Bioresorbable Scaffold With Drug-Coated Balloon: A “Biodegradable” Model for Bifurcation Lesions Treatment. The New Intriguing Chapter of the “Leaving Nothing Behind” Saga




Still today, bifurcation PCI represents a challenge and complex setting for interventionists. Above all, final kissing balloon inflation (KBI) is yet strongly debated. Provisional T-stenting approach with final KBI to dilate side branch (SB) is the most adopted technique worldwide, safer and more efficacies than 2-stent technique with or without final KBI that is afflicted by a higher risk of instent restenosis and stent thrombosis. Even newer drug-eluting stent (DES) has a not negligible rate of failure for SB angioplasty, in this light here we may perform further considerations.


Intravascular imaging guidance for bifurcation PCI may provide helpful information for optimal SB treatment, in fact, preprocedure intravascular ultrasound provides useful information for residual stenosis at SB ostium after KBI. Moreover, according the Japanese Registry Study in Comparison Between Everolimus-Eluting Stent and Sirolimus-Eluting Stent for the Bifurcation Lesion (J-REVERSE) registry, final KBI is associated with increased SB dissection but greater luminal gain in the proximal main vessel (MV) and SB with a little major incidence of major adverse cardiac event rate respect to non-KBT treatment up to 9-month follow-up. Furthermore, high-pressure final KBI, mandatory in case of 2-stent technique, could cause an increase of periprocedural myocardial infarction.


In this setting, some investigators have investigated a novel strategy without KBI at bench test, comprising initial proximal optimizing technique (POT), then side branch inflation and final POT, called “re-POT” that have shown more effectively than KBI to optimize the final result of provisional coronary bifurcation stenting.


In this scenario, drug-coated balloon (DCB) represents an intriguing solution for SB PCI. In fact, according BIOLUX I study ​ (paclitaxel-eluting balloon and everolimus-eluting stent for provisional stenting of coronary bifurcations), bifurcation angioplasty with everolimus-eluting stent deployment on MV and DCB on SB appears to be a novel way of treatment, safe and effective even at 1-year follow-up. Important to underline is the predilatation of both branches, postdilatation of MV stent deployment and final KBI was routinely performed. Stenting on SB was deployed in case of prolonged ischemia due to SB complication, Thrombolysis In Myocardial Infarction grade flow 0 or 1, dissection in the SB, and >70% residual stenosis.


An intriguing solution seems to be a “biodegradable bifurcation PCI.” In our own experience, we use biovascular resorbable scaffold (BVS) on MV with final KBI using DCB on SB. To the best of our knowledge, our group was the first to report this new provocative strategy for bifurcation lesions treatment. Here, we would like to suggest this new safe and feasible way to treatment of these challenging settings based on literature review and our own experience.


The technical rationale once absorbed BVS is to attempt the restore of “neo-carina” and native coronaries anatomy with improvement of hemodynamic factors and blood flow on SB contrary to DES that permanent obstruct the flow because of metallic struts obstruction. Moreover, the advantages of DCB respect DES implantation on SB is that eternal metal prosthesis can be avoided and, in case of failure of SB angioplasty, DCB can be used multiple times for recurrent restenosis. Again, in cases of a coronary vessel non–flow-limiting dissection, DCB angioplasty may be leave without stent deployment.


In conclusion, there is not clear and univocal results about the effective bifurcation PCI treatment and better technique and further trials are needed. In this light, everolimus-eluting stent on MV with DCB on SB seems an intriguing and safe treatment performing, but “biodegradable bifurcation PCI” with BVS on MV and final KBI with DCB on SB may represent “the kiss of true love” as an interesting and nontraumatic solution with native anatomical vessels restoration in contraposition to 2-stent technique that could symbolize “Judas kiss” due to higher SB angioplasty failure.


References



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Nov 25, 2016 | Posted by in CARDIOLOGY | Comments Off on Bioresorbable Scaffold With Drug-Coated Balloon: A “Biodegradable” Model for Bifurcation Lesions Treatment. The New Intriguing Chapter of the “Leaving Nothing Behind” Saga

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