February 1st 2018

Step Wise of Stent Delivery After Wire Crossing CTO: “Buddy balloon technique”

Category: Complex PCI, Coronary,



Johan Senihardja Cardiology resident, Sam Ratulangi University



Bambang Budiono Heart & Vascular Center Awal Bros Makassar Hospital

Clinical Information
A 51 years old male was admitted with stable angina pectoris and already received medical therapy. However, he still complaint chest pain while doing light activity. Two months earlier, he was hospitalized due to unstable angina pectoris and was done diagnostic coronary angiography at that time. He had a previous history of hypertension, well controlled. ECG has shown Q pathologic in inferior leads.

Figure 1. ECG prior admission to the hospital


His diagnostic angiogram has shown that there were severe lesion and chronic total occlusion (CTO) at the mid LCx and nonsignificant lesion at the proximal LAD (Video 1 and 2). There was severe stenosis and CTO in ostial to proximal RCA (Video 3). It was planned to perform PCI to the RCA.

Video 1. CA diagnostic shown nonsignificant lesion at LAD

Video 2. CA diagnostic shown CTO at mid LCx

Video 3. CA diagnostic shown CTO at proximal RCA


Procedural Step

PCI to RCA was done using trans radial technique. A 6 Fr TR 4.0 guide catheter was inserted to engage right coronary ostium. A 0.014” (Runthrough Hypercoat) wire was inserted into the RCA. After the wire successfully crossed the lesion (Video 4), a 2,0 x 20 mm (Maverick) balloon was used to pre-dilate the proximal to mid RCA at 6 atm. After serial predilatation, there was a difficulty in advancing a 3,0 x 38 mm (CRE8) through the lesion (Video 5).

Video 4. Wire crossed the lesion

Video 5. Difficulty in stent delivery through the lesion

Another 0.014” (Runthrough Hypercoat) wire was inserted for side wire anchoring techinique (Video 6). It was still unable to cross the stent through the lesion. Additional several predilatation was then performed, but the stent still remained unable to be delivered. The side wire anchoring was removed and then was advanced to the distal RCA for buddy wire. The stent was tried to be advanced over the buddy wire, and still unable to be delivered. 

Video 6. Side wire anchoring technique failed to cross the stent through the lesion

The next step was that the operator chose to use buddy balloon technique to overcome in difficulty of delivery stent (Video 7). While the stent was positioned at tip of catheter, a 2,0 x 20 mm (Maverick) balloon was advanced to distal RCA and inflated at 4 atm. Re-advanced the stent was successful, and then distal anchoring balloon was removed. The lesion was treated with 3,0 x 38 mm (CRE8) stent (Video 8). 

Video 7. Distal balloon anchoring technique

Video 8. Stent inflation at ostial to proximal RCA

The final angiographic result was very good with TIMI 3 flow (video 9).

Video 9. Final result


Dealing in CTO lesion is challenging and tricky. Therefore well prepared strategies are needed. We should never force in advancing long stent through the lesion if it could not pass the lesion smoothly.  It may cause further complication, and be better using other methods. In such a case, buddy balloon technique gives a greater chance to deliver the stent, as the low pressure inflated balloon in distal RCA may trap the other guide wire to stabilize guide catheter, it is used as a railway for the stent. Once the stent is already on the landing zone, the buddy wire and balloon can be pulled out from coronary artery, then finish the procedure with usual manner. Knowing various technique in delivery long stent through the lesion is mandatory to prevent further complication or “failed PCI”.

what the experts say

M. Munawar
Binawaluya Cardiac Center

Stent delivery failure has been reported to occur in 3.7% of all cases and 92% of these failures are due to vessel tortuosity and/or calcification. The case of Step Wise of Stent Delivery After Wire Crossing CTO: “Buddy balloon technique” presented here is excellent technique. This technique is also called as “anchoring balloon technique” and was long been reported by Fujita et al. The original anchoring balloon technique was used in PCI of chronic total occlusions and was achieved by inflating a balloon in a non-target vessel in order to obtain enough support to cross the lesion. Anchor balloon technique in a non-target vessel cannot be performed in all stent delivery failure because of failure of an appropriate non-target vessel, or due to low support by non-axial traction. Consequently, should use a modified technique in order to allow coaxial traction. The lesion should be well prepared. A second guidewire is then placed as a “buddy”. When the initial guidewire is rigid, then the second guidewire should be more floppy, and vice versa. An attempt should be made to deliver the stent on both guidewires alternately. In case of stent delivery failure (as in this case), a balloon is then placed distally to the target lesion. In order to perform powerful anchoring, one should consider a normal to slightly bigger balloon than the “landing” reference vessel diameter. This would allow potent anchoring with low inflation pressure (<6 atm). The stent is then placed over the second guidewire. After opening the Y-connector to allow easy gliding of the four components, the operator pulls on the balloon and both guidewires as an anchor with one hand and pushes the stent down towards the target lesion with the second hand.?There are several advantages. First, as mention by presenter, that the workhorse wire for delivery stent was entrapped by the balloon and therefore make stronger backup, especially if the lesion at the very proximal RCA, or maybe some barriers such in this case. The other important thing is using the two wires and the balloon shaft, can straighten of the vessel and therefore inserting of the stent is much easier. Backup support for guiding catheter should always be attempted by optimizing coaxial alignment, deep-seat the guide catheter. Knowing of the optimal coaxial guiding catheter and RCA is best performed in RAO view. Another modification of the above technique was reported by Ashikaga et al. This technique is quite different from the anchoring balloon technique with coaxial traction as described, and applicable to other situations that were difficult to deliver the stent because of the calcification or tortuosity of the proximal section. Using this technique, the stent was inserted gently as distal as possible. And just distal stent was placed another balloon using another wire (buddy wire). The size of the balloon was same as the artery size. After balloon was fully inflated, suddenly was then deflated. While deflating of the balloon, the stent was gently push distally. There are two mechanisms that might the stent can be push further. First, the inflation of distal balloon may give the space to cross the proximal stent because of preventing of the recoil of the artery. Second, changing of the route of the proximal stent.6 However, the limitation of these two above methods is possible vessel injury and may cause arterial restenosis in the future. Other technique that may overcome this problem is using extended catheter, either using guideliner, or mother and child technique. Again, in some cases, pushing the extended catheter may be difficult. Balloon anchoring technique may be used. After extended catheter can be inserted, the stent may be easily push distally. Debulking with rotablation or modification plaque using cutting balloon or scoring balloon can be used, especially for long stent delivery.