What is The Next Step When a Non-Compliant Balloon Does Not Pass through a Freshly Deployed Stent?

In coronary intervention practice, optimal stent deployment in terms of adequate expansion and complete apposition is of paramount importance to obtain favorable immediate and long-term results. Even with the introduction of stent delivery systems based on a semi-compliant balloon allowing stent deployment at higher pressures (≥ 14 atm), adjunctive post dilation with a non-compliant (NC) balloon at very high pressures (≥ 20 atm) is still necessary to optimize the result in a vast majority of cases. After the introduction of drug-eluting stents, this issue has been highlighted in order to reduce restenosis and prevent the devastating event of stent thrombosis. 1 Nevertheless, advancing the NC balloon across the proximal edge or body of a freshly deployed stent might prove challenging in some situations. NC balloons have a higher profile than do regular balloons, but some other mechanisms are responsible for snagging NC balloons in a coronary artery segment that is widely open after stent implantation. One mechanism is that in some instances (long stenting or bifurcation stenting), we size the stent according to the distal reference lumen diameter and aim to optimize the result in the proximal part using a bigger NC balloon. In this situation, the NC balloon may get stuck to the proximal edge of the stent, which is already mal-apposed. This is especially true when the coronary artery has some tortuosity proximal to the stent site, which forces the tip of the balloon to point toward the edge rather than toward the center of the stent due to the wire bias created by the vessel tortuosity. Another issue is the friction between the balloon and the stent struts itself particularly when the stent has been deployed after a tortuosity or in a curved coronary artery in which the wire bias phenomenon develops as well. Numerous techniques have been described to help overcome difficult device delivery (mainly stent delivery) across the coronary arteries. These techniques are implemented to overcome the difficult delivery of NC balloons across the stents as well. They include the buddy wire technique, 2 buddy balloon technique, 3 balloon deflection technique, 4 having the patient take a deep breath during the balloon delivery, 5 dottering technique, rotating the balloon catheter while advancing it, inflating the balloon with 1-2 atm, and changing the wire position to a different direction. 6 In the buddy wire technique, a second wire of the extra support and/or hydrophilic type is …