Therapeutic Strategies and Future Perspectives - Management of Dissections – Juan F Iglesias

Coronary Dissections During DCB PCI: Management Strategies

Overview of Coronary Dissections

• Coronary dissections during drug-coated balloon percutaneous coronary intervention (DCB PCI) are common, with angiographically visible dissections found in 60-70% of patients.

• Despite spontaneous healing in most cases, coronary dissection remains the primary reason for bailout stenting in 5-22% of patients undergoing DCB PCI.

Management Strategies

• Effective management strategies for coronary artery dissection during DCB PCI rely on three pillars:

• Preventing complications.

• Recognizing lesions that require treatment versus those that can be left untreated.

• Assessing how to manage flow-limiting dissections.

Predictors and Procedural Aspects

• Observational studies identify predictors of coronary artery dissection, including:

• Higher DCB to reference vessel ratio.

• Longer lesion lengths.

• Presence of calcified disease.

• Important procedural aspects include using a 1:1 balloon-to-artery ratio based on distal reference vessel diameter for both lesion preparation and treatment.

Role of Scoring Balloons

• Scoring balloons are emerging as a tool not only for lesion preparation but also to prevent flow-limiting dissections.

• A study by Professor Shin indicates that scoring balloons increase rates of type B and C dissections while improving lumen gain and achieving better angiographic results compared to non-scoring balloons.

Balloon Sizing and Inflation Time

• Downsizing cutting balloons by 0.25 or 0.5 mm can achieve similar tensile stress values as larger non-compliant balloons, potentially reducing severe dissection risks.

• Prolonged inflation times (over 30 seconds for pre-dilation and over 60 seconds for DCB inflation) may help seal dissections post-balloon angioplasty, although this does not necessarily improve clinical outcomes.

Intravascular Imaging and Classification

• Intravascular imaging can assist in assessing vessel size to optimize DCB sizing, thereby reducing dissection occurrences.

• Historical classifications from the POBA era categorize type A and B dissections as safe to leave untreated; however, type C is more contentious regarding treatment necessity.

Clinical Implications

• Most dissections occurring during DCB PCI are classified as type A or B, which do not lead to high bailout stenting rates, suggesting they may be safely managed without intervention.

Coronary Dissections: Clinical Outcomes and Management Strategies

Overview of Non-Flow Limiting Dissections

• Type AC non-flow limiting dissections, regardless of severity, do not correlate with adverse clinical outcomes in patients treated for de novo coronary artery disease.

• Similar target lesion failure rates at two years are observed between untreated dissections and those without current dissections.

Recent Findings on Treatment Approaches

• Data indicates that non-flow limiting dissections after successful drug-coated balloon percutaneous coronary intervention (DCBPCI) are not linked to worse clinical outcomes.

• A shift from angiographic classification to a subtype classification is suggested, integrating TIMI flow and patient symptoms alongside angiographic appearance.

Safe Management of Selected Dissections

• Types A and B, along with selected non-flow limiting type C coronary dissections, may be safely left untreated based on contemporary evidence.

• The absence of extraluminal contrast and TIMI flow greater than three is proposed as acceptable criteria for DCBPCI without bailout stenting.

Role of Coronary Physiology in Assessing Lesions

• Utilizing a cutoff of 0.90 for PDPA in lesions with type A and B dissections can significantly reduce the metal burden implanted during treatment.

• Evidence-based thresholds for physiological assessments like FFR or QFR remain unavailable; dedicated randomized trials are necessary.

Understanding Spontaneous Healing and Benefits of Medial Dissections

• Most spontaneous coronary dissections heal within six months; medial dissections can lead to late lumen enlargement when associated with an arcom.

• Drug-coated balloons may facilitate beneficial dissection types that should remain untreated to enhance drug transfer to the vessel wall.

Emerging Concepts in Dissection Volume

• An analysis from the Transform One trial suggests a negative correlation between dissection volume and late lumen loss, indicating potential benefits from more extensive dissection.

Techniques for Managing Complications

• New modification techniques such as scoring balloons or fenestration techniques can help alleviate hematomas causing flow compromise even in occlusive lesions.

Predictors of Bailout Stenting Needs

• Factors like DCB RVD ratio, tortuosity, distal disease complexity, long lesions, smaller diameters of coated balloons, and shorter inflation times predict bailout stenting occurrences.

Reassurance Regarding Midterm Outcomes Post-Bailout Stenting

• Multicenter retrospective studies indicate that even when bailout stenting occurs due to complications, midterm outcomes remain favorable.

This structured summary provides insights into the management strategies surrounding coronary dissections while highlighting key findings from recent studies.

Understanding DCBPCI and Its Management Strategies

Key Concepts in DCBPCI Management

• Effective strategies for recognizing and managing complications inherent to Drug-Coated Balloon Percutaneous Coronary Intervention (DCBPCI) are crucial. These strategies aim to minimize the necessity for bailout stenting and promote broader adoption of DCB-based PCI.

• Most coronary dissections encountered during procedures are non-flow limiting, often resolving spontaneously. They can typically be managed conservatively without immediate intervention.

• Medial dissections may enhance drug transfer to the vessel wall, which is beneficial as they have been linked with late positive vessel remodeling, thereby reducing the risk of target lesion failure.

Techniques for Managing Coronary Dissections

• The use of scoring balloons and cutting balloons provides greater control over coronary dissections. This technique is essential not only for preparation but also allows safe modification of flow-limiting coronary dissections.

• When necessary, bailout stenting following sub-optimal DCB PCI has been deemed safe and effective, ensuring patient safety while addressing complications that arise during procedures.