This document provides several tips and tricks for navigating tortuous coronary arteries during cardiac catheterization procedures: 1) Shorter and more flexible stents and balloons can be delivered through more tortuous segments. An "anchor" technique using a buddy balloon can also aid delivery. 2) Stiffer wires can cause spasm, so microcatheters, buddy balloons, and telescopic guide systems may help. The Hi-Torque Wiggle wire can deflect to pass tortuous segments. 3) While rapid-exchange devices are faster, over-the-wire devices may track and deliver better in tortuosity. Laser or rotablater should be avoided due to risk of complications

1. Tips and tricks

2. 
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Two or more bends ≥75 proximal to the target
lesion, at least one proximal bend ≥90 , or the
presence of “significant” vessel curvature proximal
to the target lesion.
On the basis of the number of 45 bends
no/mild = 0–1
 moderate = 2 bends
 severe = 3 or more bends

Manual Interv Cardiol 2002. 237–243.

7. PASSIVE
MOTHER AND CHILD
ACTIVE
PROXIS

8. ATRIAL BRANCH
DISTAL RCA

10. 
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Shorter and thin-strut stents (such as cobalt
chromium)are more flexible and as a result more
deliverable
Shorter and lower profile balloons and stents may
be more likely to cross tortuous coronary segments
“Anchor” technique, in which a balloon is inflated
in a non target vessel and supports the guide
catheter while another balloon is advanced
through the main vessel lesion

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Stiffer wires lead to more spasm of arteries , at times
leading on to significant complications and
pseudolesions
Advancement of microcatheters , inflated buddy
balloons and telescopic guide system for tortuous
vessels
The Hi-Torque Wiggle wire (Abbott Vascular) is a wire
with a sinusoidal segment proximal to its tip which can
deflect the tip of the balloon or the stent and allow
delivery past tortuous or calcified coronary segments
but requires larger guide and difficult to pass stent.

12. 
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Although rapid-exchange devices may be faster and
easier to use, over-the-wire devices may have better
trackability and deliverability across tortuous
segments.
However, use of over-the-wire devices may be
associated with longer procedure time and higher
radiation
Laser or rotablator may be best avoided in tortuous
arteries to prevent serious complications, such as
perforation
Deep guide intubation(>20 mm in ostium) carries the
risk of pressure dampening, compromising blood flow
leading to ischemia and causing coronary dissections

13. 
Use of a „„buddy wire‟‟ technique was originally
described by Selig.
USES:Cathet Cardiovasc Diagn 1992;25:331–335.
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The reduction of balloon slippage during angioplasty for in-stent
restenosis;
Insufficient back-up of the guiding catheter
Stenting of lesions located in vessels with proximal
tortuosities/angulations
Stenting of lesions distally located in the vessel
Facilitation in the positioning of distal protection devices
Stenting of a lesion distally located from a previously implanted stent
or from a coronary segment with both calcification and sharp bend
PCI on coronary arteries with anomalous origin.
Burzotta F et al J Invasive Cardiol. 2005 Mar;17(3):171-4.

14. Catheterization and Cardiovascular Interventions 74:564–568 (2009)

15. 
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The Stereotaxis Niobe1 II MNS (Stereotaxis, St.
Louis, MO) has two permanent adjustable magnets
that can be rotated, translated, or tilted to produce
a uniform magnetic field of 0.08 T.
This field precisely directs a tiny magnet mounted
on the tip of a guidewire by changing its’ magnetic
moment and allows fine control of the orientation
of the tip of the guidewire in space.
The system is integrated with a modified C-arm
flat-panel detector fluoroscopic imagingsuite for
angiographic imaging.
Catheterization and Cardiovascular Interventions 70:662–668 (2007