Celebrating the Kissing Balloon Technique

In honor of Valentine’s Day, let’s review the kissing-balloon technique, a two-stent technique developed for dilating bifurcation lesions. Many variations of this double-stent technique have been developed for numerous unique anatomical situations depending primarily on the anatomy and clinical importance of the side branch. Just as many clever and descriptive names have been used to describe variations of the approach, including “T-stenting”, “V or Y stenting”, “culotte” and “SKS (simultaneous kissing stents)”, the buddy balloon technique, and double kissing, to name a few. Many of the articles below describe creative ways for treating bifurcation lesions using two stents. The first two articles, however, discuss the use of the new Xience SBA bifurcation stent device developed with the goal of solving many of the difficult technical issues with side branch access.

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Initial Human Experience with the XIENCE Side-Branch Access Device

David G. Rizik, MD, Bruce Samuels, MD, Thomas R. Hatten, RN, RCIS, Robert J. Gil, MD, PhD

The everolimus-eluting XIENCE side-branch access (SBA) stent has been the focus of numerous recent publications. Most of the information available on this device comes from the preclinical studies performed in ovine models as well as perfused synthetic heart models. It has now become available in Europe as part of a limited test launch.

Delivered via a low-profile, dual-lumen, single-tip catheter, a single inflation device deploys the stent in the main branch and expands a portal opening into the ostium of the side branch to allow for scaffolding and entry into the side branch. This case report describes the first-in-man experience with this novel device. J INVASIVE CARDIOL 2012;24(6):298-303

Xience SBA Bifurcation Stent for Treating Distal Left Main Disease in NSTEMI Patient

Witold Dubaniewicz, MD, Radosław Targoński, MD, Dariusz Ciećwierz, MD

The Xience SBA may represent a good alternative in lesions of this type and may help to avoid multistent techniques while preserving integrity of the side branch. To our knowledge, this is the first publication of Xience SBA stent usage in the invasive treatment of distal left main lesion.

Use of a Novel Adjunctive Kissing-Balloon Technique with the Trellis Device to Successfully Prevent Embolization Across Juxtaposed Kissing Aortoiliac Stents

Jigar H. Patel, MD, Reji M. Pappy, MD, Mazen S. Abu-Fadel, MD

Patel et al describe a novel and simple technique of adjunctive kissing balloon inflation while using the Trellis device for the management of an aortoiliac occlusion that occurred in one of two juxtaposed stents previously placed in the distal aorta into the bilateral iliac arteries. This technique prevented distal embolization into the contralateral iliac artery. J INVASIVE CARDIOL 2012;24(1):32-35

Buddy-Balloon Technique for Final Kissing-Balloon Dilatation After Crush Stenting of the Left Main Coronary Artery

Akihiko Takahashi, MD, PhD, Shingo Sakamoto, MD, Norimasa Taniguchi, MD, PhD, Yukio Mizuguchi, MD, Takeshi Yamada, MD, Shunsuke Nakajima, MD, PhD

Crush stenting mandates a final kissing-balloon technique (KBT) for a better clinical outcome; however, recrossing the 2 overlapping stent struts with the balloon catheter is technically challenging. This study evaluates the efficacy of the buddy-balloon technique for facilitating completion of the final KBT during crush stenting of the left main coronary artery (LMCA) was evaluated. Takahashi et al conclude that the buddy-balloon technique is a suitable option when used in the context of crush stenting in patients with lesions of the distal LMCA.

Use of the Kissing Microcatheter Technique to Exchange a Retrograde Wire for an Antegrade Wire in the Retrograde Approach to Intervention in Chronic Total Occlusion

Atsushi Funatsu, MD, Tomoko Kobayashi, MD, Shigeru Nakamura, MD

This technique involves placing a microcatheter inside the antegrade guiding catheter and manipulating the retrograde guidewire to pick up the tip of the antegrade microcatheter and enter it retrogradely. The retrograde microcatheter and antegrade microcatheter are on the same retrograde wire. After advancing the antegrade microcatheter until both tips kiss each other, the antegrade microcatheter is advanced to the distal portion of the CTO lesion, pulling the retrograde microcatheter back. The retrograde guidewire is pulled out and an antegrade guidewire is advanced to the distal true lumen through the antegrade microcatheter. This novel technique is a safe, feasible strategy for placing an antegrade guidewire across a CTO lesion.  J INVASIVE CARDIOL 2010;22:E74–E77

Kissing Balloon Technique within a 5 Fr Guiding Catheter Using 0.010 Inch Guidewires and 0.010 Inch Guidewire- Compatible Ball

Fuminobu Yoshimachi, MD, Motomaru Masutani, MD, Takashi Matsukage, MD,
Shigeru Saito, MD, Yuji Ikari, MD

In the 1990s, the kissing balloon technique (KBT) required an 8 Fr guide catheter that would accept 2 balloons. In this article from Yoshimachi et al, the characteristics of a new balloon with a smaller outer diameter are reported. The key technological advancement that now allows the use of small-diameter balloons was the reduction of the guidewire lumen, which is now a suitable diameter of 0.010 inch. We also report on an animal experiment using a porcine model and a clinical case of the use of a 5 Fr guide catheter to perform the KBT. J INVASIVE CARDIOL 2007;  volume 19 (number 12)

Unprotected Left Main “Kissing” Stent Implantation With a Percutaneous Ventricular Assist Device

Srihari S. Naidu, MD, Sameer Rohatgi, MD, Howard C. Herrmann, MD, Ruchira Glaser, MD

Description of a patient who was at high risk for surgical revascularization is described. Naidu et al treated the patient with hemodynamically supported left main angioplasty with the TandemHeart percutaneous ventricular assist device (Cardiac Assist). A 21 French (Fr) in-flow cannula was advanced via the transseptal technique into the left atrium under intracardiac guidance, a 15 Fr out-flow cannula was inserted into the right femoral artery and advanced to the right common iliac artery, and resultant left atrial-to-distal aorta bypass was achieved with a non-pulsatile flow rate of 3.0 liters per minute. The LAD and LCx were both wired, and stented utilizing two sirolimus-eluting stents simultaneously deployed with a “kissing” technique. During balloon inflation, hemodynamic monitoring revealed a significant decrease in aortic pulse pressure due to diminished stroke volume. Despite the drop in pulse pressure, mean perfusion pressure was maintained and the patient remained hemodynamically stable without angina or arrhythmia. J INVASIVE CARDIOL 2004; Volume 16, number 11

COMMENTARY: Bifurcations: The Problem is the Side Branch

James Hermiller, MD and Ali Rizvi, MD

When committed to a two-stent strategy (side-branch and main-branch stenting), which technique is best? Provisional T-stenting is at present the default approach for most lesions; however, it is limited by sacrificing access to the side branch, even if the side-branch wire is left in during main-branch stenting (trapping of side branch wire).

Bifurcation Coronary Artery Disease: Current Techniques and Future Directions (Part 1)

David G. Rizik, MD, Kevin J. Klassen, MD, James B. Hermiller, MD

Tips and Tricks for Stenting of Bifurcation Coronary Lesions

Tak W. Kwan, MD, Lori Vales, MD, Michael Liou, MD, Yumiko Kanei, MD, Shao-Liang Chen, MD

DK Crush (Double-Kissing and Double-Crush) Technique for Treatment of True Coronary Bifurcation Lesions: Illustration and Comparison With Classic Crush

Shaoliang Chen, MD, Junjie Zhang, MD, Fei Ye, MD, Zhongsheng Zhu, MD, Song Lin, MD, Shoujie Shan, MD, Tak W. Kwan, MD    2007 Apr;19(4):189-93.

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