Session 3: BBRAUN - Future applications of DCB in complex cases and drug choice – Tuomas Rissanen

Future Perspectives on DCB and PCI Techniques

Introduction to DCB and Hybrid Approaches

• The speaker expresses pleasure in sharing perspectives on the future of DCB (Drug-Coated Balloon) techniques and complex case studies.

Key Insights on Patient Populations

• The ideal scenarios for using DCB only or hybrid approaches are identified as cases where stents are not performing optimally, particularly in patients with small vessels, diffuse disease, diabetes, multi-vessel disease, bifurcations, CTO PCI (Chronic Total Occlusion Percutaneous Coronary Intervention), aneurysms, and calcified lesions.

Importance of Dual Antiplatelet Therapy

• High bleeding risk patients can benefit from shortened dual antiplatelet therapy or even single antiplatelet therapy. The speaker emphasizes that drug-eluting stents (DES) should not be viewed as adversaries but rather as complementary to DCB strategies.

Meta-analysis Findings

• A meta-analysis indicates that CABG (Coronary Artery Bypass Grafting) remains a primary option for treating multivessel disease and diabetic patients.

Case Study: Successful Treatment Approach

• An early case is presented involving a patient with a bifurcation lesion treated effectively with a cutting balloon followed by a DCB-only approach. This resulted in excellent long-term outcomes after 11 years.

Complex Case Presentation

Young Patient with STEMI

• A complex case is introduced involving a young patient presenting with STEMI (ST-Elevation Myocardial Infarction), showcasing an acute occlusion in the intermediate PL branch alongside left CTO.

Treatment Strategy Overview

• After initial treatment, the plan involved staging the left CTO PCI within four weeks due to the complexity of the lesions.

Technical Details of Procedure

• The procedure included advanced techniques such as guided puncture of the proximal cap and parallel wiring methods to navigate through challenging anatomy successfully.

Final Results Post-Treatment

• The final results showed non-flow limiting dissection but fulfilled criteria for leaving no metal behind. Follow-up at four months indicated positive remodeling in the vessel despite some healing still occurring.

Exploring Left Main Lesions

Challenges with Distal Left Main Lesions

• Discussion shifts to distal left main lesions treated successfully using a DCB-only approach. These cases often involve high-risk patients requiring urgent interventions without causing acute closure of vessels.

Aggressive Calcium Debulking Techniques

• Effective treatment requires aggressive calcium debulking to achieve sufficient minimal lumen area (MLA). Cutting balloons are frequently used post-debulking for optimal results.

Sequential Treatments Consideration

Hybrid Approach in PCI: Future Directions

Overview of Hybrid PCI Techniques

• The use of MLA (Minimum Lumen Area) with imaging is deemed sufficient for current cases, indicating that even with potential future wrist stenosis, tools are available to address lesions effectively.

• A hybrid approach combining PCI (Percutaneous Coronary Intervention) with intravascular imaging may significantly impact multivessel treatment strategies moving forward.

• In cases of diffuse disease and CTO (Chronic Total Occlusion) PCI, staged procedures might be beneficial to avoid over-dilation and aggressive initial interventions, allowing for improved blood flow and vessel size over time.

Drug Selection in PCI Procedures

• There are pros and cons associated with different drug-eluting stents; Pakitel may play a role in preventive PCI for vulnerable plaques, while Prioxel could be favored after suboptimal results due to its positive remodeling effects.