How to perform distal anchoring technique by 6 French radial approach in complex coronary procedures

•Distal anchoring balloon technique performed by a 6 Fr radial approach is described in detail, in a very didactic manner in the setting of stent delivery failure, in complex anatomical scenarios.•Three cases are illustrated, in which distal anchoring allowed to advance a stent to the target lesion.•The peculiarity of the present cases is that all have been performed by 6 Fr radial approach.•A distinctive feature is the description of the “train maneuver” to fully utilize the inner lumen of the 6 Fr guiding catheter.

Despite remarkable advances in the interventional landscape, device delivery during percutaneous coronary intervention (PCI) can still present technical challenges especially when performed in complex anatomical settings and through radial approach. To overcome difficult coronary stent delivery, several strategies have been developed. A niche option in such complex cases is the anchoring balloon technique, which involves inflation of a balloon non-coaxially in a side branch or distally to the target lesion in a coaxial fashion, to facilitate stent delivery. However, the main limitation of this technique is the requirement of a large guide catheter (≥ 7 French) which may preclude the use of radial approach. We describe, step-by-step, the distal anchoring ballooning technique performed by a 6 Fr radial approach to overcome the stent delivery failure in complex anatomical scenarios and to safely and successfully carry out the PCI procedures.