Guidewire Technique Research Articles

Sharp recanalization of peripheral arterial chronic total occlusions.

Peripheral arterial chronic total occlusions (CTOs) usually have calcified caps at either ends. When attempting endovascular recanalization, these calcified CTO caps may prevent the interventionist in crossing the lesion with conventional catheter and guidewire techniques. Using specialized CTO devices or re-entry devices can help crossing the CTO, but such devices are usually expensive, not always readily available and require specialist training prior to usage."Sharp recanalization" is an alternative method of crossing the CTOs. If it is not possible to cross the CTO with conventional catheter and guidewire technique, one can take out the floppy end of the guidewire and use the stiff or the "sharp" end of the guidewire to break the hard CTO cap. Once the CTO cap is broken, the stiff end is replaced by the floppy end of the guidewire again to proceed with balloon angioplasty and/or stenting.In order to safely use the sharp recanalization technique while minimizing the risk of perforation, sharp recanalization should only be attempted once conventional methods have failed. The interventionist should plan sharp recanalization with the vascular path in mind and decide in advance how far s/he will proceed. It can be helpful to set a time limit together with the intervention team, past which the sharp recanalization attempt will be abandoned. Using straight catheters can help directing the stiff guidewire tip to the center of the vascular lumen and reduce the risk of sub intimal dissection or arterial wall perforation.

A new cannula for antegrade selective cerebral perfusion.

ObjectiveOur aim was to perform antegrade selective cerebral perfusion with a different surgical technique using a new type of cannula.MethodsThis cannula has been designed to be introduced in the supra-aortic vessels directly using a standard guidewire technique (Seldinger technique). The cannula can also be inserted from the ostia of a vessel if preferred. Furthermore, this device can be introduced before the institution of hypothermic circulatory arrest and opening the aortic arch.ResultsWe have performed operations on 5 patients so far using this cannula. No stroke or spinal cord injuries were detected. At the moment, both intraoperatively and at computed tomography scan follow-up, no significant stenosis of the cannulation sites were noted. Follow-up at 2 years found that patients are alive and free from new major neurological events.ConclusionsTransarterial introduction using the Seldinger technique of our cannula (AV Flow; MedEurope Srl, Bologna, Italy) represents an alternative to the current well-established techniques. The major advantages we describe are complete cerebral protection throughout the hypothermic circulatory arrest and easier arch vessels reimplantation or hemiarch operations.

Double Guidewire Technique Using an Uneven Double Lumen Catheter for Endoscopic Ultrasound-Guided Interventions.

Endoscopic ultrasonography (EUS)-guided interventions are often performed using a single guidewire (SGW), but there are a few reports on the use of double guidewire (DGW) technique to facilitate multiple drainage placement during EUS-guided drainage of pancreatic fluid collections. This DGW technique may have advantages other than multiple drainage placement during EUS-guided interventions such as scope stabilization, support for stone extraction and device insertion. Consecutive patients who underwent EUS-guided interventions between Feb 2012 and Apr 2019 were retrospectively reviewed. The rate and reasons of DGW technique, and clinical outcomes were evaluated. DGW technique was performed, using an uneven double lumen cannula (UDLC), which facilitates insertion of 0.025-in. and 0.035-in. guidewires. A total of 249 EUS-guided interventions were analyzed, and DGW technique was utilized primarily in 65 cases (25.7%) and as a salvage after failed SGW technique in 18 cases (7.1%). The reasons for DGW technique were 60 multiple drainage placement, 10 scope stabilization, 7 device insertion, 5 safety guidewire, and 4 antegrade stone removal. Insertion of UDLC and DGW was successful in 100%. Technical success rate of preplanned interventions was 92.7% (96.9% in primary DGW and 77.8% in salvage DGW technique). Adverse events were observed in 19.5% after DGW but were not related to DGW technique. DGW technique using UDLC during EUS-guided interventions was technically feasible and safe. In addition to multiple drainage insertion, it can potentially support complex EUS-guided interventions.

Externalized transapical guidewire technique after artificial aortic valve replacement during complete endovascular aortic arch repair.

An externalized transapical guidewire (ETAG) technique has been used for safe delivery of high-profile devices through a tortuous aorta to zone 0, which is currently precluded after mechanical artificial aortic valve replacement (AVR). The aim of the study was to report one center’s experience (based on 3 cases) of a unique modification to the ETAG technique used for the first time during total endovascular aortic arch repair after AVR.This report contains technical notes regarding a new method of steering the guidewire from the apex inside the artificial aortic valve during total endovascular aortic arch repair after AVR and the details crucial in preparation for this mini-invasive procedure.As a conclusion, the ETAG technique could be performed after mechanical AVR with active positioning of the guidewire carried out under the control of transesophageal echocardiography.

A novel guidewire-assisted silicone spigot placement for endobronchial occlusion in a complicated airway tract: application of medical thoracoscopy.

The Endobronchial Watanabe Spigot (EWS) is a bronchoscopic device with a silicon plug used to occlude a bronchial fistula. Under bronchoscopy, localization of bronchopleural fistula poses a clinical issue and EWS placement in bilateral upper lobes often requires a skillful technique. To facilitate its placement, we introduced a new guidewire technique using two scopes, a bronchoscope and a medical thoracoscope, for localization of the bronchopulmonary fistula using a water-seal test and occlusion of the responsible bronchus without fluoroscopy. We report a case of a patient with chronic empyema with a bronchopleural fistula of the right upper lobe who had undergone a temporary Clagett open-window thoracostomy that was successfully occluded with four spigots using this new method.

Native Microchannel Recanalization with Orbital Atherectomy as a Viable Alternative to Failed Standard Recanalization of TASC II D Aortoiliac Occlusive Disease

Endovascular treatment of Trans-Atlantic Inter-Society Consensus (TASC) II D aortoiliac lesions is now an accepted form of revascularization. We sought to demonstrate that native microchannel recanalization and orbital atherectomy is a successful recanalization method of TASC II D aortoiliac lesions refractory to standard recanalization techniques. Four consecutive patients from 2016 to 2018 with symptomatic TASC II D aortoiliac occlusive disease prohibitive for open bypass and failed traditional prodding guidewire or device recanalization technique were identified and underwent advanced native microchannel selection and subsequent orbital atherectomy (Cardiovascular Systems, Inc, St Paul, MN). Native microchannels of the calcified lesions were probed and traversed with a 0.014″ wire. The atherectomy crown was tracked over the wire, and orbital atherectomy was initiated with a 1.25mm crown starting at the lowest revolution and continued until the microchannel is sufficiently large to track a 1.2mm-balloon for angioplasty. Serial microchannel angioplasty with exchange for stiffer and/or larger profile wires and balloons was achieved until a covered stent could be safely deployed across the target lesion. The kissing stent technique was then used to recreate the aortic bifurcation. A ViperSlide lubricant solution was used in all cases per indication for use. Patients were all heparinized to maintain an activated clotting time of 250. Lesion characteristics, survival, limb salvage, patency, and change in clinical symptoms were also analyzed. All 4 patients underwent successful native microchannel recanalization and orbital atherectomy of the common iliac artery (CIA). There were no intraoperative ruptures, embolizations, or dissections. All 4 patients presented with unilateral CIA occlusion with contralateral CIA stenosis. The average occlusion lesion length of the CIA was 6.0cm. The average contralateral stenosis length was 2.3cm. The kissing stent technique was used in all patients for reconstruction of the aortic bifurcation. At 30days, all patients had improvement in pain and primary patency of 100%. Long-term follow-up at 21.6months noted continued improvement in symptoms and primary patency of 75%. The fourth patient died at 4months from lung cancer with occluded iliac stents by imaging at that time. Native microchannel recanalization with subsequent orbital atherectomy is an option in high-risk patients with TASC II D aortoiliac disease who have failed traditional recanalization techniques. Further work in proper patient selection and safe utilization of atherectomy devices in the CIA is needed.

A modified technique for intraluminal stenting of glaucoma drainage devices: The guide-wire technique.

Glaucoma drainage tubes have become increasingly popular in the surgical management of uncontrolled glaucoma. Flow restriction is essential to prevent early postoperative hypotony with non-flow restrictive glaucoma drainage devices. Herein, we describe a new way of using a 3–0 Supramid suture as an intraluminal stent. This technique confers no risk of stent exposure, can be removed ab interno without disturbing the conjunctiva, and aids insertion of the tube into the anterior chamber through a scleral tunnel.

Performing Antegrade Selective Cerebral Perfusion Using the AV Cannula: A Novel Approach.

Antegrade selective cerebral perfusion has become the preferred choice for brain protection during aortic arch surgery. To perform antegrade selective cerebral perfusion, cannulas have been introduced directly into the ostia of the supra-aortic vessels (SAV) after institution of hypothermic circulatory arrest and opening the aortic arch. We describe a different surgical technique with a new type of cannula for antegrade selective cerebral perfusion. This cannula, called AV (Andrea Venturini) cannula, has been designed to be introduced in the SAV directly using a standard guidewire technique (Seldinger's technique). The AV cannula can also be introduced from the ostia of the SAV if preferred. The AV cannula can be introduced before the institution of hypothermic circulatory arrest and before opening the aortic arch. One great advantage of this technique is that the ostia of the SAV remain free from a cannula, allowing the operator easier access and a faster anastomosis or reimplantation.

A modified guidewire technique for deflating a non-deflating Foley catheter in the emergency department

Stuck catheter due to a non-deflating balloon is one of the complications of urinary catheters and these patients usually seek visits in the emergency department. The guidewire technique for deflating the balloon of a stuck Foley catheter is easy and non-invasive. But due to the characteristics of the guidewire in some instances, it could not be passed through the tight and narrow inflation port of the Foley catheter and the procedure would be frustrating for the physician and the patient. We made a modification that was successful in a case series of 8 male patients and made further invasive steps (rupture of the balloon by suprapubic or transrectal puncture) unnecessary.

A simple guidewire and angiocatheter technique for urinary catheter placement.

To report on a simple technique of inserting any difficult urinary catheter using a hydrophilic guidewire and an angiocatheter. A total of 764 requests were made to the urology team for assistance with a difficult urinary catheter placement. For all patients, either a regular or bent-tip catheter was attempted first. If the initial placement attempt failed, our technique using an angiocatheter, a hydrophilic guidewire, and a urinary catheter of choice was then employed. We were able to successfully insert 526 regular or bent-tip indwelling urinary catheters on first attempt (68.8%). Two hundred and four (26.7%) placements required the use of our described technique. No complication was encountered from the bedside maneuver. Our method is safe, easily learned, and performed. The technique saves time, effort, and resources, as it averts the necessity of rare use of expensive equipment, bedside flexible cystoscopy, and cystotomy.

Su1213 DOUBLE GUIDEWIRE TECHNIQUE USING A DOUBLE LUMEN CANNULA FOR INTERVENTIONAL EUS

There are a few reports on the use of double guidewire (DGW) technique to facilitate multiple drainage placement for EUS-guided drainage of pancreatic fluid collections (PFC). However, this technique can provide advantages other than multiple drainage placement during interventional EUS, such as scope stabilization, support for stone extraction or device insertion.

P156. Analysis of Patient Anxiety related to Magseed and Guide-wire localisation techniques

P156. Analysis of Patient Anxiety related to Magseed and Guide-wire localisation techniques

Hammering reverse guide wire technique for safe placement of anterior column retrograde in-tramedullary screw in pelvic and acetabular surgery

Objective To evaluate the efficacy and accuracy of hammering reverse guide wire technique for safe placement of anterior column retrograde intramedullary screw in pelvic and acetabular surgery. Methods From September 2015 to March 2018, 46 patients with pelvic or/and acetabular fracture involving the anterior column were treated with hammering reverse guide wire technique for safe placement of anterior column retrograde intramedullary screw at Department of Orthopaedics, Lishui Municipal Central Hospital. They were 28 men and 18 women, aged from 21 to 85 years (mean, 55.6 years). There were 34 pelvic ring fractures, 9 acetabular fractures and 3 combined pelvic ring and acetabular fractures. After the anterior lateral spine of pubic tuberosity was drilled by a guide pin and drill bit as the entry point, a reverse guide wire was knocked into the bone lightly by a hammer. For each retrograde intramedullary screwing into the acetabular anterior column, we recorded operation time, fluoroscopic frequency, and attempts to establish an acceptable screw pathway by the guide pin. The accuracy of screwing and the quality of fracture reduction were evaluated by imaging examination. For each patient, we recorded fracture union time and complications. Functional recovery of the pelvis and acetabulum was assessed by postoperative physical examination at the last follow-ups. Results The operation time of retrograde intramedullary screwing for the 46 patients averaged 28.9 minutes (from 16 to 55 minutes); the fluoroscopy frequency averaged 16.3 times (from 9 to 35 times); an acceptable screw pathway was established by the first attempt in 43 of the 46 patients (93.5%) and re-established after adjustment of the guide pin in the other 3. Forty patients were followed up for an average of 15.2 months(from 6 to 36 months). Postoperative CT scan and three-dimensional reconstruction showed that all the screws had been placed safely and accurately in the acetabular anterior column. Implant loosening and fracture displacement occurred in one case and lower limb thrombosis in another. No nail breakage, fracture nonunion, incision necrosis or infection, neurovascular injury or femoral head necrosis was observed. All fractures united after an average of 14.7 weeks (from 12 to 18 weeks). According to the Majeed scoring at the last follow-ups, the pelvic and acetabular function was evaluated as excellent in 29 cases, as good in 9, and as fair in 2, giving an excellent and good rate of 95.0%. Conclusion Hammering reverse guide wire technique is an effective method for safe placement of anterior column retrograde intramedullary screw in pelvic and acetabular surgery, because it can increase accuracy of screwing and reduce intraoperative radiation, operation time and incidence of complications though it is simple. Key words: Pelvis; Acetabulum; Fractures, bone; Surgical procedures, minimally invasive; Fracture fixation, internal

Double Guidewire Technique versus Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

Double Guidewire Technique versus Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

Double Guidewire Technique versus Transpancreatic Sphincterotomy for Difficult Biliary Cannulation

Background: The standard biliary cannulation technique has been reported to fail in approximately 5– 20% of cases so, several supplementary techniques have been recommended to facilitate access to the common bile duct (CBD); Double-guidewire technique (DGT) and transpancreaticsphincterotomy (TPS) are effective method in cases of standard biliary cannulation failure. Objective: To compare the outcomes between DGT and TPS in patients with difficult biliary cannulation regarding the procedure duration, success rate and complications. Patients and Methods: This was a randomized study conducted in Al-Hussein University Hospital, Endoscopy Unit in the period between May, 2016 to October, 2017. A total of 40 patients, who bile duct cannulation was not possible and selective pancreatic duct cannulation was achieved were randomized into DGT (n = 19) and TPS (n = 21) groups. DGT or TPS was done for selective biliary cannulation. We measured the technical success rates of biliary cannulation, median cannulation time, and procedure related complications. Results: The distribution of patients after randomization was balanced, and both groups were comparable in baseline characteristics. There was no significant difference between both groups regarding age and sex distribution, clinical presentation, laboratory findings and sonographic findings. Successful cannulation rate and mean cannulation times in DGT and TPS groups were 94.7% vs 95.2% and 20.1 ± 8.7min vs 21.5 ± 7.8min, P = 0.602, respectively. There was no significant difference between the two groups. Conclusion: When free bile duct cannulation was difficult and selective pancreatic duct cannulation was achieved, DGT and TPS facilitated biliary cannulation and showed similar success rates. However, post-procedure pancreatitis and Cholangitis were significantly higher in the DGT group.

Clinical value of double guidewire technique for perforation of duodenal papilla by guidewire in endoscopic retrograde cholangiopancreatography

Objective To evaluate the efficacy and safety of double guidewire technique in perforation of duodenal papilla caused by guide wire during endoscopic retrograde cholangiopancreatography (ERCP) intubation. Methods A retrospective analysis was performed on data of 57 patients whose duodenal papilla were perforated by guidewire in ERCP from January 2008 to September 2016. Among the 57 patients, 30 patients were cannulated with double guidewire technique (double guidewire group) and 27 patients were performed with traditional technique (standard group) for continue. The biliary intubation success rate, intubation time, and post-ERCP complication rate were compared between the two groups. Results The rate of successful intubation of the double guidewire group was significantly higher than that of the standard group[96.7% (29/30) VS 74.1% (20/27), χ2=5.545, P=0.019]. The intubation time of the double guidewire group was significantly shorter than that of the standard group (21.8±7.8 min VS 40.7±8.4 min, t=8.076, P=0.000). The double guidewire group had a similar incidence of post-ERCP complication compared to the standard group[13.3% (4/30) VS 11.1% (3/27), χ2=0.292, P=0.596], and the complication in two groups was hyperamylasemia. Conclusion Double guidewire technique is safe and effective for difficult biliary cannulation because of perforation of duodenal papilla with a higher success rate and less time compared to classic technique. Key words: Cholangiopancreatography, endoscopic retrograde; Cannulation; Bile ducts; Duodenal papilla

Externalized transapical guidewire technique for complex aortic disease: a single-centre experience.

The through-and-through guidewire technique has been utilized for safe advancement of a high-profile stent graft delivery system through the tortuous aorta. A brachial-to-femoral configuration is most commonly established, but a few alternatives have been described. This study aimed to report our experience with the externalized transapical guidewire (ETAG) technique in patients who underwent thoracic endovascular aortic repair (TEVAR) and to explore its utility, feasibility and safety. Patients who underwent TEVAR between April 2015 and March 2017 were retrospectively reviewed, and 5 patients who underwent the procedure with the ETAG technique were found eligible for the study. Indications for the ETAG technique were the following challenging aortic anatomical configurations: (i) severely angulated aorta in 3; (ii) proximity of the proximal landing zone to the aortic valve in 2; (iii) a limited proximal landing zone in 1; and (iv) complex atheroma predominantly on the greater curvature of the aorta in 3 patients. TEVAR was completed in all cases. The ETAG technique was utilized in all patients. The delivery system tip was navigated along the lesser curvature of the aortic arch as it was advanced. During deployment, conformability was increased by pushing both ends of the wire. Tip retrieval was also enhanced in 3 patients. Patients with complex aortic atheroma had no embolic complications. All patients survived TEVAR, but 1 patient with an aorto-oesophageal fistula did not survive the second-stage oesophagectomy. Postoperative complications included delayed cardiac tamponade requiring drainage in 2 patients. The ETAG technique was useful in overcoming several anatomical challenges encountered during TEVAR. Contact of the delivery system with the greater curvature of the aortic arch could be avoided with this technique, potentially reducing embolization risk related to the complex aortic arch atheroma.

LEA 22. Totally Percutaneous Femoral-Popliteal Bypass: The Best of Both Worlds

Endovascular techniques are now leading the revascularization of lower limbs, mainly because of the interest in a percutaneous approach. Despite huge progress, failure of recanalization may occur, or more often, recurrence darkens the evolution. In these cases, surgical bypasses are required, but they have a higher morbidity and mortality impact. We describe an innovative technique of femoral-popliteal bypass realized through a totally percutaneous approach and the early results of the initial study. From January to June 2018, six totally percutaneous bypasses (four male patients; age, 62-89 years [mean, 74.5 years]) were performed at the femoral-popliteal level: three above the knee and three below the knee. All the bypasses where prosthetic. Four patients had critical limb ischemia; two had severe claudication (50 m or less). Two patients had failure of previous endovascular revascularization, three had multibypass failure, and one had early iterative severe restenosis. In addition, three had adverse skin conditions for a surgical approach (multiple scars in two patients and lymphedema with inguinal surgical infection in one patient). Percutaneous puncture under ultrasound guidance allowed placement of three intravascular sheaths in the femoral, popliteal, and contralateral femoral positions, followed by extravascular and subfascial tracking of the guidewire and rendezvous technique, then deployment of covered self-expandable stents bypassing the occluded segment of the artery with respect to the profunda femoral artery as well as collaterals. In all the cases, technical success occurred, with clinical resolution of the critical limb ischemia or vascular symptoms and satisfactory blood flow through the stent graft. No death occurred, and there was no major complication. Local bruising or a small hematoma occurred in two patients, and there was quick recovery and stand-up at day 1 in all the cases. On early follow-up (1-7 months; mean, 4.1 months), primary patency remained in five patients. One occlusion occurred 45 days after implantation, needing in situ fibrinolysis (no technical defect but a poor runoff). Although this is an early and short-term study, it demonstrates the feasibility of totally percutaneous bypass, combining the main advantages of both endovascular and bypass revascularization. Further evaluation is required.

PMS25 - COST COMPARISON OF OPEN, MINIMALLY INVASIVE AND GUIDE-WIRELESS MINIMALLY INVASIVE SURGERY TRANSFORAMINAL LUMBAR INTERBODY FUSION (GMIS/TLIF) INTERVENTION FOR LUMBAR DEGENERATIVE DISC DISEASE IN THE UK

Minimally invasive surgery (MIS) for transforaminal lumbar interbody fusion is used to treat lumbar degenerative disc disease (DDD). MIS has been acknowledged to reduce the probability of perioperative muscular damage compared to the traditional open surgery (OS) approach, however MIS requires a steep learning curve due to its technical complexity. Recently a novel gMIS/TLIF technique has been developed to simplify the procedure and improve clinical outcomes using a streamlined approach which eliminates the need for Jamshidi and guidewire techniques used in previous MIS. To inform evolving treatment practices this study compares estimated costs and outcomes of the gMIS/TLIF technique with existing MIS and OS approaches. A deterministic Excel model was developed to estimate direct costs of the different alternatives for treating DDD in the United Kingdom (UK). The model was populated with cost and clinical inputs from published studies and UK reference cost databases, including: resources used for each alternative, theatre time, imaging procedures, pharmaceuticals consumed, and hospitalization days. Treatment costs were adjusted to the base year 2017. After factoring in additional costs associated with gMIS/TLIF, an overall cost savings of £2,790.24 per case was estimated compared with OS that was mostly attributed to reduced surgical time (£1,586.46) and hospitalization costs (£1,335.60). When compared to MIS, a reduction in the number of instruments needed and the number of instrument passes can result in shorter operation times for gMIS/TLIF, with an estimated cost savings of £1,606.58 per case. The gMIS/TLIF approach offers a less invasive alternative for treating DDD that may limit soft-tissue damage and benefit health systems that may save costs. However, further study is required to fully interrogate its clinical benefits.

A técnica do duplo fio-guia para recuperação de guia retido no sistema coronário

Entrapment and breakage of devices used in coronary interventions are rare complications, but have occurred with increasing frequency. Knowledge and mastery of techniques to rescue these materials are of paramount importance to solve these incidents. We report a successful withdrawal of a 0.014” retained guidewire in the coronary artery, by the so-called twin guidewire technique. Twin guidewire technique for retrieval of retained guidewire in the coronary system