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Fezzi S, Malakouti S, Sivalingam J, Khater J, Ribichini F, Cortese B. Drug-Coated Balloon in Acute Coronary Syndromes: Ready for the Prime Time? Curr Cardiol Rep 2024; 26:359-372. [PMID: 38619711 DOI: 10.1007/s11886-024-02037-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE OF REVIEW Acute coronary syndromes (ACS) are a major global health concern. Percutaneous coronary intervention (PCI) with new-generation drug-eluting stents (DES) has been endorsed as safe and effective in the management of culprit and non-culprit lesions of ACS. However, permanent metallic implants may have drawbacks, including the need for prolonged dual antiplatelet therapy (DAPT) and the risk of long-term stent-related complications. An alternative approach using drug-coated balloons (DCBs) is gaining growing interest, having the potential of delivering therapy directly to vulnerable plaques, avoiding the need for permanent metallic implants, and potentially allowing for better long-term medical treatment. Despite limited evidence, DCB is being explored in several patients' subgroups. This review aims to discuss the existing evidence regarding DCB in ACS management. RECENT FINDINGS DCB appears to be a promising strategy in the management of ACS, showing comparable angiographic and clinical results as compared to new-generation DES in relatively small clinical trials or large prospective registries. The advantage of avoiding permanent implants is particularly appealing in this setting, where DCB has the potential of delivering anti-atherogenic local therapy directly to vulnerable plaques still amenable to atherogenic regression. This review seeks to underline the theoretical background of DCB use and reports the available evidence in its support in the specific setting of ACS. In the context of ACS, the use of DCB is highly attractive, offering a dedicated anti-atherogenic local therapy, capable of addressing a broad range of vulnerable plaques and patients.
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Affiliation(s)
- Simone Fezzi
- Fondazione Ricerca e Innovazione Cardiovascolare, Milan, Italy
- University of Verona, Verona, Italy
| | | | | | - Jacinthe Khater
- DCB Academy, Milan, Italy
- Faculty of Medical Sciences, Lebanese University Rafic Hariri University Campus, Hadath, Lebanon
| | | | - Bernardo Cortese
- Fondazione Ricerca e Innovazione Cardiovascolare, Milan, Italy.
- DCB Academy, Milan, Italy.
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Lu K, Ye X, Chen Y, Wang P, Gong M, Xuan B, Tang Z, Li M, Hou J, Peng K, Pei H. Research progress of drug eluting balloon in arterial circulatory system. Front Cardiovasc Med 2024; 11:1287852. [PMID: 38601040 PMCID: PMC11005962 DOI: 10.3389/fcvm.2024.1287852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 03/04/2024] [Indexed: 04/12/2024] Open
Abstract
The arterial circulatory system diseases are common in clinical practice, and their treatment options have been of great interest due to their high morbidity and mortality. Drug-eluting balloons, as a new type of endovascular interventional treatment option, can avoid the long-term implantation of metal stents and is a new type of angioplasty without stents, so drug-eluting balloons have better therapeutic effects in some arterial circulatory diseases and have been initially used in clinical practice. In this review, we first describe the development, process, and mechanism of drug-eluting balloons. Then we summarize the current studies on the application of drug-eluting balloons in coronary artery lesions, in-stent restenosis, and peripheral vascular disease. As well as the technical difficulties and complications in the application of drug-eluting balloons and possible management options, in order to provide ideas and help for future in-depth studies and provide new strategies for the treatment of more arterial system diseases.
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Affiliation(s)
- Keji Lu
- Department of Cardiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- School of Medical and Life Sciences, Chengdu University of TCM, Chengdu, China
| | - Xianglin Ye
- Department of Cardiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Yaoxuan Chen
- School of Medical and Life Sciences, Chengdu University of TCM, Chengdu, China
| | - Peng Wang
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Meiting Gong
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Bing Xuan
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Zhaobing Tang
- Department of Rehabilitation, The General Hospital of Western Theater Command, Chengdu, China
| | - Meiling Li
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Jun Hou
- Department of Cardiology, Chengdu Third People's Hospital, Chengdu, China
| | - Ke Peng
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
| | - Haifeng Pei
- Department of Cardiology, The Affiliated Hospital, Southwest Medical University, Luzhou, China
- Department of Cardiology, The General Hospital of Western Theater Command, Chengdu, China
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Damara FA, Alameddine D, Slade M, Cardella J, Tonnessen B, Guzman RJ, Ochoa Chaar CI. Arterial dissection during peripheral vascular interventions. J Vasc Surg 2024; 79:339-347.e6. [PMID: 37838217 DOI: 10.1016/j.jvs.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/03/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023]
Abstract
OBJECTIVE Arterial dissection (AD) is a known complication of peripheral vascular interventions (PVIs), but its incidence and significance have not been well-characterized. This study examines AD in the Vascular Quality Initiative database for patients treated for peripheral arterial disease. Our hypothesis is that AD is associated with decreased patency and worse limb outcomes. METHODS The Vascular Quality Initiative PVI registry (2016-2021) was reviewed. Patients were divided based on the presence or absence of reported AD during the procedure. Trend of incidence and management of AD was derived. The characteristics and outcomes of patients with and without AD were compared. The primary endpoint was primary patency. RESULTS There was a total of 177,790 cases, and 3% had AD. The incidence of AD significantly increased over the study period from 2.4% to 3.6% (P = .007). Endovascular therapy was used to treat AD in 83.7% of cases, 14.5% were treated medically, and only 1.8% required open surgery. Patients with AD were significantly more likely to be female (47.4% vs 39.7%; P < .001). Patient with AD were more likely to have a history of smoking (79.7% vs 77.2%; P < .001), but were significantly less likely to be on dialysis (8.2% vs 9.3%; P < .001) compared with patients without AD. Patients with AD were more likely to have femoropopliteal disease (45.2% vs 38.0%; P < .001) and undergo treatment of more complex disease as denoted by higher mean number of lesions treated (1.95 ± 1.01 vs 1.71 ± 0.89; P < .001), longer occlusion length (8 ± 16 vs 7 ± 15 cm; P < .001), and more severe TransAtlantic Inter-Society Consensus grade (Grade D: 36.2% vs 29.1%; P < .001). The proportion of stenting as a treatment modality was higher in the dissection group (55.4% vs 41.1%; P < .001). After a mean follow-up of 828 days, patients with AD had significantly lower primary patency than patients without AD. Kaplan-Meier curves demonstrated that the AD group had lower primary patency (86.9% vs 91%; P < .001) and reintervention-free survival (79.5 % vs 84.1%; P < .001) at 1 year with difference in amputation-free survival. Cox proportional hazard regression confirmed the independent association of AD with primary patency and reintervention-free survival. CONCLUSIONS AD is more common in women and is more likely to occur during treatment of the femoropopliteal segment. AD is associated with decreased primary patency and reintervention-free survival after PVI for peripheral arterial disease.
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Affiliation(s)
- Fachreza Aryo Damara
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | - Dana Alameddine
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Martin Slade
- Yale Occupational and Environmental Medicine Program, Yale University School of Medicine, New Haven, CT
| | - Jonathan Cardella
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Britt Tonnessen
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale University School of Medicine, New Haven, CT
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El Khoury A, Lazar L, Cortese B. The fate of coronary dissections left after sirolimus-coated balloon angioplasty: A prespecified subanalysis of the EASTBOURNE study. Catheter Cardiovasc Interv 2023; 102:979-986. [PMID: 37937671 DOI: 10.1002/ccd.30906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/05/2023] [Accepted: 10/27/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES We sought to understand the clinical outcomes of dissections left untreated after sirolimus drug-coated balloon (DCB) angioplasty. BACKGROUND DCB may be a valuable alternative to stents for the treatment of native coronary lesions, but the risk of having a dissection after DCB-angioplasty is not negligible. While type A and B dissections can be safely treated conservatively, some debate exists regarding type C dissections. We previously showed the safety of dissections left untreated after second-generation paclitaxel-DCB. However, the fate of dissections after sirolimus-DCB angioplasty has not been investigated so far. METHODS EASTBOURNE is a prospective, multicenter, international, investigator-driven study aiming to explore the safety and efficacy of a novel sirolimus-DCB. This study enrolled a consecutive, all-comer population of coronary artery disease patients and is the largest prospective study on DCB so far. Primary endpoints of the study, target-lesion revascularization (TLR), and other clinical endpoints at 12 months, have been presented elsewhere. This is a prespecified subgroup analysis of the patients left with not-flow limiting dissection after DCB angioplasty, with complete 12 months follow-up and comparison between patients left with a dissection versus patients with DCB used for de novo lesions. RESULTS Between September 2016 and November 2020, a total of 2123 patients were enrolled at 38 study centers. Seventy-three patients were left with nonflow limiting dissections (43 type A, 27 type B, 3 type C) and underwent complete 1-year clinical follow-up. In the nondissection group, 1110 patients had de-novo coronary artery disease while 900 had in-stent restenosis. Baseline characteristics were similar between the groups, while the dissection group was associated with longer lesions (23.8 vs. 18.4 mm, p < 0.001) and more frequent use of predilation (100 vs. 91.4%, p = 0.016). At 12-month follow-up, no significant differences among the groups were found, with a total of 1.25% TLR in the dissection cohort versus 5.6% in the de-novo cohort (p = 0.13), and an overall rate of major adverse cardiovascular events of 4.4% versus 10.1% (p = 0.18). Total death (1.5 vs. 2.6, p = 0.87), cardiac death, myocardial infarction (0% vs. 2.5%, p = 0.35), and bleedings did not differ significantly among the groups as well. CONCLUSIONS In this subgroup analysis of the EASTBOURNE study of consecutive patients treated with new-generation sirolimus DCB, dissections left untreated after angioplasty did not lead to an increase in adverse events.
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Affiliation(s)
- Antoine El Khoury
- Department of Cardiology, Faculty of Medicine and Medical Sciences, University of Balamand, Beirut, Lebanon
| | - Leontin Lazar
- Department of Cardiology, Medical Clinic Number 1, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Bernardo Cortese
- Scientific Committee, Cardiovascular Research Group, Fondazione Ricerca e Innovazione Cardiovascolare, Milano, Italy
- Scientific Committee, DCB Academy, Milano, Italy
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Shin ES, Ann SH, Jang MH, Kim B, Kim TH, Sohn CB, Choi BJ. Impact of Scoring Balloon Angioplasty on Lesion Preparation for DCB Treatment of Coronary Lesions. J Clin Med 2023; 12:6254. [PMID: 37834898 PMCID: PMC10573989 DOI: 10.3390/jcm12196254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of scoring balloon angioplasty for drug-coated balloon (DCB) treatment in percutaneous coronary intervention. BACKGROUND The scoring balloon angioplasty may play a pivotal role in enhancing the outcomes of DCB treatment. METHODS A total of 259 patients (278 lesions) with coronary artery disease successfully treated with DCB were retrospectively enrolled. The mean age of the patients was 62.2 ± 11.1 years, and the majority of patients were men (68.7%). The study's endpoint was defined as achieving an optimal angiographic result, which consisted of Thrombolysis in Myocardial Infarction (TIMI) flow grade 3, residual diameter stenosis ≤ 30%, and dissection less than type C after the procedure. RESULTS Angioplasty was performed for 61 lesions with a scoring balloon and 217 lesions with a non-scoring balloon. All lesions were TIMI flow grade 3 except two lesions in the non-scoring balloon group. The scoring balloon group had a higher prevalence of residual diameter stenosis ≤ 30% (68.9% vs. 39.6%, p < 0.001), while severe dissection, defined as type C or greater, was observed less frequently (9.8% vs. 31.8%, p = 0.001). Moreover, the scoring balloon group achieved a superior rate of optimal angiographic results (60.7% vs. 28.6%, p < 0.001). In multivariable analysis, scoring balloon (OR: 3.08 [95% confidence interval, 1.47-6.58], p = 0.003) and DCB balloon-to-artery ratios (OR: 5.46 [95% confidence interval, 1.43-21.93], p = 0.014) were independent factors in the increasing rate of optimal angiographic result. CONCLUSIONS The application of a scoring balloon catheter for lesion preparation, aiming to make them suitable for DCB treatment, was associated with a decreased risk of severe dissection and a greater occurrence of optimal angiographic outcomes compared with non-scoring balloon angioplasty.
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Affiliation(s)
- Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea; (S.H.A.); (M.H.J.); (B.K.)
| | - Soe Hee Ann
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea; (S.H.A.); (M.H.J.); (B.K.)
| | - Mi Hee Jang
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea; (S.H.A.); (M.H.J.); (B.K.)
| | - Bitna Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Republic of Korea; (S.H.A.); (M.H.J.); (B.K.)
| | - Tae-Hyun Kim
- Department of Cardiology, Ulsan Medical Center, Ulsan 44686, Republic of Korea; (T.-H.K.); (C.-B.S.); (B.J.C.)
| | - Chang-Bae Sohn
- Department of Cardiology, Ulsan Medical Center, Ulsan 44686, Republic of Korea; (T.-H.K.); (C.-B.S.); (B.J.C.)
| | - Byung Joo Choi
- Department of Cardiology, Ulsan Medical Center, Ulsan 44686, Republic of Korea; (T.-H.K.); (C.-B.S.); (B.J.C.)
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Shin ES, Jun EJ, Kim B. Vascular Remodeling After Drug-Coated Balloon Treatment: Insight From Optical Coherence Tomography. Korean Circ J 2023; 53:191-193. [PMID: 36914609 PMCID: PMC10011222 DOI: 10.4070/kcj.2022.0297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/04/2023] [Accepted: 02/01/2023] [Indexed: 03/02/2023] Open
Affiliation(s)
- Eun-Seok Shin
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea.
| | - Eun Jung Jun
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Bitna Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Establishment of a Nomogram for Predicting the Suboptimal Angiographic Outcomes of Coronary De Novo Lesions Treated with Drug-Coated Balloons. Adv Ther 2023; 40:975-989. [PMID: 36583823 DOI: 10.1007/s12325-022-02400-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/01/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Factors affecting the angiographic outcomes of coronary de novo lesions treated with drug-coated balloons (DCBs) have not been well illustrated. The aim of the study is to establish a nomogram for predicting the risk of suboptimal diameter stenosis (DS) at angiographic follow-up. METHODS A retrospective analysis was performed on a cohort of patients who underwent DCB intervention for coronary de novo lesions with angiographic follow-up data. Multivariable logistic regression analysis was applied to determine the independent predictors of DS ≥ 30% at follow-up, and then a nomogram model was established and validated. RESULTS A total of 196 patients (313 lesions) were divided into the suboptimal (DS ≥ 30%) and optimal (DS < 30%) DS groups according to quantitative coronary angiography (QCA) measurements of the target lesions at follow-up. Seven independent factors including calcified lesions, true bifurcation lesions, immediate lumen gain rate (iLG%) < 20%, immediate diameter stenosis (iDS) ≥ 30%, DCB diameter/reference vessel diameter ratio (DCB/RVD) < 1.0, DCB length and mild dissection were identified. The area under the curve (AUC) (95% CI) of the receiver-operating characteristic (ROC) curve of the nomogram was 0.738 (0.683, 0.794). After the internal validation, the AUC (95% CI) was 0.740 (0.685, 0.795). The Hosmer-Lemeshow goodness of fit (GOF) test (χ2 = 6.57, P = 0.766) and the calibration curve suggested a good predictive consistency of the nomogram. CONCLUSIONS The well-calibrated nomogram could efficiently predict the suboptimal angiographic outcomes at follow-up. This model may be helpful to optimize lesion preparation to achieve optimal outcomes.
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Yang YX, He KZ, Li JY, Fu Y, Li C, Liu XM, Wang HJ, Chen ML, Su PX, Xu L, Wang LF. Comparisons of Drug-Eluting Balloon versus Drug-Eluting Stent in the Treatment of Young Patients with Acute Myocardial Infarction. J Cardiovasc Dev Dis 2023; 10:jcdd10010029. [PMID: 36661924 PMCID: PMC9865202 DOI: 10.3390/jcdd10010029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/08/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The incidence of acute myocardial infarction (AMI) in the younger population has been increasing gradually in recent years. The objective of the present study is to investigate the safety and effectiveness of drug-eluting balloons (DEBs) in young patients with AMI. METHODS All consecutive patients with AMI aged ≤ 45 years were retrospectively enrolled. The primary endpoint was a device-oriented composite endpoint (DOCE) of cardiac death, target vessel myocardial infarction (MI), or target lesion revascularization (TLR). The secondary study endpoints included heart failure and major bleeding events. RESULTS A total of 276 young patients presenting with AMI were finally included. The median follow-up period was 1155 days. Patients treated with DEBs had a trend toward a lower incidence of DOCEs (3.0% vs. 11.0%, p = 0.12) mainly driven by the need for TLR (3.0% vs. 9.1%, p = 0.19) than those treated with DESs. No significant differences between the two groups were detected in the occurrence of cardiac death (0.0% vs. 0.5%, p = 0.69), MI (0.0% vs. 1.4%, p = 0.40), heart failure (0.0% vs. 1.9%, p = 0.39), or major bleeding events (1.5% vs 4.8%, p = 0.30). Multivariate regression analysis showed that DEBs were associated with a trend toward a lower risk of DOCEs (HR 0.13, 95% CI [0.02, 1.05], p = 0.06). CONCLUSIONS The findings of the present study suggested that DEBs might be a potential treatment option in young patients with AMI. A larger scale, randomized, multicenter study is required to investigate the safety and effectiveness of DEBs in this setting.
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Kawasaki D, Nakata A, Nishian K, Nishimura M, Fujiwara R, Nakata T, Fukunaga M. Impact of Peak Systolic Velocity Ratio after Drug-Coated Balloon for Femoropopliteal Disease: Three-Month Serial Observation Vessel Echo Study. J Atheroscler Thromb 2021; 29:1352-1358. [PMID: 34588389 PMCID: PMC9444800 DOI: 10.5551/jat.63197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIM No flow-limiting dissection after drug-coated balloon (DCB) treatment for femoropopliteal (FP) lesions is considered as one of the endpoints, but it has not investigated the difference between each vessel dissection. This study aimed to clarify whether there is a difference between no dissection and type C dissection without flow-limiting dissection for 3 months by peak systolic velocity ratio (PSVR) based on duplex ultrasonography. METHODS Between February 2020 and April 2021, 44 consecutive de novo FP diseases that underwent endovascular therapy (EVT) with DCB were enrolled in this study. 65.9% of the patients had intermittent claudication, and mean lesion lengths were 194±107 mm. The chronic total occlusion was 38.6%. After DCB treatment, vessel dissection pattern was categorized by angiography. The minimum lumen area (MLA) identified by intravascular ultrasound was serially evaluated with PSVRs at 1 day, 1 month, and 3 months after EVT. RESULT All lesions were treated with DCB without provisional stents. The vessel dissection pattern after DCB treatment showed that types D, E, and F were not observed, 9% were no dissection, 27% were type A, 32% were type B, and 32% were type C. In all cases, the PSVR values of MLA site were less than 2.6 at 3 months, and there were no significant differences between no dissection and type C dissection. CONCLUSION Up to dissection pattern "C" is considered acceptable as one of the endpoints to determine the need for provisional stenting after DCB treatment.
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Affiliation(s)
- Daizo Kawasaki
- Cardiovascular Division, Department of Internal Medicine, Morinomiya Hospital
| | - Aya Nakata
- Department of Clinical Engineer, Morinomiya Hospital
| | - Kunihiko Nishian
- Cardiovascular Division, Department of Internal Medicine, Morinomiya Hospital
| | - Machiko Nishimura
- Cardiovascular Division, Department of Internal Medicine, Morinomiya Hospital
| | - Reiko Fujiwara
- Cardiovascular Division, Department of Internal Medicine, Morinomiya Hospital
| | - Tsuyoshi Nakata
- Cardiovascular Division, Department of Internal Medicine, Morinomiya Hospital
| | - Masashi Fukunaga
- Cardiovascular Division, Department of Internal Medicine, Morinomiya Hospital
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