Balloon deflection technique to facilitate stent delivery in impassable situations

Author(s): Santosh Kumar Sinha, Mohit Kejriwal, Umeshwar Pandey, Awdesh Kumar Sharma, Mahmodullah Razi, Ramesh Thakur, Vinay Krishna

Background: Long and multiple lesions especially in the background of tortuous coronary artery often require multiple stents. The entry and passage of another stent through an already deployed stent becomes challenging because of poorly expanded stent struts, calcified tissue, underlying tortuosity, highly angulated takeoff of the vessel, and lack of co-axiality. It can be facilitated by balloon deflection technique where balloon at proximal edge of main vessel stent over a buddy wire helps to deflect second stent either distally or into side branch by blocking potential dead.

Method: The present retrospective, single-center study included 16,189 consecutive patients who underwent percutaneous coronary intervention (PCI) either through transfemoral or transradial route from January 2014 to August December 2019 at LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, India where balloon deflection technique was used in situation of impassable stent among 37 patients.

Result: The mean age of patients was 75.4 ± 6.5 years. The commonest clinical presentation was chronic coronary syndrome (n=19; 51.3%) followed by NSTEMI (n=9; 24.4%), STEMI (n=5; 13.5%), and UA (n=10; 10.8%). Type-B2 lesion was commonest (45.9%) followed by type C (35.2%) and B1 (18.9%). The commonest indication for balloon deflection technique was angulation (n=10; 27.1%) followed by tortuosity (n=9; 24.3%), chronic total occlusion (n=8; 17.9%), calcification (n=7; 18.9%), and distally located lesion (n=3; 8.1%). The left circumflex artery (LCx) was the most commonly intervened artery (n=16; 43.2%) followed by left anterior descending (n=11; 29.7%) and right coronary artery (n=10; 27.1%). Mean diameter and mean length of stents were 3.3 ± 0.9 mm and 18 ± 6 mm respectively. The mean diameter and mean length of deflection balloon were 3 ± 0.5 mm and 20 ± 05 mm respectively. Lesions were modified using aggressive pre-dilatation in all cases while 19.4% of lesion required cutting balloon for additional modification. Additional wire as buddy wire was used in 54% of cases while wire in main vessel acted as buddy wire in dedicated bifurcation stenting. Stent implantation was successful in 36 cases with success rate of 97.3% while in one case, stent could not be delivered using BDT. Stent was finally delivered using GuideZilla mother-in-child catheter. Overall failure rate was 2.7% which were contributed by extreme tortuosity, angulation, and severe calcification.

Conclusion: In selected cases of impassable lesions; the deflection balloon technique may provide a simple, convenient, and inexpensive solution without further need of additional hardwares except a buddy wire and a balloon.