Vertebral artery origin stenting with buddy wire technique in tortuous subclavian artery

1. Introduction 

Positioning of a guiding catheter is the first and most important step of endovascular procedures in supraaortic interventions. It may be difficult to place a guiding catheter to the subclavian artery via transfemoral approach because of tortuosity. In this study, we contemplated using a microguidewire as a buddy wire in the vertebral artery (VA) origin stenting procedures.

2. Materials and methods 

2.2. Technical report 

We have catheterized the subclavian artery with a 5-French diagnostic catheter and placed an exchange 0.035in. guidewire (Roadrunner; Cook, Denmark) to distal subclavian artery then placed a 6-French guiding catheter (Envoy; Cordis, Miami Lakes, FL) to the subclavian artery. While the exchange guidewire was in the artery we have placed a 0.014in. extrasupport mikroguidewire (Choice Extrasupport; Target/Boston Scientific, Miami, FL) to distal subclavian artery as a buddy wire to stabilize the guiding catheter in its position (Fig. 1a and b).

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Fig. 1. (a) Right subclavian angiography shows significant stenosis of the right vertebral artery origin (black arrow), note the tortousity of subclavian artery. (b) Roadmap image shows the placement of exchange 0.035in. guidewire and 0.014in. support microguidewire to the distal subclavian artery. (c) Right subclavian angiography after passage of 0.014 soft-tip microguidewire through the vertebral artery origin stenosis and removal of exchange guidewire, note the buckling of guiding catheter (black arrow). (d) Right subclavian angiography after advancement of the guiding catheter and positioning of the balloon-expandable stent to the stenotic segment at the vertebral artery origin stenosis (white arrow), note the kinking and buckling of the guiding catheter (black arrow) but still in a acceptable position. (e) Control right subclavian angiography after delivery of stent shows good recanalization of the stenosis (black arrow), guiding catheter is still in appropriate position.

Then, a soft tip 0.014in. microguidewire (Transend softtip; Target/Boston Scientific) was easily passed through the origin stenosis (Fig. 1c). After stabilization of the guiding catheter with these microguidewires we have withdrawn the 0.035in. exchange guidewire and navigate the monorail, balloon-expandable stent to the stenotic segment and made balloon angioplasty without any difficulty (Fig. 1d). In case of moving back of the guiding catheter tip, it was advanced over the wires. After the stent deployment control DSA was performed to evaluate both extra- and intracranial arteries to assess the presence/or absence of dissection or embolization (Fig. 1e). After control angiography both of the microguidewires were withdrawn. All patients have a neurological examination before and just after the stenting procedure. Patients transported to intensive care unit under monitorization and hospitalized at least 24h after the procedure. None of the patients have additional neurologic signs or symptoms after the procedure.

3. Discussion 

Almost all neuroendovascular procedures are performed by initially placing a guiding catheter or long introducer sheath into the carotid or subclavian–vertebral artery to permit coaxial delivery to the distal vasculature [1], [2], [3].Tortuous anatomy of the aortic arch and subclavian artery may create problems during interventions through the VA origin or intracranial portion.

As many as, 4–6% of cases fail in carotid or vertebral interventions because of tortuosity of the access vessel [4], [5], [6], [7]. Buckling of the introducer sheath or guiding catheter back into the aorta frequently occurs in such cases, which may result with slipping out of the carotid or vertebral artery. Slipping of the microguidewire and/or stent during the positioning may result with dislodgement of the plaque material and embolization.

This study defines a new application area of a previously described buddy wire technique, to provide a stable platform in the subclavian artery for stenting of the vertebral artery origin in patients with tortuous access vessels

Options that have been described to overcome the vessel tortuosity other than buddy wire technique include, use of stiff or large-caliber guiding catheter, placement of a stiff microguidewire to the target vessel and direct puncture of the carotid artery or brachial access.

Large-caliber coronary guiding catheters in the size range of 7F–10F, with either a Judkins right 3.5 or 4.0 curve were found to have success for accessing to most proximal brachiocephalic vessels [1]. Use of stiff guidewires allow extrasupport for the guiding catheters and straighten the vessel, although straightening may be acceptable for coronary vessels it is not a desired technique for the cerebral vessels [5], [8]. Disadvantages of the use of large-caliber guiding catheters have increased rate of complications at the access site, trauma to the vessel which may result with catheter-induced vasospasm or dissection and embolization, and formation of thrombi around the larger surface of these catheters [1], [9].

With direct puncture of the carotid artery access place hematoma and/or carotid thrombosis is the major concern. In cases where the VA origin is deeply located and not parallel to the axis through the distal subclavian artery, passage of the vertebral artery origin show difficulty and brachial access may fail.

The smallest system that will enable to perform the procedure should be selected to minimize the access problems [1]. Monorail balloon-expandable stents are almost all compatible with 5-French guiding catheters, but for performing easy road-mapping and angiography during the stent placement, 6-French catheters may prefer.

Buddy wire technique is a well-known technique, mostly preferred in coronary interventions [10]. Satow et al. described use of buddy wire technique in the carotid stenting for passing the PercuSurge guardwire system through severe and tortuous stenotic lesions [11]. Use of buddy wire gives additional support to the stability of guiding catheter. The major advantage of using buddy wire technique, there is no need for larger calibrated guiding catheters then standart procedure (we have used 6-French guiding catheters with or without buddy wire technique). We think applying the buddy wire technique is very easy and safe for neurovascular interventions. The technique is not time consuming as well as not makes the procedure complicated.

As a conclusion; we are describing a new application area of a previously described technique. We have found that in the presence of unfavorable anatomy of subclavian artery resulting from dolioectasia, use of buddy wire technique is extremely useful for vertebral artery origin stenting procedures.