Intraluminal crossing of near-impenetrable occlusions by balloon-assisted battering ram technique.

PURPOSE: Subintimal crossing of total occlusions and acquiring reentry into the true lumen may be hazardous in highly calcified lesions, with or without the use of expensive reentry devices. Even when desirable, intraluminal crossing may not be feasible, because the guidewire tends to follow a path of least resistance between the intimal plaque and the adventitia. TECHNIQUE: A standard percutaneous transluminal angioplasty balloon is positioned just above the proximal cap of the occlusion and insufflated to 6 atmosphere. The balloon is used (1) to increase guidewire support close to the lesion and (2) for centralization purposes (limiting lateral movement of the guidewire). The ultra stiff back end of a regular guidewire can then be used to target the center of the cap while repeatedly pounding against it until it breaches.
CONCLUSIONS: The balloon-assisted battering ram technique may be attempted if intraluminal crossing is warranted before resorting to other complicated, expensive devices.