# Optimizing Guide Extension Catheter Advancement in Percutaneous Coronary Intervention: A Stepwise Approach Enhanced by Repeated Proximal to Distal Balloon Anchoring

## TL;DR

A new stepwise technique using balloon anchoring helps deliver stents to hard-to-reach coronary artery lesions when standard methods fail.

## Contribution

A stepwise approach with repeated proximal to distal balloon anchoring is introduced to advance guiding catheters in complex coronary interventions.

## Key findings

- The stepwise balloon anchoring technique enabled successful DES delivery in a severely calcified and tortuous RCA.
- Three DES were placed from distal to proximal after multiple balloon anchoring steps.
- The procedure resulted in no residual stenosis and TIMI III flow in the RCA.

## Abstract

The advancement of drug-eluting stents (DES) to distal, severely calcified, and tortuous coronary artery lesions presents a significant challenge in interventional cardiology. Techniques such as extra-backup catheters, buddy wires, and guiding extension catheters are commonly employed to overcome these difficulties. When these conventional methods fail, the stepwise approach enhanced by repeated proximal to distal balloon anchoring helps advance the guiding extension catheter deep into the coronary artery, allowing the delivery of DES to the distal calcified lesions even in tortuous arteries, and serves as an effective bailout strategy. The stepwise approach enhanced by repeated proximal to distal balloon anchoring is used to overcome difficulties in DES delivery. It allows deep advancement of the guiding extension catheter into the coronary artery over the shaft of the anchored (inflated) balloon, facilitating DES delivery.

This case report details the percutaneous coronary intervention (PCI) of the right coronary artery (RCA) in a 69-year-old male patient with multiple severe diffuse calcified stenosis. Despite initial attempts with a Judkins right curve (JR4) 6 French guiding catheter (Medtronic, Inc., Minneapolis, MN) and a buddy wire technique, DES delivery was unsuccessful, given that the guiding catheter support was unstable when the DES was advanced into the artery. Thus, to facilitate DES delivery, a guiding extension catheter was used, but it failed to advance into the RCA. However, using the stepwise approach with repeated proximal to distal balloon anchoring allowed deep advancement of the guiding extension catheter into the RCA over the anchored (inflated) balloon shaft. This anchored balloon technique was done three times starting at the proximal part of the RCA and advancing the guiding extension catheter to proximal, mid, and finally distal part of the vessel, ultimately allowing the successful placement of three DES from the distal to the proximal part of the vessel, demonstrating the technique's efficacy in overcoming complex anatomical challenges. At the end of the procedure, all lesions were successfully stented with no residual stenosis and a thrombolysis in myocardial infarction (TIMI) III flow in the RCA, and the patient was stable hemodynamically with no chest pain.