Intimal disruption affects drug-eluting cobalt-chromium stent expansion: A randomized trial comparing scoring and conventional balloon predilation

Procedural safety of rotational atherectomy and modified balloon angioplasty: insights from a German national registry

BACKGROUND

Modified balloons (MB) and rotational atherectomy (RA) are recommended tools for treatment of coronary plaques with superficial calcium. Knowledge about in-hospital safety is limited.

METHODS

Patients with coronary artery disease who underwent coronary angiography with RA or MB angioplasty in Germany were identified via ICD and OPS codes from 2017 to 2020. Acute coronary syndromes were excluded. Since patients were not randomized toward MB or RA, potential confounding factors were taken into account using the propensity score methods. Thereby, inverse probability weighting was applied.

RESULTS

Ten thousand.ninety-twopatients underwent RA with an increasing trend from 1817 in 2017 toward 3166 in 2020. MBs were used in 22,378 patients also with an increasing trend from 4771 in 2017 toward 6078 in 2020. Patients receiving RA were older (74.23 ± 8.68 vs. 71.86 ± 10.02, p < 0.001), had a higher Charlson Comorbidity Index (2.07 ± 1.75 vs. 1.99 ± 1.76, p = 0.001) and more frequently left main (17.96% vs. 12.91%, p < 0.001) or three vessel disease (66.25% vs. 58.10%, p < 0.001). Adjusted procedural risk of major adverse cardiac and cerebrovascular events (MACCE) was similar in both groups, while pericardial effusion (RR 2.69; 95% CI 1.88-3.86, p < 0.001), pericardial puncture/pericardiotomy/pericardial tamponade (RR 2.66; 95% CI 1.85-3.81, p < 0.001) and bleeding (RR 1.65; 95% CI 1.12-2.43, p < 0.011) occurred more frequently in patients receiving RA. Patients treated with RA at high volume centers were hospitalized shorter (p = 0.005) and had a lower rate of acute cerebrovascular events (p < 0.001). Rate of MACCE, bleeding and pericardial puncture were not influenced by the annual RA numbers per center.

CONCLUSION

MBs had a lower risk of bleeding and pericardial puncture. Patients treated at centers with high annual RA procedure numbers had a lower risk of acute cerebrovascular events and were hospitalized shorter.

Lower revascularization rates after high-speed rotational atherectomy compared to modified balloons in calcified coronary lesions: 5-year outcomes of the randomized PREPARE-CALC trial

BACKGROUND

In the PREPARE-CALC trial, severely calcified lesion preparation with rotational atherectomy (RA) before biodegradable polymer sirolimus-eluting stent (SES) implantation demonstrated higher procedural success and comparable rates of acute lumen gain and late lumen loss compared to modified balloons (MB) (scoring/cutting). We aimed to analyze the 5-year outcomes of both lesion preparation strategies.

METHODS

PREPARE-CALC randomly assigned 200 patients 1:1 to MB or RA, followed by SES implantation. The principal endpoint of the current analysis was target vessel failure (TVF) at 5 years.

RESULTS

At 5 years, MB had comparable rates of TVF to RA (19% vs. 21%, HR 1.14, 95% CI 0.60-2.16, p = 0.687). Subgroup analysis showed a lesion length treatment interaction, favoring MB for short lesions and RA for long ones (p for interaction = 0.042). Target lesion revascularization (TLR) was significantly less common with RA (12 vs. 3%, HR 0.28, 95% CI 0.08-0.98, p = 0.048). In a multivariate analysis, RA was independently protective against TLR (adj. HR 0.17, 95% CI 0.04-0.78, p = 0.022), while ostial lesions were associated with higher TLR independent of treatment strategy (adj. HR 11.3, 95% CI 2.98-42.6, p < 0.001).

CONCLUSION

In patients with severely calcified coronary lesions, using MB or RA for lesion preparation followed by biodegradable polymer SES implantation was associated with comparable rates of TVF at 5 years. However, a significant reduction of TLR was observed after RA. PREPARE-CALC is the first randomized trial showing potential clinical advantages of RA over MB during long-term follow-up.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov . Unique identifier: NCT02502851.

Combination of Laser Atherectomy and Super High-pressure Non-compliant Balloon to Treat Stent Under-expansion in Cases of Failed Interventional Options

Patients with calcified, fibrotic native coronary vessels with prior suboptimal stenting outcomes are at major risk of stent thrombosis and could face serious consequences if untreated. In cases of multiple layers of under-expanded stents, the risk is multiplied. If conventional balloon post-dilatation is unsuccessful after stent implantation without proper lesion preparation, few interventional options remain. The authors report on a patient with prior numerous right coronary unsuccessful coronary interventions resulting in partially crushed multiple layers of stent material with critical lumen narrowing caused by stent under-expansion. Balloon angioplasty and stent rotational atherectomy (ROTA) had been attempted to overcome stent under-expansion but were unsuccessful. The authors investigated a new combination therapy of laser atherectomy (ELCA) and super high-pressure balloon (OPN non-compliant balloon) to treat single or multiple layers of stent with severe under-expansion due to fibrotic, calcified tissue surrounding the under-expanded stent structure.

Current Management of Highly Calcified Coronary Lesions: An Overview of the Current Status

The amount of coronary calcium strongly correlates with the degree of atherosclerosis and, therefore, with the rate of future cardiac events. Calcified coronary lesions still represent a challenge for interventional cardiologists, bringing not only a higher risk of immediate complications during percutaneous coronary interventions (PCI), but also a higher risk of late stent failure due to under-expansion and/or malapposition, and therefore, have a relevant prognostic impact. Accurate identification of the calcified plaques together with the analysis of their distribution pattern within the vessel wall by intracoronary imaging is important to improve the successful treatment of these lesions. The aim of this review is to guide readers through the assessment of the calcified plaque distribution using intracoronary imaging in order to select the best devices and strategies for plaque debulking and lesion preparation.

Safety and efficacy of systematic lesion preparation with a novel generation scoring balloon in complex percutaneous interventions: results from a prospective registry

BACKGROUND

Coronary lesions predilatation with semicompliant (SC) or non-compliant balloons (NC) may be insufficient to obtain an optimal stent expansion, which can lead to in-stent restenosis or thrombosis. Moreover, increasing evidence supporting an optimal lesion preparation is mandatory when drug coated balloons (DCB) are used. To this extent, more "aggressive tools" such as cutting/scoring balloons, atherectomy or lithotripsy may play an important role and improve outcomes.

METHODS

We enrolled 78 consecutive patients from March 2020 to October 2020 with calcific/fibrotic or ostially-located lesions, which were prepared using scoring balloons, in addition to SC/NC balloons and other plaque modification strategies. The final treatment consisted in either stent or DCB usage. The primary endpoint was the rate of clinically-driven target lesion revascularization. Secondary endpoints entailed the procedural success and the individual rates of major adverse cardiac events (MACE) at 12 months.

RESULTS

Most of the patients had left main (LM) or ostial lesions, 65% of them being moderate/severely calcified, with further debulking strategies being required in 15 (19.2%) patients (rotational atherectomy, 3.8% or coronary intravascular lithotripsy, 15.3%). A high-rate of DCB usage was reported. Angiographic and procedural success was obtained in 77 and 76 patients, respectively. We encountered one vessel perforation, which was sealed with a covered stent, without consequence. During follo- up, we observed only 6 MACE, 6 target lesion revascularizations (TLR) and 2 cardiovascular deaths.

CONCLUSIONS

Among patients with high complexity and calcific lesions, an optimal lesion preparation using a dedicated scoring balloon was associated with low clinical events at mid-term follow-up and may be considered to improve immediate procedural success rate.

The factors influencing the efficiency of drug-coated balloons

The drug-coated balloon (DCB) is an emerging percutaneous coronary intervention (PCI) device that delivers drugs to diseased vessels to decrease the rate of vascular stenosis. Recent clinical studies have demonstrated that DCBs tend to have both good safety and efficacy profiles, leading to extended application indications in the clinic, including in-stent restenosis (ISR) for metal stents such as drug-eluting stents (DESs), small vascular disease, bifurcation disease, large vascular disease, acute coronary syndrome (ACS), and high bleeding risk. However, some previous clinical data have suggested that DCBs performed less effectively than DESs. No studies or reviews have systematically discussed the improvement strategies for better DCB performance until now. Drug loss during the process of delivery to the target lesion and inefficient delivery of the coating drug to the diseased vascular wall are two key mechanisms that weaken the efficiency of DCBs. This review is the first to summarize the key influencing factors of DCB efficiency in terms of balloon structure and principles, and then it analyzes how these factors cause outcomes in practice based on current clinical trial studies of DCBs in the treatment of different types of lesions. We also provide some recommendations for improving DCBs to contribute to better DCB performance by improving the design of DCBs and combining other factors in clinical practice.

Contemporary Management of Severely Calcified Coronary Lesions

Coronary artery calcification is increasingly prevalent in our patient population. It significantly limits the procedural success of percutaneous coronary intervention and is associated with a higher risk of adverse cardiovascular events both in the short-term and long-term. There are several modalities for modifying calcified plaque, such as balloon angioplasty (including specialty balloons), coronary atheroablative therapy (rotational, orbital, and laser atherectomy), and intravascular lithotripsy. We discuss each modality’s relative advantages and disadvantages and the data supporting their use. This review also highlights the importance of intravascular imaging to characterize coronary calcification and presents an algorithm to tailor the calcium modification therapy based on specific coronary lesion characteristics.

Contemporary Evidence-Based Diagnosis and Management of Severe Coronary Artery Calcification

Percutaneous treatment of heavily calcified coronary lesions remains a challenge for interventional cardiologists with increased risk of incomplete lesion preparation, suboptimal stent deployment, procedural complications, and a higher rate of acute and late stent failure. Adequate lesion preparation through calcium modification is crucial in optimising procedural outcomes. Several calcium modification devices and techniques exist, with rotational atherectomy the predominant treatment for severely calcified lesions. Novel technologies such as intravascular lithotripsy are now available and show promise as a less technical and highly effective approach for calcium modification. Emerging evidence also emphasises the value of detailed characterisation of calcification severity and distribution especially with intracoronary imaging for appropriate device selection and individualised treatment strategy. This review aims to provide an overview of the non-invasive and invasive evaluation of coronary calcification, discuss calcium modification techniques and propose an algorithm for the management of calcified coronary lesions.

Verification of the differences of scoring effect in current scoring balloons

The characteristics of each scoring balloon seem to be different because material or configuration of scoring element in each device is unique. The aim of this study is to clarify the difference of scoring effect among 3 different scoring devices. We prepared 3 different scoring devices [Wolverine™ Cutting Balloon™ (CB), ScoreFlex™ NC (SF), NSE Alpha™ (NSE), n = 5 respectively. Balloon diameter is 3 mm and 2 types of silicone tubes with different elasticity [140 kPa (tube S) and 576 kPa (tube H), respectively. Inner diameter is 3 mm]. We dilated each balloon in each silicone tube with nominal pressure (NP) and 20 atmosphere (HP) and took a picture using a micro CT. We measured penetration depth of all scoring elements into silicone tube wall and calculated their percentage using the following formula; penetration depth/original scoring element height × 100. We also observed the deformation of scoring element during balloon inflation in each device. Scoring element of CB cut deeper into both tubes significantly than SF and NSE at both pressure (40.5% vs 25.1% and 16.8% at NP and 86.1% vs 33.5% and 29.1% at HP in tube S, p < 0.01, respectively, 62.6% vs 33.5% and 17.0% at NP and 93.3% vs 45.1% and 36.5% at HP in tube H, p < 0.01, respectively). Although no deformation of scoring element was recognized in CB, some deformations were observed in 50% of NSE and 40% of SF (p = 0.0377). Scoring balloon with sharp and firmly fixed scoring elements like CB may show definite scoring effect.

Comparison of optical coherence tomography-guided and intravascular ultrasound-guided rotational atherectomy for calcified coronary lesions

Background

To compare the effect and outcomes of optical coherence tomography (OCT)-guided rotational atherectomy (RA) with intravascular ultrasound (IVUS)-guided RA in the treatment of calcified coronary lesions.

Methods

Data of calcified coronary lesions treated with RA that underwent OCT-guided or IVUS-guided from January 2016 to December 2019 at a single-center registry were retrospectively analyzed. The effect and outcomes between underwent OCT-guided RA and IVUS-guided RA were compared.

Results

A total of 33 lesions in 32 patients received OCT-guided RA and 51 lesions in 47 patients received IVUS-guided RA. There was no significant difference between OCT-guided RA group and IVUS-guided RA group in clinical baselines characteristics. Comparing the procedural and lesions characteristics of the two groups, the contrast volume was larger [(348.8 ± 110.6) ml vs. (275.2 ± 76.8) ml, P = 0.002] and the scoring balloon was more frequently performed (33.3% vs. 3.9%, P = 0.001) after RA and before stenting in the OCT-guided RA group. Comparing the intravascular imaging findings of the two groups, stent expansion was significantly larger in the OCT-guided RA group ([82 ± 8]% vs. [75 ± 9]%, P = 0.001). Both groups achieved procedural success immediately. There were no significantly differences in the incidence of complications. Although there was no statistical difference in the occurrence of MACE at 1 year between OCT-guided RA group and IVUS-guided RA group (3.1% vs. 6.4%, P = 0.517), no cardiovascular death, TVR and stent thrombosis occurred in OCT-guided RA group.

Conclusions

OCT-guided RA compared to IVUS-guided RA for treating calcified coronary lesions resulted in better stent expansion and may have improved prognosis.

Procedural effectiveness with a focused force scoring angioplasty catheter: Procedural and clinical outcomes from the Scoreflex NC trial

BACKGROUND

The Scoreflex NC scoring angioplasty catheter is designed with a short rapid-exchange tip distal to a non-compliant, high-pressure balloon and an integral wire outside of the balloon, such that the guidewire and the integral wire act as scoring elements during balloon inflation. The external scoring elements enable a focal stress pattern facilitating expansion of resistant lesions at lower pressures using a focused force angioplasty effect.

METHODS

Patients undergoing elective percutaneous coronary intervention (PCI) were enrolled in a prospective, single-arm study conducted at 12 centers in the United States. The primary endpoint was device procedural success, defined as the composite of successful device delivery to the target lesion with balloon inflation and deflation; absence of vessel perforation, flow-limiting dissection or reduction in TIMI flow from baseline; and achievement of final TIMI 3 flow.

RESULTS

Among 200 patients (234 lesions), lesion complexities included: bifurcation disease (37.6%), moderate/severe calcification (36.6%), and total occlusions (5.0%). Successful delivery to the target lesion, inflation and removal of the balloon catheter was achieved in 95.5% of patients (191/200). Procedural success was achieved in 93.5% (187/200) of patients, and final TIMI 3 flow was observed in 99.0% of cases (198/200). No unanticipated device-related events occurred. In-hospital major adverse events were reported in 4.5% of patients (9/200), related to periprocedural myocardial infarction (8/200, 4.0%) and target lesion revascularization (1/200, 0.5%).

CONCLUSIONS

Among patients undergoing elective PCI and with varied lesion complexity, these results support the safety and effectiveness of a dilation strategy using the Scoreflex NC scoring catheter.

Calcium Modification Techniques in Complex Percutaneous Coronary Intervention

Percutaneous coronary intervention is the most common mode of revascularization and is increasingly undertaken in high-risk subsets, including the elderly. The presence of coronary artery calcification is increasingly observed and significantly limits technical success. The mechanisms for this are multi-factorial, including increased arterial wall stiffness and impaired delivery of devices, leading to suboptimal stent delivery, deployment, and expansion which are harbingers for increased risk of in-stent restenosis and stent thrombosis. Although conventional balloon pretreatment techniques aim to mitigate this risk by modifying the lesion before stent placement, many lesions remain resistant to conventional strategies, due to the severity of calcification. There have been several substantial technological advancements in calcium modification methods in recent years, which have allowed improved procedural success with low periprocedural complication rates. This review will summarize the current adjunctive modification technologies that can be employed to improve technical outcomes in percutaneous coronary intervention in calcific disease and the evidence supporting these tools.

Current Treatment Modalities for Calcified Coronary Artery Disease: A Review Article Comparing Novel Intravascular Lithotripsy and Traditional Rotational Atherectomy

The coronary artery calcium score is considered the most useful marker for predicting coronary events. The high score reflects heavy calcification in the vessel, which is more challenging to treat with the percutaneous intervention (PCI). To prepare this type of heavily calcified lesion intravascular lithotripsy (IVL) technology can be used prior to PCI, which is based on the concept of converting electrical energy into mechanical energy. It harmlessly and selectively disrupts both the shallow and deep deposits of calcium. The balloon-based catheters of this system emit sonic waves that transfer to the adjacent tissue resulting in improvement in vessel compliance with the slightest soft tissue loss. Therefore, making the treatment of calcified lesions more feasible, effective, and also simplify complex lesions. The lesions considered for lithotripsy-enhanced balloon dilation include calcified coronary lesions and peripheral vasculature lesions. This article reviews the use of IVL in calcified coronary artery disease, its advantages, and disadvantages while comparing it with other techniques like high-pressure balloons and rotational atherectomy devices. A thorough search of databases like PubMed and Google Scholar was performed, which uncovered 35 peer review articles. Keywords utilized in the data search were calcified coronary artery disease, coronary lithotripsy, calcification, and calcified atherosclerotic plaque. According to rotational atherectomy and intravascular lithotripsy trials, the latter was safer, mainly by decreasing atheromatous embolization risk. Deciphering these studies, it seems like IVL is better at parameters like procedural and clinical success rate, acute lumen gain, and less residual stenosis except in-hospital major adverse cardiovascular events (MACE), which was better in rotational atherectomy (RA). However, when lesion crossings are present, the atherectomy technique is still considered as first-line therapy. In clinical practice, despite these encouraging data for treating calcified lesions, IVL is grossly underutilized because of substantial costs and perceived significant procedural risk effects on the cardiac rhythm like causing 'shock topics' and asynchronous cardiac pacing. More longer-term clinical data and extensive researches are required to validate its safety and efficiency.

Improved crossability with novel cutting balloon versus scoring balloon in the treatment of calcified lesion

Cutting balloons and scoring balloons are commonly used for the preparation of calcified lesion. However, problems with crossability occasionally limit the use of cutting balloons. We prospectively selected 173 calcified lesions treated using a novel cutting balloon (Wolverine™, C group). As control, we retrospectively analyzed 146 calcified lesions treated using a scoring balloon (Lacrosse NSE ALPHA™, S group). Either intravascular ultrasound (IVUS) or optical coherence tomography (OCT) was used by the operator's discretion. The primary outcome was delivery success, which was defined as successful passage to the target lesion immediately after IVUS or OCT evaluation. The secondary outcome was acute cross-sectional area (CSA) gain, which was defined as post-interventional minimum stent area minus pre-procedural minimum lumen area. A multivariate analysis evaluated the independent predictors for delivery success. The delivery success rate was significantly higher in the C group versus the S group (90.8% versus 79.5%, P = 0.006). However, the acute CSA gain was similar between the two groups (IVUS: 3.2 ± 1.8 mm² versus 3.4 ± 1.9 mm², P = 0.53; OCT: 3.6 ± 1.4 mm² versus 4.1 ± 1.9 mm², P = 0.11). Usage of cutting balloon was an independent predictor for delivery success even after the adjustment for the patient and lesion characteristics [odds ratio (OR): 2.72 (95% confidence interval 1.38-5.33), P = 0.004] as well as the procedural characteristics [OR: 2.34 (1.15-4.86), P = 0.018]. Novel cutting balloons demonstrated better crossability and similar acute CSA gain compared with scoring balloons in calcified lesion.

Performing percutaneous coronary interventions with predilatation using non-compliant balloons at high-pressure versus conventional semi-compliant balloons: insights from two randomised studies using optical coherence tomography

Introduction

Stent underexpansion is a predictor of in-stent-restenosis and stent thrombosis. Semi-compliant balloons (SCBs) are generally used for lesion preparation. It remains unknown whether routine predilatation using non-compliant balloons (NCBs) improves stent expansion in ordinary coronary lesions.

Methods

The PREdilatation by high-pressure NC balloon catheter for better vessel preparation and Optimal lesion preparation with non-compliant balloons for the implantation of bioresorbable vascular scaffolds studies randomised patients presenting with stable coronary artery disease or non-ST-elevation myocardial infarction requiring stent implantation to lesion preparation using NCBs versus SCBs. Stent expansion index (SEI-minimal luminal area/mean luminal area on optical coherence tomography) and periprocedural complications were compared.

Results

We enrolled 104 patients: 53 patients (54 lesions) vs 51 patients (56 lesions) to the NCB and SCB groups, respectively. Predilatation pressure was higher in the NCB group (24±7 atmospheres (atm) vs 14±3 atm, p<0.0001). Postdilatation using NCBs was performed in 41 (76%) lesions vs 46 (82%) lesions pretreated with NCBs versus SCBs (p=0.57). Similar pressures were used for postdilatation with NCB in both groups (23±8 atm vs 23±9 atm, p=0.65). SEI after stent implantation was 0.88±0.13 in the NCB vs 0.85±0.14 in the SCB group (p=0.18). After postdilatation, SEI increased to 0.94±0.13 in the NCB group vs 0.88±0.13 in the SCB group (p=0.02). No relevant complications occurred.

Conclusions

In simple coronary lesions, predilatation/postdilatation with NCBs at high pressures appears to result in better scaffold and stent expansion. Using SCBs only for predilatation might lead to inadequate stent expansion and postdilatation with NCBs might only partially correct this. Predilatation and postdilatation using NCBs at high pressure is safe.

Trial registration number

ClinicalTrials.gov no. NCT03518645.

Contemporary Approach to Heavily Calcified Coronary Lesions

Percutaneous treatment of heavily calcified coronary lesions still represents a challenge for interventional cardiology, with higher risk of immediate complications, late failure due to stent underexpansion and malapposition, and consequently poor clinical outcome. Good characterisation of calcium distribution with multimodal imaging is important to improve the successful treatment of these lesions. The use of traditional or new dedicated devices for the treatment of calcified lesions allows better lesion preparation; therefore, it is important that we know the different mechanisms and technical features of these devices.

Calcific lesion preparation for coronary bifurcation stenting

Bifurcating coronary lesions are a very common challenge in interventional cardiology because of the technical complexity in their treatment, the risk of side branch occlusion and an overall worse outcome when compared to non-bifurcating lesions. The presence of calcifications represents further complexity due to the difficulty in device delivery and stent expansion as well as enhanced risk of side branch occlusion. Rotational and orbital atherectomy, scoring and cutting balloons, coronary lithoplasty are available tools which have been introduced over the last three decades to overcome such issue. Nevertheless, their application in different contexts of bifurcations presents specific caveats and the studies directed at comparing such techniques have never been expressly oriented in the subset of the bifurcating lesion. In this paper, we review these devices and their usefulness in bifurcations by analyzing consistent data from clinical trials, and we propose a practical algorithm for the treatment of severely calcified bifurcating lesions according to their anatomical features.

Prognostic Impact of Scoring Balloon Angioplasty After Rotational Atherectomy in Heavily Calcified Lesions Using Second-Generation Drug-Eluting Stents: A Multicenter Registry-Based Study

BACKGROUND

We aimed to assess the impact of scoring balloon angioplasty (SBA) after rotational atherectomy (RA) on long-term clinical outcomes in patients who underwent percutaneous coronary intervention (PCI) using second-generation drug-eluting stents (DES). The long-term outcomes associated with SBA after RA in severely calcified lesions is unknown.

METHODS

Using the J2T ROTA registry data, we evaluated the clinical events of patients who underwent PCI using RA for heavily calcified lesions from January 2004 to December 2015. A total of 307 patients who underwent PCI with second-generation DES were analyzed and divided into the SBA (n = 96) and conventional balloon angioplasty (CBA) groups (n = 211). Eighty-two and 189 patients comprised the "SBA after small burr (SBA-SB)" and "CBA after small burr (CBA-SB)" subgroups, respectively, for the subgroup analysis. Study endpoints were incidence of 3-year major adverse cardiac events (MACE), target vessel revascularization (TVR), and target lesion revascularization (TLR).

RESULTS

Kaplan-Meier analysis revealed that the incidence of 3-year cumulative MACE, TVR, and TLR were comparable between groups, and that the incidences of 3-year cumulative MACE, TVR, and TLR were significantly lower in the SBA-SB subgroup than in the CBA-SB subgroup (log-rank p = 0.008; log-rank p = 0.047; log-rank p = 0.045; respectively). Multivariate Cox regression model indicated that SBA after RA was an independent predictor of MACE (hazard ratio: 0.337; 95% confidence interval: 0.139 to 0.817; p = 0.016).

CONCLUSIONS

Additional SBA following RA was associated with lower MACE incidence in patients undergoing RA with a small-sized burr.

Clinical and angiographic outcomes of coronary dissection after paclitaxel-coated balloon angioplasty for small vessel coronary artery disease

The mechanism of how angiographic results following paclitaxel-coated balloon (PCB) treatment for small vessel disease affect patient outcome remains unknown. In the present study, we aimed to investigate the correlation between coronary dissection immediately after PCB angioplasty and midterm outcome. From March 2014 to March 2017, 171 consecutive patients with 228 native coronary artery lesions who received PCB angioplasty at a single center were enrolled retrospectively. Lesions with a reference vessel diameter > 2.8 mm were excluded. There were dissections in 80% of the lesions immediately following PCB angioplasty. Of these, 38% were type A, 29% were type B, and 13% were type C or more severe dissection. No patient required revascularization during hospitalization. We were able to follow 159 patients (212 lesions) clinically for > 6 months, from among whom target lesion revascularization (TLR) was performed in 7% of the patients. Follow-up angiography was performed on 143 lesions (67%), and complete healing of all dissections was noted. The rates of restenosis and late lumen enlargement were 12% and 56%, respectively. Multivariate analysis identified that a bending lesion was an independent predictor of TLR, and type C-E dissection and imaging device use were independent predictors of restenosis. Conversely, lesions with type B dissection had a larger net gain than lesions with type A or no dissection. Leaving the dissection uncovered after PCB angioplasty seems to be safe, resulting in a low acute event rate. The type B dissection after PCB angioplasty was the most therapeutic dissection.