Session 7: DCB-PCI: Current Indications I - Small vs. Large Vessel Disease – Antonio Colombo

Understanding Stent Performance in Small vs. Large Vessels

Overview of Stent Efficacy

• The study reveals that stents perform significantly better in large vessels compared to small vessels, with a notable difference in outcomes.

• There is skepticism about the effectiveness of drug-coated balloons (DCB) in small vessels, suggesting that good drug-eluting stents (DS) are preferable for larger vessels.

Historical Context and Findings

• A reference to a 1998 paper highlights that late loss rates are higher in small vessels than in large ones, indicating a greater risk when placing foreign bodies like stents.

• The speaker speculates that the "tax rate" or complications associated with stenting is higher for small vessels due to their size constraints.

Challenges with Small Vessel Stenting

• In small vessels, the amount of metal from stents may be excessive relative to vessel area, leading to suboptimal implantation outcomes.

• Suboptimal deployment is more common in smaller vessels; optimal techniques are often neglected due to the challenges posed by their size.

Complications and Considerations

• While drug-eluting stents can mitigate some risks, complications still arise from suboptimal placements; optimization efforts can sometimes lead to increased complications.

• Evidence supporting the replacement of metal with devices allowing remodeling remains inconclusive; further research is needed on long-term impacts.

Patient Demographics and Treatment Strategies

• Analysis shows that older patients and those with chronic kidney disease do not benefit as much from DS compared to younger patients.

• Emphasis on focusing treatment strategies on complex lesions rather than simple ones where DCB might be more beneficial.

Optimal Use of Drug-Coated Balloons

Identifying Suitable Cases for DCB

• Examples illustrate scenarios where DCB could simplify procedures, such as treating left main lesions without complicating factors like carina shift.

• The speaker advocates for using DCB selectively based on lesion characteristics rather than defaulting to traditional stenting methods.

Procedural Insights and Techniques

• Discusses procedural efficiency improvements when utilizing DCB over traditional stenting approaches, highlighting shorter procedure times and reduced complexity.

• Monitoring techniques during procedures (e.g., PDPA usage), which help assess progress and optimize outcomes without relying solely on FFR measurements.

Angiography and Stenting Insights

Evaluating Angiographic Results

• The importance of following the PDPA (presumably a procedural guideline) is emphasized when assessing angiographic results, particularly for stable readings of 91 and 92.

• In cases involving proximal LED (Left Anterior Descending artery), stent implantation is common; however, predilation can yield acceptable outcomes if a good result is achieved.

• The criteria for evaluating angiographic success focus on the size of the true lumen rather than just the presence of dissection. A true lumen diameter of at least 6.5 to 7 mm is necessary after dilating with a 3.5 balloon.

Need for Objective Evaluation Criteria

• There’s a call for more precise evaluation methods beyond the vague standard of less than 30% residual stenosis, indicating that current metrics may not be sufficient in modern practice.

• Discussion around drug-coated balloons (DCB) highlights their established efficacy in small vessels, while their application in large vessels remains under evolution without conclusive trial support.