Buddy Wire Research Articles

Severe angulation of the descending aorta with a kink: Buddy wire is key for a successful transfemoral transcatheter aortic valve replacement.

Severe angulation of the descending aorta with a kink: Buddy wire is key for a successful transfemoral transcatheter aortic valve replacement.

Selective aneurysmal sac neck-targeted embolization during endovascular repair of abdominal aortic aneurysm with hostile neck anatomy.

To evaluate the efficacy and safety of selective aneurysmal sac neck-targeted embolization in endovascular aneurysm repair (EVAR) in patients with a hostile neck anatomy (HNA). Between October 2020 and June 2022, patients with an abdominal aortic aneurysm (AAA) and HNA who underwent EVAR with a low-profile stent graft and a selective aneurysmal sac neck-targeted embolization technique were analysed. An HNA was defined by the presence of any of the following parameters: infrarenal neck angulation > 60°; neck length < 15mm; conical neck; circumferential calcification ≥ 50%; or thrombus ≥ 50%. Before occluding the entire aneurysm during the procedure, a buddy wire was loaded prophylactically into the sac through the contralateral limb side. If a type Ia endoleak (ELIa) occurred and persisted despite adjunctive treatment such as balloon moulding or cuff extension, this preloaded wire could be utilized to enable a catheter to reach the space between the stent graft and sac neck to perform coil embolization. In the absence of ELIa, the wire was simply retracted. The primary outcome of this study was freedom from sac expansion and endoleak-related reintervention during the follow-up period; secondary outcomes included technical success and intraoperative and in-hospital postoperative complications. Among the 28 patients with a hostile neck morphology, 11 (39.5%) who presented with ELIa underwent intraprocedural treatment involving sac neck-targeted detachable coil embolization. Seventeen individuals (60.7%) of the total patient population did not undergo coiling. All patients in the coiling group underwent balloon moulding, and 2 patients additionally underwent cuff extension. In the noncoiling group, 14 individuals underwent balloon moulding as a treatment for ELIa, while 3 patients did not exhibit ELIa during the procedure. The coiling group showed longer operating durations (81.27 ± 11.61 vs. 70.71 ± 7.17min, P < 0.01) and greater contrast utilization than the noncoiling group (177.45 ± 52.41 vs. 108.24 ± 17.49ml, P < 0.01). In the entire cohort, the technical success rate was 100%, and there were no procedure-related complications. At a mean follow-up of 18.6 ± 5.2months (range 12-31), there were no cases of sac expansion (19 cases of sac regression, 67.86%; 9 cases of stability, 32.14%) or endoleak-related reintervention. Selective aneurysmal sac neck-targeted embolization for the treatment of ELIa in AAA patients with an HNA undergoing EVAR is safe and may prevent type Ia endoleak and related sac expansion after EVAR.

The Horrible Scenario in Cath Lab: Percutaneous Management of Guide Wire Entrapment During Coronary Intervention

The Horrible Scenario in Cath Lab: Percutaneous Management of Guide Wire Entrapment During Coronary Intervention

Buddy Wires Strategy for Sheath-Uncrossable Interatrial Septum Management During Left Atrial Appendage Closure

Buddy Wires Strategy for Sheath-Uncrossable Interatrial Septum Management During Left Atrial Appendage Closure

The Elevator Technique: A New Bailout Maneuver to Achieve Target Vessel Patency During Challenging BEVAR.

The purpose of the study is to describe a new bailout maneuver for use during branched endovascular thoracoabdominal aneurysm repair (BEVAR) while dealing with challenging target vessel cannulation. A 54-year-old woman underwent urgent BEVAR with a low-profile T-branch device to exclude a type 2 thoracoabdominal aneurysm (TAAA). The endovascular procedure was challenging because the left renal artery ostium was covered by the endograft fabric, compounded by diseased target vessels. A novel bailout maneuver is described. After angioplasty of the left renal artery (LRA), the LRA remained precannulated and a low-profile T-branch was implanted. The 3 proximal branches (superior mesenteric artery, inferior mesenteric artery, and the right renal artery) were connected to their respective target vessels swiftly with a steerable sheath from a femoral approach. Access to the left renal artery was not achieved because it was obstructed by the fully deployed endograft. We subsequently stented the LRA over the "pre-positioned buddy wire," using a balloon-expandable covered stent protruding inside the aneurysm lumen. The proximal stent was then flared and lifted upward using an 8.5 Fr steerable sheath, which made cannulation and stenting of the LRA through the side-branch from above finally achievable. The elevator technique described in this article will help achieve technical success in challenging BEVAR cases. We describe in this technical note the "elevator technique" that will complement the "Snare-Ride" and "Balloon Anchoring" techniques over a buddy wire positioned in a target vessel, to provide successful bailout options for challenging TV cannulations during BEVAR.After failed access to the renal artery through the renal branch, a covered stent was implanted in the renal artery over the buddy wire with 10 mm protruding into the aortic lumen. This stent was then flared, prior to advancing a curved steerable sheath into the stent, which shaped it with a superior-facing funneled aortic segment. This maneuver resulted in the renal stent facing its corresponding branch, finally easy to access from the endograft lumen.

Long-Sheath Assisted Transcatheter Aortic Valve Replacement: The Best and Worst Cases.

Transfemoral transcatheter aortic valve replacement (TAVR) is quite challenging in patients with tortuous aorta. Recently, the combined method of buddy wire and long-sheath use was reported. We describe 2 cases having tortuous aorta undergoing transfemoral TAVR following opposite clinical courses. A long-sheath supported transfemoral approach is an effective method in patients with tortuous aorta; however, the tip of a large-bore sheath could cause an aortic injury during the procedure. The advantage of the transfemoral approach and risk of aortic injury should be counterbalanced, especially in patients with fragile tortuous aorta.

Description of a novel retrograde buddy wire jailining technique.

Description of a novel retrograde buddy wire jailining technique.

Abstract 13005: Tips and Tricks for Successful Trans-EVAR TAVR: Buddy Up

Trans-catheter aortic valve replacement (TAVR) via tortuous iliofemoral access with prior endovascular aneurysm repair (EVAR) is challenging. 83 year old male with severe aortic stenosis and prior EVAR was evaluated for TAVR with 29 mm Edwards Sapien 3 valve. Right femoral access was planned with ipsilateral protection. CT angiogram showed EVAR with tortuosity, rigidity, and graft protrusion concerning for advancement of equipment. The right iliofemoral system was accessed using a 4F radial sheath, Judkins JR4 catheter, and 0.035” angled glide wire exchanged for Amplatz Superstiff wire. A 30 cm 6F sheath was advanced over the wire followed by additional Superstiff buddy wire. Two Proglides were deployed over two separate wires, without rewiring. To overcome friction on removing second Proglide, predilatation of the arteriotomy should have been performed with a 8-9F sheath. An 8F sheath was advanced over one of two Superstiff wires. A V18 0.018” wire was placed in the ipsilateral protect site, exchanged for a third Superstiff wire to ease insertion of the Edwards sheath. The sheath was advanced followed by successful valve deployment. After removing the delivery system, two pre-deployed Proglides closed the arteriotomy site. Detailed planning enables operators to overcome challenges using the following strategies: 1) avoid unnecessary rewiring of the iliofemoral system by use of a 30 cm 6F sheath, 2) predilate the TAVR arteriotomy with larger sheaths prior to deploying Proglides to avoid limited manipulation space for Proglides and two wires, 3) use buddy wires if TAVR sheath advancement has failed over one wire and consider additional buddy wires from within the TAVR arteriotomy or ipsilateral protection site, and 4) use ipsilateral protection to avoid challenges of crossing over from contralateral iliofemoral. Although trans-EVAR TAVR remains somewhat unpredictable, these strategies may simplify and reduce the inherent failure rate of such procedures.

Novel endovascular technique for repair of superior mesenteric arteriovenous fistula with portal vein aneurysm

BackgroundA superior mesenteric arteriovenous fistula (SMAVF) is a rare, aberrant connection between the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). Management includes either open surgical repair or endovascular repair with embolization coils or covered stents. We report a novel in-stent coil embolization technique successfully used for repair of a challenging SMAVF. Case presentationA 56-year-old man presented with an enlarging SMV and portal vein aneurysm. His history was significant for a small bowel resection of a desmoid tumor 14 years prior. Computed tomography (CT) angiography revealed a high-flow SMAVF in the midsegment of the SMA, and the patient was taken to the operating room for endovascular repair. Embolization was initially attempted with detachable coils, but this approach was aborted as the coils did not have sufficient purchase to anchor securely and would migrate into the portal venous system prior to full release and deployment. Placement of a covered stent in the SMA to exclude the fistulous connection was not feasible due to the presence of multiple adjacent major SMA branches. Therefore, a balloon-expandable covered stent was placed across the fistula and crushed distally to create a blind end into which embolization coils were able to nest without migrating. This was achieved with the use of multiple buddy wires to deploy a VBX balloon-expandable stent graft (WL Gore, Flagstaff, AZ) across the fistulous connection and crush the distal end of the stent with a buddy balloon. The funneled covered stent then served as a backstop for packing with embolization coils, and completion angiography demonstrated complete occlusion of the SMAVF and filling of all SMA branches. Both 6-month and 1-year postoperative surveillance CT scans confirmed continued resolution of the fistula. ConclusionThis case demonstrates a novel endovascular technique to create a funneled covered stent across a high-flow SMAVF as a platform to enable embolization and prevent coil migration. This in-stent coil embolization technique is a viable option for cases in which embolization coils and covered stents fail or are unsuitable.

Buddy Balloon versus Buddy Wire Technique Regarding Accuracy of Stent Placement during Percutaneous Coronary Intervention.

We aimed to evaluate whether the buddy balloon technique (BBT) is superior to the buddy wire technique (BWT) with regard to the accuracy of stent placement during percutaneous coronary intervention (PCI).We enrolled patients who had been identified with significant stent movement before the stent was dilated at five hospitals and were randomly converted to either the BBT or BWT technique. The primary endpoints were the incidence of technical success and major adverse cardiovascular events (cardiac death, myocardial infarction, target lesion revascularization, and in-stent restenosis) at 2 years of follow-up. The secondary endpoints were the contrast volume used for the procedure and the total procedural time.From August 2018 to July 2019, 66 patients were enrolled, with 33 patients in each group. All patients were successfully followed up to 2 years. At the primary endpoints, compared with patients treated using BWT, those in the BBT group showed significantly better technical success (93.94% versus 39.39%, respectively; P < 0.0001). There was no significant difference in the incidence of major cardiovascular adverse events (6.06% versus 12.12%, respectively; P = 0.392). At the secondary endpoints, the contrast volume used for the procedure was lower with BBT (85.97 ± 22.45 versus 115.00 ± 21.45 mL, respectively; P < 0.0001); similarly, the total procedural time was shorter with BBT (65.94 ± 12.14 versus 74.33 ± 15.36 minutes, respectively; P < 0.0001).BBT could better restrict stent movement and facilitate precise stent deployment, with significant superiority over BWT. In addition, BBT can reduce the procedural time and contrast dose.

A Modified Buddy-Wire Technique for Crossing of the Interatrial Septum With the Sapien 3 Valve During Transseptal Mitral Valve-in-Valve/Ring Procedures

BackgroundCrossing of the interatrial septum (IAS) with the Edwards Sapien-3 transcatheter heart valve (THV) may fail, despite preparatory balloon septostomy. A planned buddy guidewire placed in the left ventricle may help facilitate crossing of the IAS and mitral bioprosthesis with the THV. MethodsA retrospective study of 12 consecutive patients undergoing transseptal, mitral valve-in-valve or valve-in-ring procedures using the Edwards Sapien-3 THV since 2018 with a planned buddy-wire technique. The primary endpoint was the composite of successful delivery of the buddy wire and deployment of the first intended Sapien 3 within the mitral valve without removal from the body, additional interatrial septal puncture, or placement of a further buddy wire. Secondary objectives included safety endpoints, as follows: access-site bleeding, tamponade, stroke, intraprocedural death, sustained ventricular arrhythmia, and 30-day vascular complications. ResultsFrom January 2018 to March 2022, a total of 12 consecutive patients who underwent transseptal mitral valve-in-valve (9) or valve-in-ring (3) procedures were identified. Three patients (25%) required repeat septostomy on the buddy wire after initial THV crossing failure. Crossing of the IAS and successful deployment in the mitral valve with the THV was achieved in all cases, without removal from the body or need for an additional wire or septal puncture. No access-site bleeding, stroke, tamponade, ventricular arrhythmia, intraprocedural death, or 30-day vascular complication occurred. ConclusionsThe planned buddy-wire technique was successful in all cases and facilitated successful crossing of the IAS and deployment of the THV in the mitral position without removal from the body, additional wires, or septal punctures, with no adverse events.

P70 ESPERIENZA CLINICA DELLE PRIME 41 PROCEDURE DI LITOTRISSIA INTRACORONARICA IN UN CATH–LAB ITALIANO

Abstract Introduction Stent under expansion is one of the main predictors of percutaneous coronary intervention (PCI) failure, being a trigger for both in–stent restenosis and stent thrombosis, with their obvious clinical impact. Among the main causes of stent failure, the presence of a severely calcified lesion is the most frequent and dangerous. Correct recognition and preparation of target lesion are therefore mandatory before stenting. Methods We enrolled all the patients treated with angioplasty and IVL (Shockwave Medical Inc, Santa Clara, USA) from October 2020 to October 2021 in our cath lab. Each patient signed informed consent. Results We enrolled 35 patients (with 41 lesions treated with IVL). Mean age was 73 years old, 29 were males (82%). Clinical characteristics are shown in the table. Twenty–one lesions (50%) were treated up–stream before stenting, 6 (16%) were bail–out IVL for inadequate stent expansion after post–dilation and 14 (37%) were in–stent restenosis with evidence of stent under–expansion because of the high burden of calcium. Fifty–four per cent of patients were treated in the context of Acute Coronary Syndrome (ACS). Seventy–three per cent of patient had three–vessel disease. The majority of procedure were done through radial access (74%) and 79% of the stenosis was prepared with NC balloons (at least 2.5 mm diameter) before deployment of the IVL balloon; in 2 case IVL was done after rotational atherectomy. Intravascular ultrasound (IVUS) guidance was used in in 15 pts. Two balloon were broken during lithotripsy. In 26 of 41 stenosis (63%) IVL delivery was obtained on a single wire, while 11 required buddy–wire (of whom 8 required child–in–mother technique to obtain adequate support for delivery). We had two major complications: 1 case of ventricular fibrillation (in a patients with recent myocardial infarction and severe reduction of ejection fraction, and 1 case of perforation at the time of inflation of the NC balloon after IVL easily treated with positioning of a covered stent which was easily delivered thanks to the previous IVL treatment). Conclusion IVL is a safe and all–around technique for treatment of severely calcified lesion in different clinical contexts from stable coronary artery disease to ACS, useful for upstream calcium treatment as well as bail–out stent optimization and correction of under expansion in calcified in–stent restenosis.

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.

Balloon Deflection Technique to Facilitate Stent Delivery in Impassable Situations During Percutaneous Coronary Intervention.

BackgroundLong and multiple lesions especially in the background of tortuous coronary artery often require multiple stents. The entry and passage of another stent through an already deployed stent becomes challenging because of poorly expanded stent struts, calcified tissue, underlying tortuosity, highly angulated takeoff of the vessel, and lack of coaxiality. It can be facilitated by balloon deflection technique (BDT) where balloon at proximal edge of main vessel stent over a buddy wire helps to deflect second stent either distally or into side branch by blocking potential dead.MethodsThe present retrospective, single-center study included 16,189 consecutive patients who underwent percutaneous coronary intervention (PCI) either through transfemoral or transradial route from January 2014 to August December 2019 at LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, India where BDT was used in situation of impassable stent among 37 patients.ResultsThe mean age of patients was 75.4 ± 6.5 years. The commonest clinical presentation was chronic coronary syndrome (n = 19; 51.3%) followed by non-ST-segment elevation myocardial infarction (NSTEMI) (n = 9; 24.4%), ST-segment elevation myocardial infarction (STEMI) (n = 5; 13.5%), and unstable angina (UA) (n = 10; 10.8%). Type B2 lesion was commonest (45.9%) followed by type C (35.2%) and B1 (18.9%). The commonest indication for BDT was angulation (n = 10; 27.1%) followed by tortuosity (n = 9; 24.3%), chronic total occlusion (n = 8; 17.9%), calcification (n = 7; 18.9%), and distally located lesion (n = 3; 8.1%). The left circumflex artery (LCX) was the most commonly intervened artery (n = 16; 43.2%) followed by left anterior descending (n = 11; 29.7%) and right coronary artery (n = 10; 27.1%). Mean diameter and mean length of stents were 3.3 ± 0.9 mm and 18 ± 6 mm respectively. The mean diameter and mean length of deflection balloon were 3 ± 0.5 mm and 20 ± 5 mm respectively. Lesions were modified using aggressive pre-dilatation in all cases while 19.4% of lesion required cutting balloon for additional modification. Additional wire as buddy wire was used in 54% of cases while wire in main vessel acted as buddy wire in dedicated bifurcation stenting. Stent implantation was successful in 36 cases with success rate of 97.3%; while in one case, stent could not be delivered using BDT. Stent was finally delivered using GuideZilla mother-in-child catheter. Overall failure rate was 2.7% which was contributed by extreme tortuosity, angulation, and severe calcification.ConclusionsIn selected cases of impassable lesions; the deflection balloon technique may provide a simple, convenient, and inexpensive solution without further need of additional hardwares except a buddy wire and a balloon.

Coronary angioplasty and stenting in acute coronary syndromes with very low contrast volume (Less than 30ml) using cordis diagnostic catheters and improved clinical outcomes

Funding AcknowledgementsType of funding sources: None.AimsTo safely perform angioplasties in acute coronary syndromes with very low contrast volume using Cordis diagnostic catheters and thereby improve the cardiovascular and renal outcomes. Methods and results In 1432 patients (1857 lesions/ 2148 stents) with acute coronary syndromes, angioplasty was performed with Cordis 6F diagnostic catheters. Primary angioplasty was performed in 457 cases. In 76% of cases, iodixanol was used. All contrast injections were given by hand. A regular follow-up of the patients was performed 30 days after the procedure. All the procedures were performed through the femoral route. Tirofiban was used in 99% cases with adjusted dosages based on the creatinine values. The mean contrast volume used per patient was 28 ml (±6 ml) including the angiogram prior to the angioplasty. Ninety one patients had creatinine more than 2mg/dl before the angioplasty procedures. Left main angioplasty was performed in 37 patients using single stents. 70 patients had cardiogenic shock at presentation. 76% of the cases had diabetes. IVUS was used in only two patients. A variety of coronary stents from various companies were used. Buddy wires were used in 36 cases. Ticagrelor was used in 92 cases, and in other cases clopidogrel was used. Mild reversible nephropathy (CIN) was observed in six patients. Four patients were already on dialysis, and dialysis was continued thereafter. Switch-over of angioplasty to the radial route was performed in five cases due to associated aortic/iliac obstructive lesions. 26 deaths in total were observed in this series; 16 of these patients had cardiogenic shock (7 late presenters), and three patients expired after discharge due to possible acute stent thrombosis. Groin haematoma was seen in five cases requiring one unit of blood transfusion. Proximal mild edge dissection in the deployed stent was seen in 3 cases which were treated with stents. Wire breakages were not seen. Acute in-hospital stent thrombosis was seen in 6 cases, which were managed with balloon dilatations and stents. Covid19 was positive in 16 cases by RT PCR.ConclusionsAngioplasty and stenting can be performed safely in patients with acute coronary syndromes using Cordis diagnostic catheters and a very low volume of contrast with improved clinical outcomes.

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

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

Through and Through Wire Technique for Stabilization of EVAR Main Body during Contralateral Limb Deployment

Contralateral gate cannulation is one of the key steps of endovascular aortic aneurysm repair (EVAR), and multiple different techniques and tips have been described to ensure accurate and swift performance of this step. In some cases, acrossover approach, entailing an up-and-over wire access from the ipsilateral limb into the contralateral gate followed by snaring the wire to the contralateral groin and proceeding with contralateral limb deployment is needed.The risks with this technique include the necessity of completely deploying the stent-graft main body, ipsilateral limb, and release of its trigger wires which essentially render the graft untethered, and cause concerns about the graft migrating upwards or "buckling" during advancement of the contralateral limb in challenging anatomy. To overcome this issue, we describe a modification of this technique which involvesretaining the through and through wire used for crossover cannulation as a stabilizing mechanism for the stent-graft and advancing a second "buddy wire" into the contralateral gate for deployment of the contralateral limb.

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.

Small buddy balloon catheter technique facilitates deliverability of other balloons or stents in challenging cases.

Despite improvements in balloon and stent technology, percutaneous coronary intervention (PCI) in calcified, tortuous, angulated or previously stented vessels is still a therapeutic challenge. The proper preparation of the vessel, confirmed by the smooth passage of smaller balloon catheters, often remains insufficient to deliver a larger, stiffer balloon or stent catheter in place of the target lesion. We describe a modified buddy balloon catheter technique that facilitates the deliverability of larger balloons or stents to these challenging lesions when the routinely used buddy wire technique as the first step fails. The small buddy balloon catheter technique is a simple extension of the buddy wire technique in which a small monorail uninflated balloon, of up to 1.5 mm, is positioned on the buddy wire distally or at the point where the balloon/stent becomes stuck. The small buddy balloon catheter appears to reduce the resistance of the rough surface, especially the angulated segment of the vessel, and facilitates other balloon or stent catheter passage. This does not concern a balloon inflation but rather catheter shaft properties. Since that technique is used in our high-volume catheterization laboratory with a surprisingly high success rate we think that it is worth sharing our experience with other operators. Consequently, we have decided to present these 2 cases.

Carotid Artery Stenting Using the Snake Hunt Technique for Highly Tortuous Carotid Artery Stenosis: A Technical Note.

In carotid artery stenting (CAS) for highly tortuous carotid stenosis, it is often difficult to guide rigid devices such as carotid stents. There are various adjunctive techniques using a guidewire: the buddy wire technique, the sheep technique, and the stiff guide technique. We report a case in which the tortuous vessel was straightened and a stent could be inserted. A 64-year-old man with amaurosis had highly tortuous left carotid stenosis. Despite the best medical treatments, he often had transient cerebral ischemic symptoms, so we planned CAS. We could insert the first stent, but the proximal vessel was kinked by the placement of the stent. It was so tortuous that the second stent could not be inserted by adjunctive techniques. Therefore, the proximal balloon was inflated and pulled back to straighten the tortuous vessel, and then we could insert the stent. We named this technique the “snake hunt technique” because it was just like catching a snake given that the tortuous vessel was stretched. This technique could be a troubleshooting step when it is difficult to insert a stiff device such as a stent or balloon even with the use of various adjunctive techniques.