1. Takashi Ashikaga,MD,PhD
The effectiveness of inch compatible balloon for not only the passage of CTO but also stent delivery in LCX lesion
Takashi Ashikaga,MD,PhD

2. Background(1)
0.010-inch compatible balloon is designed exclusively for a inch guidewire. The cross-sectional area of the entry profile is 1.5 to 2 times smaller than that of a conventional inch compatible balloon. In addition, the outer diameter of entry profile of inch compatible balloon is equivalent to the outer diameter of the standard inch guidewire.
0.010-inch compatible balloon can sometimes cross through the CTO lesion because the passing ability of this balloon is excellent compared with any inch balloon because of the low profile.
0.010-inch compatible 1.5/9mm balloon could be crossed the CTO lesion after the failure of inch 1.3mm balloon and Tornus.

3. Background (2)
We previously demonstrated the effectiveness of distal balloon deflation technique as a stent delivery to the distal lesion for difficult cases.
Because of a limited inner lumen size of 6F guide catheter, inch compatible balloon could not be placed alongside the stent within 6F guide catheter.
In 6F guide system, inch compatible balloon could be placed alongside the stent .
Stent delivery could be accomplished with distal balloon deflation technique using 1.5/9mm inch compatible balloon after the failure of 5F inner catheter, 4F inner catheter and buddy wire technique.

4. CASE PRESENTATION
Case: 79 year old Male Risk Factors: Diabetes Mellitus, Hypertension, Dyslipidemia, Smoking, CKD History: The patient had undergone CABG in 2000 with LITA-LAD, SVG-OM-PL and GEA-LAD). He was admitted due to exertional angina in Coronary MDCT and coronary angiogram revealed that LITA-LAD was patent with occlusions of SVG and chronic total occlusion in mid LCX(Fig. 1,2). Echocardiogram revealed hypokinesis of posterolateral LV wall. His symptom was not improved with medical therapy.
(Fig.1)
(Fig.2)
(Fig.3)

5. So he was referred for coronary angioplasty. 6F IL3
So he was referred for coronary angioplasty. 6F IL3.5 guide catheter(GC) could be engaged from left femoral approach after the failure of 7F GC and 6F EBU because of the elongation and calcification of left common iliac artery (Fig.4,5).
(Fig.4)
(Fig.5)

6. Wizard 0.78 with microcatheter could not be crossed the CTO lesion(Fig.6).
Parallel wire technique with Miracle Ultimate Bros and Wizard3 was employed. Miracle Ultimate Bros with microcatheter could be crossed the CTO lesion (Fig. 7).
However, 1.3mm balloon and Tornus could not be crossed the CTO lesion (Fig. 8).
Tornus (White arrow)
(Fig.6)
(Fig. 7)
(Fig.8)

7. Then 0.010-inch guidewire (Eel slender) was replaced using microcatheter (Fig. 9).
0.010-inch compatible balloon (1.5/9mm) could be crossed the lesion easily and predilatation could be accomplished with this balloon (Fig. 10).
After the exchange to inch Fielder FC guidewire, 2.5/15mm balloon also could be crossed and dilated in mid LCX lesion (Fig.11).
(Fig.9)
(Fig.10)
(Fig.11)

8. After the predilatation with 2. 5/15mm balloon, Xience Prime (2
After the predilatation with 2.5/15mm balloon, Xience Prime (2.5/38mm) could not be crossed at the ostium of LCX (Fig. 12,13).
5F inner catheter was tried to be engaged deeply with anchor technique using 2.5/15mm balloon (Fig. 14).
6F guide catheter(black arrows) , 5F inner catheter (white arrow)
(Fig.12)
(Fig.13)
(Fig.14)

9. Xience Prime (2.5/38mm) could not be crossed at the ostium of LCX using 5F inner catheter (Fig. 15).
After retrieval of 5F inner catheter, 4F inner catheter was engaged within 6F guide catheter. However, Xience Prime (2.5/38mm) also could not be crossed at the ostium of LCX ostium (Fig.16).
After the retrieval of 4F inner catheter, inch guidewire was placed alongside the Fielder FC through 6F guide catheter (Fig. 17).
6F guide catheter(black arrows) , 5F inner catheter (white arrow), 4F inner catheter(blue arrow)
(Fig.15)
(Fig.16)
(Fig.17)

10. Xience Prime (2.5/38mm) could be deployed at the mid LCX (Fig. 20)
Buddy wire technique and distal balloon deflection technique using inch guidewire were not effective for the stent delivery .
Distal balloon deflation technique was employed using inch compatible balloon (1.5/9mm). At first, this balloon was placed at the ostium of LCX. Then, the stent could be easily crossed the LCX just after the deflation of this balloon (Fig.18,19).
Xience Prime (2.5/38mm) could be deployed at the mid LCX (Fig. 20)
(Fig.18)
(Fig.19)
(Fig.20)

11. By using the same method, 2
By using the same method, 2.5/18mm Xience V could also be deployed at the proximal LCX (Fig.21)
1.5mm inch compatible balloon (yellow arrows) ,
proximal edge of the stent(red arrows) A B C
A; 1.5mm balloon was placed at the ostium of LCX.
Stent was placed through 6F guide catheter
B; During inflation of 1.5mm balloon (6atm), stent was
placed near the balloon.
C; Just after the balloon deflation, stent could be crossed
easily alongside the balloon.
D; After positioning the stent, balloon and inch
guidewire were retrieved. Then the stent was deployed. D

12. Postdilatation was performed with 2.5/15mm balloon (Fig. 22).
Final angiogram was acceptable (Fig. 23).
The exertional chest pain disappeared after the stent deployment.
(Fig.22)
(Fig.23)

13. Comment (1)
In this particular case, PCI should be performed with 6F guide system. So the stent delivery with distal balloon deflation technique using inch balloon was unable.
By using inch compatible balloon, stent delivery could be accomplished with distal balloon deflation technique after the failure of 5F, 4F inner catheter and double wire technique.
Inner lumen 1.8 mm
6Fr. GC
6Fr. GC
XIENCE PRIME
XIENCE PRIME
0.014-inch balloon
IKAZUCHI X 0.010” Hyp
0.010-inch balloon
0.86 mm
0.84 mm
0.71 mm
0.86 mm
0.71 mm
0.36 mm
.014” Wire
.014” Wire
.014” Wire
010” Wire
0.36 mm
0.36 mm
0.26 mm

14. Comment (2)
Possible mechanism of distal balloon deflation technique is as follows.
Even though a smaller balloon (1.5/9mm), distal balloon deflation technique could be accomplished.
0.010-inch compatible balloon is effective for not only the passage of the CTO lesion but also the passage of stent for difficult cases.
The inflation of distal balloon may give the space to cross the proximal balloon, stent and GC.
The inflation of distal balloon may change the route of the proximal balloon, stent and GC.

15. Conclusion
0.010-inch compatible balloon is effective for not only the passage of difficult CTO lesion but also the passage of stent delivery even with a smaller guide system.
Distal balloon deflation technique could be accomplished for the difficult stent delivery through a small profile balloon (0.010-inch and 1.5/9mm).