How to perform simultaneous kissing balloon inflation with a single inflation device

A problem-solving step by step tutorial

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Summary

Kissing balloon inflation (KBI) consists of the simultaneous inflation of two balloons in both the main vessel (MV) and the side branch (SB), and represents a fundamental technique to treat patients with coronary bifurcation lesions.

Indeed, during the provisional stenting (PS) technique, if SB treatment is needed, distal rewiring and KBI are valuable options to optimize the SB result.

Furthermore, when complex bifurcation lesions are treated by double-stent techniques (DST), KBI always represents a key procedural step, and could also be repeated several times during the same procedure (for example when adopting DK-crush).

The classic way to perform KBI consists of connecting the two balloons to two Indeflator™ inflation devices, which are manipulated by two operators.

Herein, we present our simple technique to perform KBI with a single Indeflator™, which has been regularly adopted in our center for the past two decades. This technique allows to perform KBI by a single operator, while warranting the achievement of simultaneous deflation of the two balloons, in order to minimize the risk of bifurcation carina shift.

The problem

Technical steps of PS and DST have been standardized over years to achieve predictable procedural results. Nowadays, in bifurcation PCI, KBI represents an option in case of PS and is mandatory in DST.

In both approaches, simultaneous balloon deflation is mandatory to reduce the bifurcation carina shift and to maintain the centrality of eventually present metallic stent struts. KBI is usually performed using two  connected to each balloon, and needs two operators to perform simultaneous deflation. Furthermore, interventional cardiologists might be the only experts at the table (in specific clinical settings, like on-call procedures) and simultaneous proper handling of two Indeflator™ inflation devices might be cumbersome.

The main idea

The idea is to simplify the clinical practice of kissing balloon inflation (KBI) by making this technique single-operator and automatically associated with simultaneous balloon deflation.

Material needed

Three-way stopcock (one male and two female entry ports), double-male connector, one balloon for MV, one balloon for SB, and one  device.

Method step-by-step

Step 1

Place one guidewire in the MV, and one in the SB.

Step 2

Select two balloons according to the distal MV and SB diameter.

Step 3

Build the double-balloon inflation system by:

1. selecting a three-way stopcock with one male and two female entry ports (Figure 1)
2. selecting a double-male connector (Figure 2)
3. tightening the double male connector to a switch side port (Figure 3)

Figure 1: Three-way stopcock with one male and two female entry ports

Figure 1: Three-way stopcock with one male and two female entry ports

Figure 2: Double-male connector

Figure 2: Double-male connector

Figure 3: Tighten the double male connector to a switch side port

Figure 3: Tighten the double male connector to a switch side port

Step 4

Deliver both balloons inside distal MV and SB, and consider performing isolated dilations of both the MV and the SB in order to appropriately check for the expansion of each of them (this step is also called “sequential” KBI).

Step 5

When ready for KBI, connect an Indeflator™ to the female port (Figure 4), and eliminate air in the system.

Figure 4: Connection between an Indeflator™ and the female port

Figure 4: Connection between an Indeflator™ and the female port

Step 6

Connect each balloon to one male side port, starting from the double-male connector side (Figure 5).

Figure 5: Connection between a balloon and a male side port

Figure 5: Connection between a balloon and a male side port

Step 7

Perform simultaneous balloon inflation and deflation with the single Indeflator™.

Step 8

Remove both balloons after KBI.

Step 9

Perform subsequent procedural steps as usual.

Supplementary video

Points of specific attention

• Prepare the double-balloon inflation system before advancing the balloons inside the coronary artery (to avoid time lapse before their inflation)
• Carefully remove air in both side ports of the three-way switch
• Make sure the balloons are securely locked onto the two female connectors (to avoid loss of inflation efficacy or air entry)
• Prefer balloons of same type and manufacturers (to increase the chance of a similar inflation and deflation time)

A word from the reviewer - Nina Glavnik Poznič

Nina Glavnik Poznic

@NGlavnik

Interventional cardiologist / Cardiologist

University Medical Centre Maribor - Maribor, Slovenia

Kissing balloon inflation is an important step in bifurcation PCI. Comparing to POT as mandatory step, KBI is not obligative in some techniques. However, using single indeflation device makes this step simpler, faster and cheaper. Therefore, it is more applicable in everyday practice.

Authors

Francesco Burzotta

@burzotta_f

Interventional cardiologist / Cardiologist

Policlinico Universitario Agostino Gemelli - Roma, Italy

Lazzaro Paraggio

@KayserSoze84

Interventional cardiologist / Cardiologist

Fondazione Policlinico Universitario A. Gemelli IRCCS - Rome, Italy

Cristina Aurigemma

@CristinaAuri17

Interventional cardiologist / Cardiologist

Fondazione Policlinico Universitario Agostino Gemelli - Roma, Italy

Enrico Romagnoli

Interventional cardiologist / Cardiologist

Fondazione Policlinico Universitario A. Gemelli IRCCS - Rome, Italy

Francesco Fracassi

Interventional cardiologist / Cardiologist

Fondazione Policlinico Universitario A. Gemelli IRCCS - Rome, Italy

Antonino Buffon

Interventional cardiologist / Cardiologist

Fondazione Policlinico Universitario A. Gemelli & Università Cattolica del Sacro Cuore - Rome, Italy

Carlo Trani

Interventional cardiologist / Cardiologist

Fondazione Policlinico Universitario Agostino Gemelli - Roma, Italy