Combined Snare and Buddy-Balloon Strategy for Failed Valve Crossing in Valve-in-Valve Transcatheter Aortic Valve Replacement

BACKGROUND: Retrograde valve crossing during valve-in-valve transcatheter aortic valve replacement (ViV TAVR) may fail despite modern delivery systems. CASE SUMMARY: A 67-year-old man with a degenerated 27-mm Magna Ease bioprosthesis and unfavorable aortic geometry (kinked ascending aorta at a prior surgical graft site) underwent ViV TAVR, where retrograde valve crossing failed despite multiple stiff guidewires and snare traction alone. Successful delivery of a 29-mm Evolut FX+ was ultimately achieved by combining gooseneck-snare traction for coaxial realignment with a partially inflated Tyshak buddy balloon acting as a mechanical ramp across the surgical valve frame. DISCUSSION: This case demonstrates a structured, stepwise approach to managing failed valve crossing in ViV TAVR, highlighting the mechanical roles of snare traction and balloon-mediated coaxial alignment. TAKE-HOME MESSAGE: A combined snare and buddy-balloon strategy can facilitate valve delivery when conventional retrograde crossing fails during ViV TAVR.