The interventional cardiologist Gerardo Nau.
Why is it that despite different revascularization strategies and multiple devices, treating bifurcations remains a challenge?
Bifurcation lesions constitute a frequent group of lesions that involve, in one way or another, three coronary segments. Medina’s classification of bifurcated lesions, expanded in daily practice, manages to logically order these parameters, showing a gradient of risk of the lesion to be treated.
However, other variables have been added to try to achieve a deep anatomical understanding and, thereby, reduce the risks in short-term and long-term treatment increased in this group of injuries. This is how differences in the study scenarios were evidenced (for example, TCI vs. other bifurcations), complementary imaging techniques were added, multiple devices were incorporated into the percutaneous arsenal, and optimization therapeutic techniques multiplied.
At present, all this has allowed the inclusion of a wide variety of lesions to be treated, multiplying the parameters to be taken into account, without forgetting that the simplicity of the provisional stent technique continues to be the strategy to follow in most lesions. to treat
What do drug-eluting balloons (DLB) contribute to offer solutions to the aforementioned challenges?
The provisional stent strategy prevails because it is safe and simple, and is recommended in the latest revascularization (IA) guidelines over other more complex techniques. However, it is widely known that this technique presents its failure of the revascularized lesion in areas of the carina of the bifurcation and the ostium of the lateral branch, being more frequent in true bifurcations or with compromise of the lateral branch.
The published case report tries to highlight this limitation of the technique, incorporating drug-eluting balloons as a short- and medium-term solution, interpreting that in the long follow-up other factors prevail in the failure of the treated lesion (for example, neoatheromatosis). . I also want to emphasize the importance of the lateral branches, since, in this case as in many others, restenosis manifests as an acute coronary syndrome, affecting the patient’s quality of life, as well as their prognosis.
According to your data, the use of drug-eluting balloons occurs in 17% of coronary angioplasties, and of these, 57% in de novo lesions. Why is it so indicated for these cases?
The increase in the use of LABs in our unit has been gradual, reaching a higher percentage in the last year in de novo lesions than in restenosis. It is important to clarify that the percentage in de novo injuries is used in various types of injuries. The majority of LABs have been used in lesions in both main and secondary branches in their distal segments, in the context of patients with diffuse atheromatosis.
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“In bifurcations, treatment with LAB on the secondary vessel allows a simpler, safer procedure with lower contrast requirements, room time and radiation” |
He says that in the treatment of in-stent stenosis, LADs give good results, but that there are challenges in higher-risk anatomies. What is the reason for this and where do you think the solution can come from?
There are multiple meta-analyses that compare the efficacy of LABs with next-generation drug-eluting stents in restenotic lesions, the former being a safe and effective alternative, in addition to avoiding the placement of a new stent layer that affects strategies and patient outcomes. long-term. In addition, related to the case presented, a randomized study shows better angiographic results in patients treated with LAB, when the plate is prepared with modified plate balloons.
Secondary to this bibliographic background, clinical practice guidelines recommend treating restenosis associated with angina or significant ischemia by drug-eluting balloon angioplasty. However, not all restenosis responds to the same etiological mechanism. The use of intracoronary imaging provides an excellent insight into the likely causes of failed drug-eluting stent revascularization. Therefore, the efficacy provided by LABs is not the same in the presence of neoatherosclerosis as in the case of underexpansion or deterioration of the stent structure. The optimization of the final result both in the first revascularization and in the reinterventions is crucial, strongly recommending the use of images in high-risk lesions such as the treatment of bifurcations.
What benefits does the patient receive who can be treated with this technology?
The implantation of several layers of struts allows a good result in the short term, but it is recognized as a factor in the failure of the procedure in the medium-long term. This is where a deep understanding of the mechanism of restenosis becomes very important, with pharmacoactive balloons being a lasting solution in a significant proportion of patients.
In addition, related to bifurcations, the treatment on the secondary vessel allows a simpler and safer procedure with less contrast requirements, room time and radiation. Likewise, the treatment of distal or fine caliber lesions with LABs in symptomatic patients, despite medical treatment, constitutes a valid strategy, avoiding the implantation of metal in distal beds and preserving the functionality of the artery beyond that of the conductor.
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