PALS: A Guide to DCB in PCI
Introduction to PALS and Interventional Cardiology
Overview of the session and speaker's background.
Session is designed to be interactive with Q&A. The speaker encourages participants to ask questions throughout the session to enhance engagement and understanding.
Speaker is a consultant cardiologist in Bournemouth, UK.
Specializes in treating elderly patients with calcified coronary disease, as well as managing non-STEMI and STEMI patients.
The speaker's interventional cardiology practice has evolved, with historical volumes of approximately PCIs per year, which have been adjusted to around post-COVID due to changes in practice and patient management.
Appointed in 2007, initially performing approximately cases per year, and currently involved in about cases annually, reflecting a focus on more complex and carefully selected interventions.
Specialist interests:
Bifurcations (part of the European Bifurcation Club), focusing on advanced techniques for treating lesions at vessel branch points.
Intracoronary imaging (used in approximately 95% of cases) to guide interventions and optimize outcomes.
Calcium treatment (rotablation, orbital atherectomy, IVL, laser), employing various methods to modify calcified lesions for better stent deployment and vessel patency.
Extensive experience with various bifurcation stents and devices, including Abbott's Absorb bioresorbable scaffold, showcasing a commitment to innovative treatment options.
A Case Study: Treating a Young Patient with Unstable Angina
Presentation of a 32-year-old patient in December 2020 with unstable angina, highlighting the challenges in managing acute coronary syndromes in younger individuals.
Troponin rise of approximately , indicating myocardial damage.
Anterior ECG changes, suggesting ischemia in the anterior heart region.
Angiogram findings:
Tight stenosis in the proximal LAD (left anterior descending artery), indicating a significant blockage in a critical vessel.
"Widow maker" lesion with a large area of myocardium at risk, emphasizing the severity and potential consequences of the blockage.
Initial treatment with balloon angioplasty using a paclitaxel-coated Angiosculpt X balloon to open the blocked vessel and restore blood flow.
Good initial result, as noted by improved vessel diameter and flow.
Colleague's skepticism about balloon-only treatment, reflecting concerns about long-term patency and potential for restenosis.
Patient presentation a few months later with chest pain, raising concerns about recurrent ischemia.
Angiogram appeared similar to the post-angioplasty result, complicating the decision-making process.
Colleague considered stent placement but deferred based on OCT findings, illustrating the value of intracoronary imaging in guiding treatment decisions.
OCT results:
No significant stenosis was detected, challenging the initial angiographic findings.
Adequate minimal luminal area, supporting the decision to avoid stenting.
Decision against stent placement was guided by OCT findings and obtaining a second opinion, emphasizing a conservative approach based on comprehensive assessment.
The Journey to Destination Therapy in PCI
Three ways to finish a prepared vessel: metallic stent, drug-coated balloon (DCB), or scaffold, providing a range of options for interventional cardiologists.
Evolution from Andreas Grunzig's initial balloon angioplasty without stenting or drugs, underscoring the significant advancements in the field.
Contemporary practice involves lesion assessment (IVUS, OCT, physiology), vessel preparation (scoring/non-compliant balloons, calcium devices), and finishing strategy (metallic stent or DCB), highlighting a comprehensive approach to PCI.
Transition from complex solutions for simple lesions to simple solutions for complex disease, reflecting a trend towards more tailored and effective treatments.
Case example: Culotte stenting for a benign lesion in 2014, showcasing a specific technique for bifurcation lesions.
Experience with access stents for bifurcations to keep the carina free of metal, representing efforts to optimize bifurcation stenting techniques.
Required extensive vessel preparation, emphasizing the importance of proper lesion preparation.
Shift towards bioabsorbable scaffolds (e.g., Absorb) in 2007, illustrating a move towards transient scaffolding.
Absorb used in a complex circumflex bifurcation with good results at 8-year follow-up, providing long-term evidence of scaffold efficacy.
Involvement in the Solution trial, comparing DCB and stent treatments, contributing to the evidence base for DCB use.
The PALS Concept: A Framework for DCB Use
Collaboration with colleagues (Paul Brady, John Hinton, Jahangar Din) to develop the PALS concept, highlighting a team-based approach to innovation.
PALS = Patients, Anatomy, Long-term, Simplification
Patients:
Younger patients (under 55) who may benefit from avoiding long-term stent implications.
Diabetics, where DCB can reduce the risk of restenosis compared to stents.
High bleeding risk patients in whom prolonged dual antiplatelet therapy (DAPT) is undesirable.
Poor compliance with medications, making shorter DAPT regimens with DCB an attractive option.
Renal failure patients who may have contraindications to certain stent types or prolonged DAPT.
Anatomy:
Restenosis cases, where DCB can be effective in treating in-stent restenosis.
Bifurcations, utilizing DCB to minimize metal layers at the bifurcation.
Tortuosity of vessels, where DCB can be deployed without the challenges of stent delivery.
Aorto-ostial disease, using DCB to avoid stent protrusion into the aorta.
Side branch ostium, where DCB can treat lesions without compromising the main vessel.
Calcium, using DCB after adequate vessel preparation with atherectomy.
Diffuse plaque, where DCB can treat long lesions without multiple overlapping stents.
Small vessels, where DCB can avoid the risks associated with small stent implantation.
Long-term:
Avoiding stent-related failures, such as stent thrombosis and restenosis.
Providing more future treatment options, as DCB leaves the vessel architecture intact.
Simplification:
Moving from heavy metal to minimal footprint strategies, reducing the long-term burden on the vessel.
Deep Dive into Small Vessels
Small vessels are a significant area for DCB application, as stents can lead to higher rates of restenosis and target lesion revascularization.
2.5 mm stents: if left at 2.5 mm, area is just . MSA should be greater than . According to Ziad's analysis of 4 aluminum stent failure, any MACE rate is higher below .
In the UK, 25% of stents used are 2.5 mm, highlighting the prevalence of small vessel interventions.
Small vessel DCB results are equivalent to stenting (from the K3 trial), providing evidence for the efficacy of DCB in this challenging anatomy.
Potential to consider 2.5mm stents as bail-out options only, reserving stents for cases where DCB is not sufficient.
Discussion and Q&A Highlights
Importance of data to back up the use of DCB, emphasizing the need for evidence-based practice.
Focus on small vessels due to existing data supporting DCB efficacy in this context.
Achieving optimal MSA (minimal stent area) is crucial for stenting.
IVUS cutoff: . for OCT: .
Leaving stents at is a disaster, highlighting the importance of appropriate stent sizing and deployment.
Address concerns about Absorb experience and lack of clinical data, providing context for its limited use.
More stringent criteria for vessel preparation needed for Absorb, emphasizing the technical challenges.
Data from registries in Japan and China suggested better outcomes with Absorb with better imaging and putting into larger vessels, highlighting specific conditions for success.
Data from the COMPARE ABSORB trial shows a higher target lesion failure rate in the absorbed group but that these were in super complex lesions, cautioning against its use in complex cases.
PALS concept will provide confidence and ability to decide whether or not to use DCB, aiding clinicians in appropriate patient selection and treatment strategy.