Session 7 - DCB-PCI: Current Indications - Bifurcations: Emerging Approaches – David Hildick-Smith

Emerging Approaches for Bifocations

Overview of Career Focus

• The speaker has dedicated many years to advocating for the use of one stent over two, and is now exploring the possibility that no stent may be better than one.

Transition to Drug-Coated Balloons (DCB)

• The speaker reflects on their extensive career in optimizing stents, including various techniques and strategies related to their placement and management.

• DCB bifocations simplify the procedure by requiring only two wires without the complexities associated with traditional stenting methods.

Advantages of DCB in Bifocation PCI

• Using DCB eliminates risks such as wire jailing, recrossing failures, and the need for OCT checks, making procedures more straightforward.

• While DCB simplifies processes, it requires careful consideration at each step rather than following a rigid plan.

Complexity and Attention to Detail

• Operators must engage critically with each stage of the procedure, assessing results continuously instead of relying on a fixed recipe approach.

• Historical trials have primarily focused on side branches rather than entire bifocations due to low major adverse cardiac event (MACE) rates.

Practical Application in Procedures

• A typical case involves treating a subtotally occluded LED by first addressing the main vessel before moving onto the side branch.

• The process includes using drug-coated balloons sequentially on both vessels while ensuring adequate flow and avoiding complications like dissections.

Challenges and Future Directions

• The speaker notes concerns about unexpected appearances during procedures but emphasizes that these do not indicate failure.

• There is an acknowledgment that operators have become complacent with traditional methods; adopting DCB could enhance overall procedural quality.

EBCDCB Study Overview

Study Design and Objectives

• The EBCDCB study aims to evaluate the treatment of non-left main bifurcation disease using drug-coated balloons (DCB) compared to provisional stent strategies.

• It involves 750 patients across eight countries and 20 sites, including a European arm with South Korea participating, focusing on bifurcations in non-STEMI settings.

• Inclusion criteria specify that both the ostium and side branch must have at least 50% narrowing, with the side vessel needing a diameter of 2.5 mm or longer than 73 mm.

Sponsorship and Endpoints

• The study is sponsored by the Medtronic family of stents and drug-coated balloons, with a primary endpoint focused on bifurcation-related events such as myocardial infarction (MI) and revascularization within one year.

• Follow-up will extend up to eight years due to anticipated gradual benefits from DCB treatment over time.

Treatment Strategy Insights

• The strategy allows for stenting if necessary; this is not considered crossover or bailout but part of the planned approach for managing complications like dissection propagation or reduced flow.

• This flexibility marks an improvement from previous eras where bypass surgery was often required in similar situations, highlighting advancements in interventional cardiology techniques.