Crossover Buddy Wire–Assisted Delivery of Steerable Guide Catheter

Abstract

Background

Transfemoral venous access is the standard for MitraClip procedures, but anatomic variations can hinder device delivery.

Case Summary

An 88-year-old man with severe mitral regurgitation underwent MitraClip therapy via the right femoral vein. During the procedure, compression by a calcified right iliac artery caused severe tortuosity of the iliac vein, preventing the advancement of the steerable guide catheter. A buddy wire was introduced through a left femoral crossover approach using a Radifocus guidewire into the right iliac vein, allowing successful catheter advancement and device deployment.

Discussion

This case highlights the importance of adaptive strategies to overcome anatomic challenges. The buddy wire technique allows for more controlled catheter manipulation and may have reduced the risk of venous injury.

Take-Home Message

The crossover buddy wire technique may be a useful bailout strategy with only minimal additional equipment to facilitate steerable guide catheter delivery in cases of venous compression.

Visual Summary

Visual Summary.

Crossover Buddy Wire Enables Steerable Guide Catheter Delivery in Tortuous Iliac Vein

(A) Severe mitral regurgitation on transesophageal echocardiography. (B) Three-dimensional reconstruction of computed tomography showing the spatial relationship among the aorta, veins, and heart. (C) Right iliac vein compressed by a heavily calcified and tortuous iliac artery. (D) Kinking of the sheath at the site of the iliac vein. (E) Obstruction of steerable guide catheter advancement. (F) Attempt to straighten the iliac artery using an Amplatz Super Stiff Guidewire. (G) Crossover buddy wire technique via the left femoral vein. (H) Successful insertion of a steerable guide catheter into the inferior vena cava using the buddy wire technique.

History of Presentation

An 88-year-old man was admitted with congestive heart failure characterized by lower extremity edema and pleural effusion. He had severe mitral regurgitation (MR) and remained symptomatic with NYHA functional class II dyspnea and persistently elevated brain natriuretic peptide levels (>400 pg/mL) despite optimal medical therapy. The patient was referred to our hospital for elective MitraClip implantation. On admission, he was afebrile, with stable vital signs and no signs of decompensated heart failure. A 3/6 systolic murmur was observed at the apex.

Take-Home Messages

• •The preprocedural assessment of venous anatomy is crucial in MitraClip candidates, especially in older patients with tortuous or calcified vasculature.
• •The crossover buddy wire technique may be a useful bailout strategy to facilitate steerable guide catheter delivery in cases of venous compression.

Past Medical History

The patient’s medical history included persistent atrial fibrillation, emphysema, stage 3b chronic kidney disease, and hyperuricemia. No evidence of coronary artery disease was found.

Differential Diagnosis

In evaluating the cause of severe MR, structural etiologies, such as mitral valve prolapse and chordal rupture, were considered.

Investigations

Transthoracic echocardiography revealed a left ventricular ejection fraction of 52%, with preserved wall motion. Transesophageal echocardiography (TEE) revealed severe MR with a posteriorly directed jet and left atrial enlargement (Figure 1, Video 1). Because resting echocardiography did not show pulmonary hypertension, and the patient had underlying emphysema, exercise stress echocardiography was performed to clarify the cause of exertional dyspnea. It revealed pulmonary hypertension associated with severe MR, supporting the diagnosis of atrial functional MR.

Figure 1.

Color Doppler Imaging Demonstrating Severe Mitral Regurgitation

Management (Medical/Interventions)

Given the patient's frailty (Clinical Frailty Scale score: 3), high Society of Thoracic Surgeons score (13.6%), and underlying comorbidities, we opted for MitraClip implantation with TEE guidance under general anesthesia.

We initially attempted to insert the MitraClip G4 (Abbott) steerable guide catheter (SGC) via a right femoral vein approach. However, because the iliac vein was compressed by the calcified and tortuous iliac artery (Figure 2, Video 2), insertion of the large-bore sheath for transseptal puncture was challenging (Figure 3A, Video 3A). A 14-F/25-cm sheath (Medikit Co, Ltd) was eventually placed using a 5-F Judkins Right catheter (JR40, Medikit Co, Ltd) and stiff guidewire, but it kinked and could not support transseptal puncture device delivery (Figure 3B, Video 3B). We therefore exchanged the 14-F sheath for a 20-F GORE DRYSEAL Flex Introducer Sheath (W.L. Gore & Associates, G.K.) (Figure 4A, Video 4A). Although we achieved transseptal puncture and placement of a super-stiff wire in the left upper pulmonary vein (Figure 4B), SGC advancement was impeded at the common iliac vein (Figure 4C, Video 4B). We attempted to straighten the iliac artery by inserting an Amplatz Super Stiff Guidewire (Boston Scientific) through the right femoral artery (Figure 4D, Video 5A), but this was unsuccessful. Thus, a left femoral vein approach was attempted but was abandoned because of similar difficulties concerning sheath insertion into the left external iliac vein (Video 5B). Eventually, the SGC was inserted into the inferior vena cava (IVC) using a buddy wire technique (Figures 5A to 5D) wherein a JR40 and Radifocus Guide Wire (Terumo) were advanced through the left femoral vein sheath before crossing over to the right common iliac vein, where they were used to guide the SGC into place (Videos 6A and 6B).

Figure 2.

Computed Tomography Showing the Spatial Relationships Among the Aorta, Veins, and Heart

Three-dimensional reconstruction of computed tomography showing the relationship of the aorta, veins, and heart. (A) Front view. (B) Right anterior oblique 90°.

Figure 3.

Iliac Vein Compression by a Calcified Artery and Sheath Kinking During the Initial Attempt

(A) Insertion of the large-bore sheath for transseptal puncture, showing compression of the iliac vein by the calcified and tortuous iliac artery. (B) Kinking of the sheath at the iliac vein site.

Figure 4.

Successful Transseptal Puncture and Failed Steerable Guide Catheter Delivery

(A) Advancing the 20-F GORE DRYSEAL Flex Introducer Sheath. (B) Successful transseptal puncture and placement of a super-stiff wire in the left upper pulmonary vein. (C) Advancement of the steerable guide catheter was obstructed near the common iliac vein. (D) Attempt to straighten the iliac artery by inserting an Amplatz Super Stiff Guidewire from the right femoral artery.

Figure 5.

Successful Steerable Guide Catheter Advancement Using the Crossover Buddy Wire Technique

(A to D) Procedure used to insert the steerable guide catheter into the inferior vena cava using a buddy wire technique.

A CDS0705-XTW clip (Abbott) was placed using a standard technique without complications, successfully controlling the MR (Video 7A). The device was removed without resistance, and digital subtraction angiography confirmed the absence of vascular injury before the procedure was concluded (Video 7B).

Outcome and Follow-Up

Postoperatively, the patient remained stable without complications. Echocardiography showed no structural cardiac damage or pericardial effusion. He was discharged home.

Discussion

Transcatheter edge-to-edge repair using the MitraClip System (Abbott Vascular) is a well-established treatment option for patients with severe MR who are at high or prohibitive surgical risk.^1,2 This minimally invasive procedure depends on safe and effective transfemoral venous access and transseptal puncture. However, anatomic variations, such as venous compression, tortuosity, or stenosis, can pose significant challenges during device delivery. Among the potential complications, iliac vein or IVC rupture is particularly critical, with reported mortality rates ranging from 6% to 22%.³ In contrast to arteries, veins have thinner walls and contain less smooth muscle and elastic tissue, making them more vulnerable to perforation during sheath advancement.⁴ The MitraClip system requires a large-caliber sheath, which can exacerbate the risk in patients with compromised venous anatomy. In our case, severe resistance to sheath advancement was encountered due to right iliac vein compression. Standard techniques proved inadequate, and additional force posed a risk of venous injury. To address this, we employed a crossover buddy wire strategy via the right femoral vein, which provided enhanced support and improved coaxiality, allowing the safe and successful advancement of the MitraClip sheath.

This case highlights the importance of adaptive strategies to overcome anatomic challenges during MitraClip procedures. The primary challenge was difficulty advancing the SGC because of significant iliac vein compression from a calcified and tortuous iliac artery. The effective strategy in this case was the buddy wire technique. It is commonly used in percutaneous coronary interventions (PCIs) to navigate tortuous or heavily calcified arteries.⁵ In the present case, both a JR40 and a Radifocus Guide Wire were advanced through the left femoral vein and crossed over into the right common iliac vein. As shown in Figure 5, the use of the buddy wire technique significantly improved the alignment of the SGC within the right common iliac vein compared with that in Figure 4C, where significant kinking was observed. This technique offered improved stabilization and coaxiality, enabling the smooth advancement of the SGC into the IVC. By mitigating kinking forces at the iliac vein, the buddy wire technique allows for more controlled catheter manipulation and may have contributed to reducing the risk of venous injury.

Venous access challenges during MitraClip procedures have rarely been reported in the literature. Several techniques have been proposed to overcome them, including predilation via balloon angioplasty and the transjugular approach.^6,7 However, the buddy wire technique is not yet considered a primary solution. Our case suggests that this method may represent a valuable option for interventional cardiologists managing iliac vein tortuosity or compression.

Originally used in PCI, the buddy wire technique is a simple yet effective method. It involves the insertion of an additional 0.014-inch guidewire to enhance guiding catheter stability and support balloon or stent delivery, especially in complex lesions with severe calcification, tortuosity, or acute angulation.^5,8 In MitraClip procedures, a similar technique has been reported to assist with passage through the interatrial septum.⁹ However, in our case, the conventional same-direction buddy wire approach was not feasible because of severe tortuosity and compression of the left iliac vein.

Instead, we used a crossover approach by inserting a guidewire from the left femoral vein into the right iliac vein. By creating a bidirectional support force and advancing the contralateral guidewire slightly toward the right lower extremity, we successfully counteracted venous resistance and enabled the smooth advancement of the SGC into the IVC. This modified buddy wire technique proved to be a practical adaptation to unique anatomic challenges.

Various adjunctive techniques have been reported to facilitate large-bore catheter advancement in patients with challenging venous anatomies. One alternative strategy involves the use of a Lunderquist Extra-Stiff Wire Guide (Cook Aortic Interventions) via a 24-F sheath to straighten the iliac vein, followed by an exchange with an SGC. This technique has been shown to improve the support and coaxiality in tortuous anatomy.

However, in our case, inserting even the 20-F GORE DRYSEAL Flex sheath required considerable force owing to the severe tortuosity and compression of the iliac vein. Therefore, we deemed the use of a Lunderquist Extra-Stiff Wire Guide and upsizing it to a 24-F GORE DRYSEAL Flex sheath for additional support to be associated with an unacceptably high risk of vascular injury. We opted for the buddy wire technique as a safer alternative.

The buddy wire technique employed here, using a contralateral femoral approach and a soft Radifocus Guide Wire, provided sufficient directional support and facilitated coaxial advancement of the SGC without requiring additional vascular intervention. Although the mechanical contribution may seem modest, it proved clinically effective in this setting, enabling safe and smooth catheter delivery without vascular injury.

Ultimately, the choice of technique should be tailored to the patient's anatomy, procedural context, and available resources. The crossover buddy wire technique may serve as a practical and reproducible option in selected cases in which more complex or costly alternatives may not be feasible.

Conclusions

As the use of the MitraClip system expands, interventionalists will increasingly encounter patients with complex venous anatomies. Preprocedural recognition of anatomic challenges and preparedness for alternative strategies are essential. This case highlights that a crossover buddy wire technique adapted from PCI practice can be an effective and minimally invasive solution for overcoming iliac vein compression or tortuosity. It may provide additional support for safe sheath advancement without increasing the procedural complexity or cost without the need for additional disposable devices. Further case series and studies are warranted to evaluate the systematic use of this technique in similar clinical settings.

Funding Support and Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

Color Doppler Imaging of Transesophageal Echocardiography Demonstrating Severe Mitral Regurgitation

Video 2

Axial Computed Tomography Scans

Video 3

Difficulty in Inserting the Large-Bore Sheath for Transseptal Puncture

(A) Attempted insertion of the 14-F/25 cm sheath via the right femoral vein was challenging because of iliac vein compression by a tortuous, calcified iliac artery. (B) Although the sheath was eventually placed with the aid of a 5-F JR40 catheter and stiff guidewire, the kinking of the sheath prevented the advancement of the transseptal puncture device.

Video 4

Use of a Larger Sheath and Difficulty Advancing the SGC

(A) The 14-F sheath was exchanged for a 20-F GORE DRYSEAL Flex Introducer Sheath to facilitate device delivery. (B) Despite successful transseptal puncture and placement of a super-stiff wire in the left upper pulmonary vein, advancement of the steerable guide catheter (SGC) was obstructed at the level of the common iliac vein.

Video 5

Attempts to Overcome Iliac Tortuosity Via Alternative Access Routes

(A) An Amplatz Super Stiff Guidewire was inserted through the right femoral artery in an attempt to straighten the tortuous iliac vein anatomy; however, this approach failed to facilitate steerable guide catheter advancement. (B) Left femoral vein approach was attempted; however, sheath insertion was unsuccessful due to external iliac vein tortuosity.

Video 6

Successful SGC Insertion Using the Buddy Wire Technique

(A) JR4.0 catheter and Radifocus Guide Wire were inserted via the left femoral vein and crossed over to the right common iliac vein, providing support for guiding the steerable guide catheter (SGC) into position. (B) An SGC was successfully advanced into the inferior vena cava using the buddy wire technique.

Video 7

Successful MitraClip Deployment and Angiographic Confirmation of Procedural Safety

(A) Successful mitral regurgitation reduction with MitraClip under transesophageal echocardiography (TEE) guidance. TEE showed the successful placement of a CDS0705-XTW MitraClip using a standard technique, resulting in effective control of mitral regurgitation without complications. (B) Safe device removal confirmed by angiography. Digital subtraction angiography after device removal showed no evidence of vascular injury, confirming procedural safety.