Direct high-frequency intravascular ultrasound visualization of drug delivery after paclitaxel urea eluting balloon angioplasty.

Abstract

Drug-coated balloons (DCBs) offer an attractive therapeutic option to avoid long stent implantation in diffuse disease, especially for small vessels. We report this first observation with high-frequency intravascular ultrasound (HF-IVUS) of effective delivery of paclitaxel together with urea excipient. A 76-year-old hypertensive and diabetic gentleman with exertional angina underwent coronary computed tomography angiography (Panel 1) showing total occlusion of the mid-segment of the left anterior descending artery, shorter than the occluded segment at selective coronary angiography, performed three months later (Panel 2, Supplemental Video 1). We antegradely crossed the lesion with a Fielder XT-R guidewire supported by a Corsair Pro XS microcatheter (both Asahi Intecc, Japan). After balloon pre-dilatation (Panel 3), HF-IVUS (Opticross™HD 60 MHz, Boston Scientific, USA) showed a subocclusive lesion with positive remodelling in the proximal occluded segment and diffuse subcritical disease in the distal occluded segment (Panel 3A–D, Supplemental Video 3). We elected to limit stent implantation to a 3.0 × 15 mm sirolimus-eluting stent in the proximal occlusion and treat the distal disease with prolonged inflation (up to 5 min) of three paclitaxel urea DCB (Prevail, Medtronic, USA), 3.0 × 30 mm, 2.75 × 25 mm and 2.5 × 20 mm, respectively (Panel 4, Supplemental Video 2). The final HF-IVUS (Panel 4A–D, Supplemental Video 4) documented a continuous intimal hyperechoic layer throughout the entire segment treated with DCB (arrows, Panel 4B–C), with similar echogenicity to the stent struts (arrowheads, Panel 4A) and not present before DCB deployment or distally (Panel 4D). We believe that this phenomenon is the result of the intimal deposition of the DCB coating. Further IVUS studies will reveal how long this pattern persists and whether its visualization is associated with better drug response and lower risk of restenosis over time.