DCBs as an adjuvant tool to DES for very complex coronary lesions.

Leontin Lazar,Rima Chaddad,Bernardo Cortese,Rami El-Mokdad

doi:10.31083/j.rcm2301013

Abstract

Drug eluting stents (DES) have revolutionised interventional cardiology and currently represent the standard for percutaneous coronary interventions (PCI). However, due to several limitations, new strategies are required, especially in very complex lesions. Drug-coated balloons (DCB) offer an attractive therapeutic alternative, and have already obtained a Class I recommendation for the treatment of in stent restenosis (ISR) with Level A of evidence. Moreover, the role of DCB has been tested in several other settings, such as de novo large vessel disease, multivessel disease or very complex lesions, with promising results regarding safety and effectiveness. In this context, a hybrid strategy consisting in the use of a DES and DCB with the aim of reducing the amount of metal implanted and minimising the risk of ISR and stent thrombosis could become the solution for very complex lesions. Several important studies already demonstrated very good angiographic results in terms of late lumen loss and restenosis for this approach in bifurcation lesions. Moreover, for long diffuse coronary disease similar rates of MACE, TVR, and TLR at 2-year follow-up in comparison to a DES-alone strategy were found. What is more, the use of this strategy in high-bleeding risk patients could safely permit the practitioners to reduce the DAPT duration, as data is suggesting. As our daily practice already strongly incorporated this strategy and with more data expected from important trials, it is our strong believe that the hybrid approach can become a standard treatment choice in the near future.

Highlights

Balloon angioplasty or plain old balloon angioplasty (POBA) revolutionized interventional cardiology, as it offered an alternative to surgical treatment for coronary artery disease (CAD) [1]
By tackling dissections and eliminating elastic recoil, the use of intracoronary bare metal stent became the standard approach for percutaneous coronary interventions (PCI), but this strategy was limited by stent thrombosis and increased neointimal hyperplasia, leading to in-stent restenosis [3]
The main concept of a “hybrid strategy” is to reduce the amount of metal implanted in complex lesions, as it has been demonstrated that the stent length is an independent predictor for in stent restenosis (ISR) and stent thrombosis, >60 mm overlapping Drug-eluting stents (DES) being associated with high target-lesion revascularization (TLR) rates of approximatively 24%

Summary

Introduction

Balloon angioplasty or plain old balloon angioplasty (POBA) revolutionized interventional cardiology, as it offered an alternative to surgical treatment for coronary artery disease (CAD) [1]. By tackling dissections and eliminating elastic recoil, the use of intracoronary bare metal stent became the standard approach for percutaneous coronary interventions (PCI), but this strategy was limited by stent thrombosis and increased neointimal hyperplasia, leading to in-stent restenosis [3]. Late stent thrombosis and recurring events, dependency on prolonged dual antiplatelet therapy and restenosis led to a quest for new treatment modalities. In this context, drug-coated balloons (DCB) offer an attractive therapeutic alternative, which consists in a combination of classical balloon angioplasty alongside with local drug delivery [5]. The purpose of this review is to outline different approaches and trial results with the use of DCB in combination with DES for de novo lesions and propose a novel design for future trials treating very complex coronary lesions

DCB design and procedural aspects

Clinical use

Hybrid approach

Conclusions

Findings

Conflict of interest