DCB for mutiple ostial side branch lesions
Author: Carlos Sánchez González – HOSPITAL REGIONAL DE MÁLAGA, SPAIN.
Angina in the presence of severe ostial side branch lesions is a complex subset. Stent placement is demanding in this context and may get complicated with serious prognostic consequences (miss of ostial side branch or involvement of main vessel). DCB emerges as an alternative way of treatment for these cases.
76 years old female. Hypertension. Diabetes. Dyslipidemia. Hip osteoarthritis and anxiety syndrome as most relevant chronic comorbidities.
Chronic ischemic heart disease started in August 2018, NSTEMI as presentation. Coronary angiogram revealed diffuse coronary disease including one severe lesion (90%) in the proximal left anterior descending and moderate isolated ostial side branch lesions in both the first and the second marginal branches. PCI for proximal LAD was performed with direct stenting, everolimus eluting stent 3.5 x 18 mm.
Patient did well during the medium long term follow up although in March 2020 she was admitted for suffering several recurrent episodes of unstable angina. A new coronary angiogram showed an important worsening of isolated ostial side branch lesions with critical 99% stenosis (Fig 1) in the first and the second marginal branches, no other remarkable findings were observed.
The following strategy possibilities were considered:
1)Stent placement with accurate positioning in the ostium.
Such approach provides good control in recoil and/or abrupt vessel closure although it also has some potential risk like missing coverage of the ostium or leaving excessive protrusion of the stent into the main vessel.
Cross-over to two stents technique would be required in those cases which could have some negative influence in the rate of events thereafter.
2)Coronary angioplasty with scoring and/or non compliant balloon followed by prolonged DCB inflation.
Although the likelihood of success with this approach is limited due to the angiographic profile of target lesions (critical stenosis, calcification) the achievement of an acceptable result would be worth it since it would provide the opportunity of performing a less complex treatment and reduced the risk of complications previously mentioned. Additionally the choice of stent placement wouldn`t be definitely excluded but deferred depending on the result initially achieved.
PCI with DCB strategy was performed including predilation with Scoring Balloon 2.5 x 10 mm balloon for ostial first marginal branch followed by DCB Essential pro 2.5 x 20 mm prolonged inflation (Fig 2).
The ostium of secondary marginal branch was treated identically with Scoring Balloon 2.5 x 10 mm predilation and Essential pro 2.5 x 20 mm prolonged inflation (Fig 3).
Angiographic final result was not excellent but acceptable including 20-30% residual stenosis and proximal focal dissection in the second marginal branch with TIMI 3 flow (Fig 4).
No serious adverse events were reported in the medium term follow up. As long as patient complained of recurrent atypical chest pain quite frequently and since angiographic result in the last procedure was not excellent a new angiogram was performed after a couple of months (May 2020).
A significant improvement in the angiographic appearance of both ostial lesions previously treated was observed including no residual stenosis and the absence of features suggestive of vascular dissections (Fig 5).
Conservative approach with DCB has been previously found to be associated with high probability of vessel healing and low rates of adverse events in the follow up1,2
1)Fahrni G, et al. Drug-coated balloon versus drug-eluting stent in small coronary artery lesions: angiographic analysis from the BASKET-SMALL 2 trial. Clin Research Cardio. 109(9):10.1007.
2)Rosenberg M, et al. Prospective, large-scale multicenter trial for the use of drug-coated balloons in coronary lesions: The DCB-only All-Comers Registry. Cath Card Interv 93(2):10.1002.
CONCLUSIONS AND REMARKS
PCI with DCB give us the opportunity of treating some complex coronary lesions like ostial side branch lesion in a simple way reducing the risk of complications related to stent usage in this particular context.
The achievement of a good angiographic result during PCI with DCB is usually less demanding than after PCI with stent implantation.
Acceptable angiographic results including non complicated yatrogenic dissections or certain grade of residual stenosis after PCI with DCB may improve in the medium-long term follow up.