Safety and efficacy of a novel traction balloon technique for guide-extension advancement in complex coronary...

Background: Severe coronary tortuosity and calcification frequently result in difficult device delivery during percutaneous coronary intervention (PCI). Conventional techniques for guide-extension (GE) insertion have reported success rates of 88-98.7% with complication rates of 1.6-5.9%. We aimed to evaluate the feasibility and safety of a novel traction balloon technique (TBT) to facilitate GE insertion to overcome these limitations and achieve reasonable procedural outcomes in complex coronary anatomy. Methods: We conducted a retrospective single-center case-series of consecutive patients who underwent GE-assisted PCI with TBT between December, 2020 and September, 2025. PCI cases in which, conventional methods of coronary device-delivery and/or GE insertion were unsuccessful were evaluated for GE-assisted PCI using TBT. The technique enables passive tracking of the GE through active traction to a large anchor-balloon inflated distally. Clinical characteristics, procedural-details, efficacy and safety endpoints were analyzed. Results: A total of 225 vessels from 214 patients (mean age 62.24 ± 9.8 years) underwent GE-assisted PCI using TBT. Clinical presentations included acute coronary syndrome (n=182, 85.05%), effort-angina (n=25, 11.68%), and heart-failure (n=7, 3.27%). Mean lesion-length was 52.15 ± 22.7 mm. All lesions were American College of Cardiology/American Heart Association type-C (n=225); and Society of Cardiovascular Angiography and Interventions type-2 (n=161, 71.56%) or type-4 (n=64, 28.44%) lesions. Median tortuosity-score was 2 (1-3) with extreme tortuosity in 75.56% of cases. Median calcification-grade was 2 (1-4) with heavy calcification in 40% of cases. Procedures were performed via upper-limb (n=194, 86.22%) or femoral (n=31, 13.78%) access. The indications for GE included distal delivery of balloons (n=195), stents (n=222) and others (n=199). The balloon-to-artery diameter ratio was 0.91 ± 0.1. The GE was inserted a median of 2 (1-6) times/vessel, achieving a mean maximum depth of 55.32 ± 17.9 mm. A total of 351 stents were deployed in 31 (12-131) minutes, with 100% procedural success. Complications included transient bradycardia and/or hypotension (n=2) and non-flow-limiting dissection (n=2). At a median follow-up of 22 (1-58) months, all patients remained asymptomatic, except for three patients who died. Conclusion: TBT-assisted GE insertion is a feasible and safe technique for device delivery during complex PCI, with high procedural success.