A Buddy When You Need One: Buddy Balloon-Assisted Bailout for Failed Valve Crossing During Transfemoral Transcatheter Aortic Valve Implantation

Failure of transcatheter heart valve advancement across a severely calcified native aortic valve is an uncommon but potentially procedure-threatening complication during transcatheter aortic valve implantation (TAVI). Various bailout techniques have been described; however, published experience with the buddy-balloon technique remains limited. A 77-year-old man with symptomatic severe calcific aortic stenosis (mean gradient 90 mmHg, valve area 0.5 cm²) was referred for transfemoral TAVI. Preprocedural imaging demonstrated extreme valvular calcification with favorable iliofemoral access. Following successful valve crossing, stiff guidewire placement, and balloon aortic valvuloplasty, advancement of a 26-mm balloon-expandable transcatheter heart valve remained impossible despite multiple conventional maneuvers, including flexion and optimization of coaxial alignment. A bailout buddy-balloon technique was therefore performed through secondary femoral arterial access. Repeat balloon inflation across the native valve temporarily modified the geometry of the heavily calcified valve complex, enabling successful passage and deployment of the prosthesis. Final angiography and echocardiography demonstrated an excellent procedural result, with only mild paravalvular regurgitation and no periprocedural complications. Severe valvular calcification remains an important cause of procedural complexity during TAVI. This case illustrates that the buddy-balloon technique may represent a feasible bailout strategy when standard methods fail to facilitate valve crossing. Familiarity with this maneuver may provide operators with an additional bailout option when confronted with challenging anatomy during transfemoral TAVI.