Abstract
Despite remarkable advances in the interventional landscape, device delivery during percutaneous coronary intervention (PCI) can still present technical challenges especially when performed in complex anatomical settings and through radial approach. To overcome difficult coronary stent delivery, several strategies have been developed. A niche option in such complex cases is the anchoring balloon technique, which involves inflation of a balloon non-coaxially in a side branch or distally to the target lesion in a coaxial fashion, to facilitate stent delivery. However, the main limitation of this technique is the requirement of a large guide catheter (≥ 7 French) which may preclude the use of radial approach. We describe, step-by-step, the distal anchoring ballooning technique performed by a 6 Fr radial approach to overcome the stent delivery failure in complex anatomical scenarios and to safely and successfully carry out the PCI procedures.
Highlights
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Distal anchoring balloon technique performed by a 6 Fr radial approach is described in detail, in a very didactic manner in the setting of stent delivery failure, in complex anatomical scenarios.
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Three cases are illustrated, in which distal anchoring allowed to advance a stent to the target lesion.
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The peculiarity of the present cases is that all have been performed by 6 Fr radial approach.
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A distinctive feature is the description of the “train maneuver” to fully utilize the inner lumen of the 6 Fr guiding catheter.
1
Introduction
Despite technological improvement, device delivery during percutaneous coronary intervention (PCI) can be still challenging especially in complex anatomies . The presence of severe coronary tortuosity and heavy calcification may indeed enhance the complexity, the duration, and failure rate of PCI . In addition, although associated with a net clinical benefit, the use of radial approach in complex lesion subsets may increase the procedural complexity and limit the success rate . A key factor for procedural success remains the ability to deliver stents to the target lesion. Stent delivery failure may occur in up to 5% of PCI and can be associated with suboptimal angiographic result and increased morbidity . To enhance the support, the operator usually appeals to tips and tricks such as catheter deep intubation, use of larger guiding catheter (GC) with more supportive shapes through femoral approach, buddy or extra support wires, predilation with progressive balloon sizes, “Child in Mother” technique with dedicated delivery catheters and shorter and more deliverable stents with an improved crossing profile . An alternative option to increase the release capability is the anchoring balloon (AB) technique, consisting in the low-pressure inflation of a balloon in a side branch or distally to the target vessel in order to cross the lesion and delivery the stent . In the classical non-coaxial AB technique, a balloon is inflated proximally in a side branch of the target coronary vessel, while in the coaxial distal AB technique, a balloon is inflated distal to, or at the target lesion to enhance support for device delivery . However, the distal AB technique is usually performed with large (≥ 7 Fr) GCs and by femoral approach to allow simultaneous device advancement . We sought to describe how the distal anchoring technique can be performed through the 6 Fr radial approach.
The main steps, with tips and tricks to perform the distal AB technique by radial approach are illustrated in Fig. 1 . Additionally, the following cases exemplify the potential applications of this technique.
1.1
Case 1
A 74-year-old man with diabetes and moderate renal failure was admitted for a non-ST elevation myocardial infarction. He had a previous history of lateral acute myocardial infarction (MI) treated with PCI on left circumflex artery (LCX) and ramus. Coronary angiography, demonstrated a tight stenosis on the middle right coronary (RCA) that was markedly calcified and tortuous ( Fig. 2A, B ). A 6 Fr AL1 Launcher (Medtronic, Minneapolis, MN, USA) GC was used to increase the back-up support through right radial approach. A Whisper MS wire (Abbott Vascular, Santa Clara, CA, USA) was advanced distally. Despite repeated lesion predilation and the use of a “buddy” wire technique with an extra-support wire (Floppy II Extra-Support guide wire, Abbott Vascular Santa Clara, CA, USA), a 3.0 × 18 mm Resolute Integrity (Medtronic, Minneapolis, MN, USA) drug eluting stent failed to cross the lesion ( Fig. 2C ). The distal AB technique was therefore performed, inflating distally to the target lesion a semi-compliant 2.5 × 15 mm Trek (Abbott Vascular Santa Clara, CA, USA) balloon at low-pressure (6 atm), allowing the advancement of the same stent ( Fig. 2D, E ). After the retrieval of the AB, the stent was successfully implanted with satisfactory final angiographic result ( Fig. 2E, F ). No complications occurred.
1.2
Case 2
An 80-year-old male, with a previous inferior MI, was admitted for worsening effort angina. Coronary angiography revealed a known chronic total occlusion (CTO) of the RCA, a mild stenosis of distal left main and a critical calcific stenosis of the proximal left anterior descending (LAD), involving the first diagonal branch (D1) with a 90 degree bend ( Fig. 3A ). PCI of the bifurcation LAD-D1 was attempted by 6 Fr radial approach. The left main was engaged with a 6 Fr EBU4 Launcher GC. After several predilations of the D1 branch and of the calcific proximal LAD with non-compliant balloons up to 3.0 × 15 mm, a 2.75 × 22 mm Resolute Integrity failed to cross the bend at the LAD lesion ( Fig. 3B ). On a buddy-wire, a semi-compliant 2.5 × 12 mm Trek balloon was then advanced distally into the LAD and inflated up to 8 atm, anchoring the main wire and the GC ( Fig. 3C ). The same stent was therefore easily advanced beyond the calcific bend of the LAD. After withdrawal of the AB, the stent was implanted with optimal final angiographic result ( Fig. 3D ).
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