A Single Operator, Final Kissing Balloons Technique Using a Stopcock-Dependent Indeflator Setup

Reconstruction of the bifurcation between a main and side branch coronary artery is reliant upon successful kissing balloon technique. This process is usually done with two indeflators, one for each balloon, with equalization of balloon pressure achieved through synchronization of inflation and deflation between two operators. Poor synchronization can potentially result in unfavorable stent(s) expansion, poor approximation of the stent against the vessel wall, and a potential decrease in luminal area. We describe a technique using one indeflator and a 4-way stopcock that ensures both pressure equalization and synchronization of balloon inflation when performed by a single operator. This technique was first described one decade ago using over-the-wire balloons.¹ We describe its implementation using rapid exchange balloons with the intention to encourage integration into current interventional practice.

The setup of the equipment is shown in Figure 1. A single indeflator is used and is connected to the proximal male port on a 4-way stopcock (solid black arrow). Its distal port (female) is then attached to the balloon intended for the main coronary vessel (white arrow). A female/female extension line is then connected the remaining (side port) stopcock port. The other end of this line is attached to the distal end of the stopcock for the side branch balloon (open black arrow). In order to fill all the lines with contrast and saline mix, the indeflator must be pre-filled with more volume than usual. (Our recommendation would be 7 ml beyond the amount normally placed in the indeflator chamber.) Once the standard balloon preparation has been completed, the system is ready for a single balloon dilation or simultaneous kissing technique. Instead of a 4-way stopcock, a 3-way stopcock can be modified for use by forcefully rotating the valve arm 180 degrees from the side port. This facilitates effortless valve rotation to divert fluid or pressure through any port. The system provides 3 potential control arm positions for regulating inflations: 

A)    Inflation of the primary balloon only.

B)    Inflation of the side branch balloon only.

C)    Synchronized inflation of both balloons (Figure 2, Video 1).

The application of our setup permits the synchronization of balloon inflation during kissing balloon procedures. This single operator technique reduces the chances of inadequate stent expansion and deformation caused by unequal pressure inflation related to unsynchronized balloon expansion. Pascal’s law dictates that the pressures of one balloon will equal the pressure in the other. This ensures synchronized inflation and uniform expansion of each balloon or stent. We show an example of using this technique in a left anterior descending and diagonal branch bifurcation intervention (Figure 3). It is easily implemented, intuitive, and time efficient, providing an elegant way for uniform balloons expansion, which could improve maximal luminal gain and thus patency of the vessels.

Discussion

Side branch vessels are vulnerable to worsening stenosis or occlusion following angioplasty of main arteries, especially when plaque is adjacent to the bifurcation. The reported incidence of side branch occlusion due to plaque shifting from an adjacent lesion during angioplasty is 14%.^2,3 Side branch occlusion becomes particularly important when branch vessels perfuse a large area of myocardium. It seems reasonable to develop techniques that will best protect these at-risk transition zones. The kissing balloon technique was first described by Valesquez et al and utilized in the management of a patient with Leriche syndrome.^4,5 The technique was subsequently adapted to the coronary circulation by Gruentzig and remains the preferred technique for ensuring adequate stent apposition and appropriate stent deformation for side branch access.⁶ These procedures are both technically challenging and require coordinated execution. A simplified method for synchronizing balloon inflation and deflation may promote appropriate stent distortion and therefore seems appealing. We have demonstrated that this technique works with modern equipment, rapid exchange balloons, and could easily be incorporated into the management protocols for bifurcation lesions. 

Note: This article contains accompanying video, available online at cathlabdigest.com/multimedia

References

1. Krikorian RK, Vacek JL, Beauchamp GB. “Kissing balloon” technique in percutaneous transluminal coronary angiography: Single-guide catheter, dual-wire, dual-balloon system with single inflation device. Cathet Cardiovasc Diagn. 1996; 37(3): 331-333.
2. Vetrovec GW, Cowley MJ, Wolfgang TC, Ducey KC. Effects of percutaneous transluminal coronary angioplasty on lesion-associated branches. Am Heart J. 1985; 109(5): 921-925.
3. Meier B, Gruentzig AR, King SB, et al. Risk of side branch occlusion during coronary angioplasty. Am J Cardiol. 1984; 53(1): 10-14.
4. Velasquez G, Castaneda-Zuniga W, Formanek A, et al. Nonsurgical aortoplasty in Leriche syndrome. Radiology. 1980; 134(2): 359-360.
5. George BS, Myler RK, Stertzer SH, et al. Balloon angioplasty of coronary bifurcation lesions: the kissing balloon technique. Cathet Cardiovasc Diagn. 1986;12(2):124-138.
6. Meier B. Kissing balloon coronary angioplasty. Am J Cardiol. 1984; 54(7): 918-920.

Disclosures: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Dr. Adam Stys at adam.stys@sanfordhealth.org