Session 4: Technical Strategies - Lesion Preparation – Victor Jimenez Diaz

Leaching Preparation Techniques

Importance of Leaching Preparation

• The speaker emphasizes the critical nature of leaching preparation, suggesting that it is essential knowledge for everyone involved in the procedure.

• A consensus on proper leaching preparation steps is established, including predilation with a Poba using an SME compiler or non-compliant volume.

Tools and Techniques for Effective Leaching

• Specialty balloons such as scarring balloons and super high-pressure balloons are recommended if predilation is inadequate.

• Functional measurements like wire-based or imaging-based physiology are increasingly important, alongside intra-coronary imaging techniques (IBL or OCT).

Criteria for Decision-Making Post-Leaching

• Acceptable angiographic results include residual SNOS ≤ 30% and no flow limit in dissection; FFR grading at 0.80 also influences the decision to use DCB.

• Angiographic criteria guide the use of DCB for in-stent restenosis, highlighting independent predictors of tarjetilition failure.

Key Parameters in Leaching Preparation

• Important parameters include residual minimal luminal diameter post-leaching and persistent extraluminal contrast observed during angiography.

• Intravascular imaging (IVUS) is crucial for determining whether to upgrade predilation efforts, providing valuable insights into treatment effectiveness.

Impact of Imaging Guidance on Outcomes

• IVUS guidance during DCBPCI correlates with lower segmental luminal loss compared to angiographic guidance alone.

• Optimal leaching preparation involves gradual pressure increments during balloon inflation and maintaining a 1:1 balloon-to-vessel ratio.

Techniques and Devices Used in Leaching

Device Characteristics and Their Roles

• Various devices such as compliant, non-compliant, cutting balloons, IBL, rotational devices, and lasers each have unique characteristics beneficial for achieving effective leaching preparation.

Visualizing Results from Different Balloons

• OCT images demonstrate medial dissection achieved with NC balloons at a 1:1 ratio under nominal inflation pressure; this outcome is desirable post-preparation.

Effects of Cutting Balloons on Plaque Modification

• Using cutting balloons can create deeper microchannels depending on size; higher pressures yield more significant cuts which may facilitate drug uptake.

Drug Delivery Considerations Post-Leaching

Analyzing Drug Delivery Efficacy

• The combination of current balloon technology with intravascular lithotripsy can lead to extensive dissections that may enhance drug delivery outcomes.

Observing Drug Deposition After Administration

Drug Interaction with Dissections and Healing Process

Observations on Drug Behavior

• The use of a current balloon and IBL allows visualization of bright particles at the end of the hotelium and in induced cuts, indicating drug interaction with dissections.

• The drug remains in the vessel wall for one month, covered by tissue, functioning normally as a stenestroid, allowing for measurement of particle size and disposition over time.

Follow-Up Imaging Techniques

• At four months post-EPCI, dissections appear healed while some particles remain visible; this highlights the importance of drug distribution within the vessel wall.

• Ongoing work involves using AI to analyze drug delivery in vessel walls through imaging techniques like CT scans for long-term patient follow-up.

Challenges in Lesion Preparation

Case Study Insights

• A case involving focal leaching in a 70-year-old man demonstrates that proper lesion preparation is crucial; initial results appeared satisfactory but led to complications later.

• After two months, the patient presented with RIST analysis showing non-tight stenosis despite previous treatment with a Cirolimus coated balloon.

Importance of Accurate Assessment

• Missed calcium deposits during initial assessment necessitated further intervention using non-compliant balloons and cutting balloons to achieve better results.

• Final outcomes after improved lesion preparation showed significant symptom relief nearly one year post-procedure.

Effective Strategies for Lesion Preparation

Comprehensive Approach Required

• Successful treatment involved utilizing various tools such as rota, NC balloons, cutting balloons, and shock wave therapy to ensure thorough lesion preparation.

• Achieving optimal lesion preparation leads to benign evolution over time in patients treated with DCB (drug-coated balloons), evidenced by three-year follow-ups showing progressive endothelial healing.

Future Directions and Recommendations

Key Takeaways from Current Practices

• Continuous learning is essential; discussions around whether to use specific types of balloons after lesion preparation are ongoing.

• Analyzing imaging roles before drug application can enhance methodologies for microcirculatory evaluation; recommendations need updating based on new findings.

Conclusion on Best Practices