Session 7 - DCB-PCI: Current Indications - Chronic Total Occlusions (CTO) – Kambis Mashayekhi

Chronic Total Occlusions and Stent Performance

Overview of Stent Efficacy in CTOs

• The presentation discusses chronic total occlusions (CTOs) and the long-term performance of drug-eluting stents, highlighting their continued target lesion revascularization (TLR) rates.

• Complex lesions, including CTOs, exhibit higher TLR rates compared to non-complex lesions when treated with drug-eluting stents.

Challenges with Small Vessels

• Drug-eluting stents show poor performance in small vessels, with TLR rates reaching up to 60%, necessitating further investigation into treatment strategies for these cases.

Mechanical Considerations in Stenting

• Long stents are associated with increased risks of cardiac death and stent thrombosis; a South Korean study indicates that longer stents correlate with higher adverse outcomes.

• Stent fractures are often overlooked but can occur at low cycles, particularly at critical locations like the ostium of the right coronary artery (RCA).

Positive Remodeling and Its Implications

• Positive remodeling is not always beneficial; a case from the Syntax 2 trial illustrates how a well-opposed stent can become malapposed over time due to vessel growth.

Treatment Strategies for CTO and Distal Disease

Case Studies on Vessel Behavior Post-Stenting

• In certain cases where no intervention was performed on diseased segments, natural vessel growth occurred over time, suggesting potential benefits from conservative management.

• Research by Freddy Gassio indicates that nitroglycerin administration during follow-up angiography may lead to significant vessel enlargement post-procedure.

Registry Insights on Treatment Approaches

• Registries reveal that untreated stenoses often resolve naturally without intervention; however, those treated with stenting have higher TLR rates.

Hybrid Approaches and Future Directions

• The discussion raises questions about hybrid approaches versus using drug-eluting balloons for complex lesions while avoiding pitfalls seen with bioresorbable stents.

Long-Term Outcomes and Emerging Techniques

Intraplaque Crossing Concepts

• Successful intraplaque crossing could allow for effective treatment using drug-coated balloons (DCBs), potentially reducing reliance on traditional stenting methods.

Trends in DCB Utilization

CTO Treatment Insights

Overview of CTO Management Strategies

• Discussion on the importance of being cautious with black modification in chronic total occlusion (CTO) cases, particularly in smaller vessels.

• Mention of upcoming insights from Paul KN regarding the CT CTO trial, comparing outcomes to a randomized trial.

• Presentation of a case study involving a 56-year-old male patient who achieved successful results with drug-coated balloon (DCB) treatment and minimal dissection at six-month follow-up.

Case Studies and Patient Outcomes

• Introduction of a 43-year-old male patient from Kazakhstan who preferred a stent-free approach; initial DCB results were satisfactory despite some concerns about future interventions.

• Description of the treatment process for the LED and diagonal branch using DCB, leading to an acceptable outcome after six months.

• Emphasis on maintaining a stent-free strategy while addressing focal dissections through cutting angioplasty techniques.

Complex Cases and Techniques

• Highlighting the effectiveness of DCB in treating multivessel disease in younger patients, allowing avoidance of drug-eluting stents and potential surgeries for many years.

• A retrograde case example involving ostial dissection treated without stenting; positive six-month follow-up results noted despite criticism from peers regarding the approach.

Safety and Efficacy Considerations

• Discussion on safety data from CTO registries indicating low event rates associated with drug-eluting balloons when guided by intravascular ultrasound, especially in larger vessels.