The editorial by Dr. Heuser and Dr. Naqi is very interesting as it describes a further technique that allows to increase the success rate in challenging coronary intervention (PCI) characterized by failure to deliver stents to the target lesion.

The description in the literature of several techniques to advance stents up to the target lesion in unfavorable coronary anatomies manifests how this problem is common in daily practice. Indeed, the interventionalists actually face with increasingly older and sicker patients, with many comorbidities, characterized by complex anatomical settings with diffuse disease, with huge amount of calcium and very tortuous coronary vessels. To overcome difficult coronary stent delivery, several strategies have been developed like mother–daughter and anchoring balloon . Moreover, expert interventional cardiologists skilled in the use of dedicated devices can deal with complex lesions such as chronic total occlusions, that were unthinkable to be tackled in the past. The authors report an interesting variant of the distal anchoring technique which is a fusion between a mother–daughter and anchoring balloon technique.

The CrossLock ™device described in this editorial is essentially a daughter catheter with the addition of a very compliant elastomeric balloon that can be inflated atraumatically in a proximal coronary segment. This device conformation, which serves as anchor in the system, makes the system capable of improving the support and avoiding sudden and involuntary movements of the guiding catheter (GC) during PCI, reducing therefore the potential risk of dissections. The CrossLock ™can be advanced in a 6 French sheet during peripheral procedures, and in 8 French GC for PCI. The need of large GC, is a contraindication to radial use. This device seems useful principally in antegrade CTO, as in the two cases here presented. As reported in the paper by Dr. Heuser and Dr. Naqi, CTO is the main limit in the performance of distal anchoring balloon technique, considering that in complete coronary occlusion it is impossible to advance a wire and a balloon distally, until the vessel is reopened.

On the other hand, the main advantage of distal anchoring balloon technique is that it can be performed at any time during a PCI performed in 6 French, particularly in unpredictable cases with underestimated vessel tortuosity and calcification, where the operator is not able to deliver the stent, despite common tips and tricks such as aggressive predilation, deep intubation, buddy and extra-support wires. The cases reported in the paper of Fiocca et al. deal mainly with such sudden difficulties during a radial PCI in 6 French .

In our opinion, the correct utilization of distal balloon anchoring, significantly increases the support of the system, allowing in many cases to advance and deliver the stent. The CrossLock ™device can be a useful alternative to distal anchoring technique to increase the support especially in the setting of CTOs.

With more arrows in the quiver, we have more probability to successfully perform complex PCI.

Best Regards.

Dr. Luigi Fiocca Dr. Chiara Bernelli.