Escalating Diameter Buddy Balloon in Transcatheter Aortic Valve Implantation With Complex Aortic Arch

BACKGROUND: The buddy balloon technique facilitates transcatheter heart valve (THV) crossing the native aortic valve. CASE SUMMARY: An 80-year-old female, with previous ascending aorta replacement and aortic valve replacement with bioprosthesis, was admitted to our hospital to undergo transcatheter aortic valve implantation due to bioprosthetic valve dysfunction. The self-expandable Allegra 23 mm, advanced through the right femoral artery, got stuck at the point of passage between the aortic arch and the prosthetic tube in the ascending aorta. A peripheral balloon was advanced from the left femoral artery and simultaneously inflated at the stalemate point, while pushing the valve toward the implantation site. Following failure with 5 mm and 7 mm balloons, crossing was successful with a 9 mm balloon. DISCUSSION: The standard buddy balloon technique involves the use of a single balloon diameter. Herein, we propose an escalating approach to increase chances of success and prevent potential complications, such as vessel rupture. TAKE HOME MESSAGE: The "escalating diameter" buddy balloon technique represents a safe and effective exit-strategy in case of challenges in advancing the THV system.