	DES 2.5–12 2.5–16	BMS 3–20	BMS 4–13
Elective vs. ad hoc PCI	Elective	Elective	Ad hoc	Elective	Ad hoc	Ad hoc	Ad hoc	Ad hoc	Ad hoc	Ad hoc
Fluoroscopy time (min)	20 min	19 min 10 s	16 min 18 s	6 min 30 s	20 min 11 s	14 min 12 s	35 min	18 min 24 s	12 min 18 s	19 min 15 s
Contrast volume (ml)	109	141	200	146	253	247	321	335	188	192

PVD, peripheral vascular disease; CRF, chronic renal failure; TRA, transradial access; BMS, bare metal stent; DES, drug-eluting stent; PCI, percutaneous coronary intervention; ‘VDL’ and ‘VDR’ are special order shaped guiding catheters.

Figure 2. A. LAO view: severe multifocal right coronary artery disease, the artery being very calcified and tortuous. The distal lesion was the most severe. B. Jailing the buddy wire during distal stenting. Note the actual shape of the 5F guide catheter in a ‘power position’. C. More proximal stent positioning over the jailed wire (JW), the free wire has been pulled back (FW). D. Final result.

Table II. Solutions for difficult PCI.

	Solutions	Potential hazard
Guiding catheter	Larger sizeExtra support shapeDeep seatingMother-and-child technique (Dedicated Child: GuideLiner^®)	Coronary artery injury (ostium/ proximal/mid vessel)Air embolism (mother and child)Vascular access injury/bleeding with larger GC
Guidewire	Optimized material: hydrophilic, stiffer, extra support, Wiggle Wire^™Anchor wiringBuddy wiring	Coronary artery perforationCoronary artery spasmTrapped wire
Balloons	Optimized material (profile, push, flex, coating)
Stents	Optimized material (profile, push, flex, coating)
Guidewire + balloon	Anchor ballooning (branch or target vessel)	Coronary artery injury
Guidewire + stent	‘Buddy-in-jail’ (proximal jailing)Proposed ‘jail and stent’ technique: (distal jailing)	Coronary artery injury (ostium, proximal vessel)Trapped wire
Misc.	Deep inspiration

Table III. Proximal versus distal buddy-in-jail techniques.

Multi lesions/multi-diseased segments	Proximal ‘buddy-in-jail’	Distal ‘buddy-in-jail’
Best indications	Unstable guiding catheter and proximal + distal lesion(s)Emergency: Need to fix quickly a proximal lesion (unstable patient)	Very distal discrete stenosis and more proximal long lesion(s) on a large and tortuous vesselEmergency: Ongoing PCI using small sized GC (≤ 5F) and anatomy more difficult than anticipated
Caution	1. Delivered proximal stent will be in the path to the distal lesion(s)2. Unsure about success for the treatment of distal lesion(s)	1. Avoid trapping a wire twice or trapping each of the two wires2. Control the GC tip during un-jailing
Avoid if	Distal lesion not reached/crossed	1. Unable to debulk a calcified distal lesion adequately2. Proximal lesions easy to reach/cross