Uncomplicated moderate coronary artery dissections after balloon angioplasty: good outcome without stenting

Predictors of target lesion failure after percutaneous coronary intervention with a drug-coated balloon for de novo lesions

BACKGROUND

There are limited data about determinant factors of target lesion failure (TLF) in lesions after percutaneous coronary intervention (PCI) using a drug-coated balloon (DCB) for de novo coronary artery lesions, including optical coherence tomography (OCT) findings.

AIMS

The present study aims to investigate the associated factors of TLF in de novo coronary artery lesions with DCB treatment.

METHODS

We retrospectively enrolled 328 de novo coronary artery lesions in 328 patients who had undergone PCI with a DCB. All lesions had been treated without a stent, and both pre- and post-PCI OCT had been carried out. Patients were divided into two groups, with or without TLF, which was defined as a composite of culprit lesion-related cardiac death, myocardial infarction, and target lesion revascularisation, and the associated factors of TLF were assessed.

RESULTS

At the median follow-up period of 460 days, TLF events occurred in 31 patients (9.5%) and were associated with patients requiring haemodialysis (HD; 29.0% vs 10.8%), with a severely calcified lesion (median maximum calcium arc 215° vs 104°), and with the absence of OCT medial dissection (16.1% vs 60.9%) as opposed to those without TLF events. In Cox multivariable logistic regression analysis, HD (hazard ratio [HR]: 2.26, 95% confidence interval [CI]: 1.00-5.11; p=0.049), maximum calcium arc (per 90°, HR: 1.34, 95% CI: 1.05-1.72; p=0.02), and the absence of post-PCI medial dissection on OCT (HR: 8.24, 95% CI: 3.15-21.6; p<0.001) were independently associated with TLF.

CONCLUSIONS

In de novo coronary artery lesions that received DCB treatment, factors associated with TLF were being on HD, the presence of a severely calcified lesion, and the absence of post-PCI medial dissection.

Impact of Dissection after Drug-Coated Balloon Treatment of De Novo Coronary Lesions: Angiographic and Clinical Outcomes

PURPOSE

Dissection after plain balloon angioplasty is required to achieve adequate luminal area; however, it is associated with a high risk of vascular events. This study aimed to examine the relationship between non-flow limiting coronary dissections and subsequent lumen loss and long-term clinical outcomes following successful drug-coated balloon (DCB) treatment of de novo coronary lesions.

MATERIALS AND METHODS

A total of 227 patients with good distal flow (Thrombolysis in Myocardial Infarction flow grade 3) following DCB treatment were retrospectively enrolled and stratified according to the presence or absence of a non-flow limiting dissection. The primary endpoint was late lumen loss (LLL) at 6-month angiography, and the secondary endpoint was target vessel failure (TVF, a composite of cardiac death, target vessel myocardial infarction, target vessel revascularization, and target vessel thrombosis).

RESULTS

The cohort consisted of 95 patients with and 132 patients without a dissection. There were no between-group differences in LLL (90.8%) returning for angiography at 6 months (0.05±0.19 mm in non-dissection and 0.05±0.30 mm in dissection group, p=0.886) or in TVF (6.8% in non-dissection and 8.4% in dissection group, p=0.799) at a median follow-up of 3.4 years. In a multivariate analysis, the presence of dissection and its severity were not associated with LLL or TVF. Almost dissections (93.9%) were completely healed, and there was no newly developed dissection at 6-month angiography.

CONCLUSION

The presence of a dissection following successful DCB treatment of a de novo coronary lesion may not be associated with an increased risk of LLL or TVF (Impact of Drug-coated Balloon Treatment in de Novo Coronary Lesion; NCT04619277).

Day case discharge of patients treated with drug coated balloon only angioplasty for de novo coronary artery disease: A single center experience

OBJECTIVE

To report our initial experience with drug coated balloon (DCB) only angioplasty and propose a protocol to achieve this safely.

BACKGROUND

There are no articles published in the literature currently regarding the safety of same day discharge in patients treated with DCB-only angioplasty.

METHODS

Retrospective review of all our patients treated with DCB-only angioplasty from September 2017 to April 2018 with identification of potential complications relating to same day discharge.

RESULTS

A total of 100 consecutive patients who underwent elective DCB-only angioplasty for de novo coronary artery disease and were discharged on the same day as the procedure were included. In 99% no cardiac symptoms relating to the procedure requiring urgent hospitalization or urgent investigations were identified. One patient was readmitted the next day requiring stenting of the previously treated lesion. Our 30-day mortality was zero. Some 97 hospital bed days were saved with 100 patients treated.

CONCLUSION

Elective day-case DCB-only angioplasty according to our local protocol is safe and cost-effective and should be considered for the majority of the patients.

Spontaneous Resolution of Catheter-Induced Iatrogenic Vein Graft Dissection: First Case Report and Review of Literature

An 86-year-old female patient with a history of bypass surgery was admitted for recurrent dyspnea and chest pain on exertion. She underwent coronary angiography showing high-grade saphenous vein graft stenosis supplying the right coronary. During an attempt to perform percutaneous intervention, saphenous vein graft to the right coronary artery was injured by the guide catheter resulting in dissection with thrombus formation but with normal distal blood flow. The procedure was abandoned since she had normal distal flow and also due to a fear of causing extension of the dissection with further manipulation. The patient was hemodynamically stable and free of chest pain after 30 minutes of observation. The patient was later discharged home on medical treatment. After 1 month, a repeat angiography showed patent saphenous vein graft to the right coronary artery with healed dissection. This is the first case report of spontaneous recovery of iatrogenic saphenous vein graft dissection. This case is followed by the review of literature.

Side-by-side false and true lumen stenting for recanalization of the chronically occluded right coronary artery

Subintimal or false lumen stent deployment is a rare complication of percutaneous coronary interventions. The most balloon-induced small non-flow limiting dissections heal spontaneously and can be treated medically with close observation if distal coronary flow is not compromised. However, the complex and severe flow-limiting postprocedural dissections may result in abrupt vessel closure and thrombosis, with ensuing myocardial ischemia and necrosis, and can be treated effectively by coronary stenting. It is essential to ensure that the guide-wire is in the true lumen before placing the stent in total occlusive lesions, otherwise the stent placement will impair distal coronary flow. We present here an interesting case of successful coronary recanalization despite false lumen stenting of the proximal right coronary artery followed by true lumen stenting.

Delayed spontaneous recanalization of a totally occluded right coronary artery following failed percutaneous coronary intervention with associated Type F dissection: case report and review

Coronary artery dissection is a well-known and frequent complication of percutaneous coronary intervention (PCI). We report the first case of a Type F dissection following PCI of the distal right coronary artery causing total vessel occlusion that could not be stented but was associated with late spontaneous recanalization and a favorable outcome.

Outcome of nonobstructive residual dissections detected by intravascular ultrasound following percutaneous coronary intervention

The purpose of this study was to assess the outcome of nonobstructive (or non-flow-limiting) residual dissection (RD) after percutaneous coronary intervention. Results of 124 consecutive native coronary lesions with angiographic nonobstructive RD in 97 patients (RD group) were compared with outcomes of 124 lesions without RD in 100 patients (non-RD group), whose characteristics were matched with those of the RD group. RD occurred after stent implantation (81 of 124 lesions, 65%) or balloon angioplasty (43 of 124 lesions, 35%). Angiographic types of RD were type A in 8 lesions (6%), B in 101 (82%), and C in 15 (12%). Stents were implanted in 65% of the lesions in each group. Clinical success (94% in RD group vs 95% in non-RD group, p = 0.77) and the in-hospital major adverse cardiac event rates were found to be similar in the 2 groups (6% vs 3%, respectively; p = 0.33). The late angiographic and clinical outcomes were also comparable. By intravascular ultrasound (IVUS) evaluation of the dissections in the RD group, area stenosis correlated with the incidence of in-hospital major adverse cardiac events (p = 0.023), whereas the final minimal lumen area correlated inversely with the occurrence of restenosis (p = 0.011). An area stenosis > or =58% was the best predictor for the incidence of in-hospital major adverse cardiac events (sensitivity 0.68, specificity 0.68). Most nonobstructive RDs are "favorable" and do not need stent implantation. IVUS evaluation identifies "unfavorable" nonobstructive (or non-flow-limiting) dissections that might be prone to acute occlusion. Nonobstructive dissections can be left untreated when final IVUS reveals an area stenosis of < 60% at the site of a dissection.