Session 10: DCB-PCI: Current Indications II - Calcified Lesions – Sandeep Basavarajaiah

DCB and Calcified Lesions: An Overview

Introduction to DCB and Calcified Lesions

• The speaker discusses the objective of their talk, focusing on data related to DCB (Drug-Coated Balloon) use in calcified lesions, emphasizing technical aspects and case studies.

• It is noted that calcium presence in stented lesions correlates with higher failure rates, making it a significant risk factor for stent failure.

Challenges with Calcium in Vascular Disease

• The complexity of treating patients with calcified lesions is highlighted due to factors like small caliber vessels, diabetes, and renal failure. These contribute to high stent failure rates.

• DCB offers advantages such as maintaining original vessel anatomy and reducing the duration of dual antiplatelet therapy (DAPT), which minimizes future complications associated with stents.

Evidence from Recent Studies

• A Japanese study identified advanced renal failure as a predictor of target lesion failure post-DCB treatment, indicating that calcium remains an independent risk factor for lesion failure.

• A Chinese trial showed no difference in hard endpoints between patients with or without calcium when treated with DCB; however, revascularization rates were higher in those with calcified lesions. This suggests that while calcium poses challenges for DCB, it may be less detrimental than for drug-eluting stents (DES).

Clinical Practice Insights

• The speaker emphasizes that the presence of calcium does not deter the choice of using DCB if appropriate for the lesion type and patient characteristics (e.g., diffuse disease or small vessels). They advocate minimizing stent length where possible.

• Technical considerations are crucial when preparing calcified lesions for DCB; effective preparation involves inducing fractures through imaging techniques to ensure drug transfer across barriers posed by solid calcium deposits.

Technical Aspects of DCB Angioplasty

• Recoil management is critical after balloon dilation; unlike non-calcified lesions where recoil can be managed easily, calcified lesions require more attention during DCB procedures due to potential flow-limiting dissections caused by aggressive preparation techniques.

• The speaker describes their approach to predilation using non-compliant balloons at a 1:1 ratio based on angiographic assessment while monitoring uniform balloon expansion and wire position within the balloon during procedures.

Case Studies Illustrating Techniques

• An example involving a left anterior descending artery (LAD) demonstrates how intra-vessel imaging revealed concentric calcium deposits leading to successful treatment using an intravascular lithotripsy balloon followed by a DCB application resulting in good outcomes.

• Another case highlights the importance of wire positioning within balloons; eccentric positions indicate areas of lesser resistance which necessitate further intervention like cutting balloons at high pressures to achieve better results before applying a DCB.

Conclusion on Managing Recoil

• In cases where recoil is observed post-dilation—especially relevant when considering whether to proceed with a DCB—the speaker illustrates this through an example involving circumflex CTO post-bypass surgery where careful management led to improved outcomes without resorting immediately to stenting solutions.

DCB Techniques and Case Studies

Overview of DCB Preparation

• The speaker discusses the readiness for Drug-Coated Balloon (DCB) procedures, emphasizing the importance of achieving optimal results before proceeding with DCB.

Challenges in DCB: Bailout Stenting

• A key challenge during DCB is determining when to consider bailout stenting, particularly in cases of persistent recoil or flow-limiting dissection.

• The speaker prefers focal stenting over long stents when addressing focal recoil after DCB treatment.

Case Study 1: Diffuse Disease Treatment

• A case involving a 49-year-old patient with severe health issues is presented. After stabilization, an angiogram revealed significant disease in the RCA and LED.

• Despite being early in their DCB experience, a long stent was placed instead of a DCB due to concerns about future restenosis.

Case Study 2: Complex Lesion Management

• In another case, extensive calcification required careful lesion preparation using rotablation and ballooning techniques before applying two long DCBs.

• Post-procedure results showed acceptable outcomes despite cosmetic concerns regarding the appearance of the artery.

Follow-Up and Outcomes

• A follow-up angiogram revealed a stent fracture in the right coronary artery, leading to further intervention. This raised questions about whether earlier use of a DCB could have avoided complications.

Conclusion on Calcified Lesions and DCB Use

• The speaker concludes that calcified lesions are not contraindications for using DCB; proper lesion preparation guided by intravascular imaging is crucial for success.