The Deployment-Retraction Crossing Technique

The Deployment-Retraction Crossing Technique. 

I couldn't cross the left duct. Wire was in. Balloon dilation done. The delivery system wouldn't follow. Tumor-induced angulation at the confluence acute, fixed, uncrossable by conventional means. I didn't accept that. 

Here's what I did. The maneuver: I positioned the delivery system 1 cm below the stricture. Started deploying the stent. The partially deployed stent more compliant than the rigid sheath followed the wire around the angle and crossed it. Then, simultaneously: I retracted the stent back into the sheath I advanced the sheath forward.At the same time. Opposite directions. The stent became a rail. The sheath rode that rail across the angulation. The system crossed. Then I deployed normally. Both ducts draining. Bilateral SEMS in place. 84-year-old man with Bismuth IV hilar cholangiocarcinoma - going home with a functioning biliary system. What makes this different from balloon dilation? Balloon dilation addresses caliber. This addresses geometry. Those are two completely different problems. A balloon opens a lumen. It cannot straighten an angle imposed by tumor mass on the ductal architecture.This technique uses the stent's own compliance its ability to flex where the sheath cannot as a mechanical tool to carry the rigid delivery system across an otherwise uncrossable curve. The stent didn't just drain the duct. It built the path to get there. I'm calling this the Deployment-Retraction Crossing Technique.