By Bernardo Cortese
In the last decade, substantial effort has been made to ease the delivery of drug-coated balloons—especially because we now understand that device delivery does not automatically warrant drug delivery. With the first-generation drug-coated balloons, we often had to deal with devices that had paclitaxel “sprinkled on”. While we may have been able to deliver a device to the lesion, we were not always sure how much drug we actually delivered. Fortunately, because of this problem, there have been huge improvements to drug-coated balloon technology. However, certain “tricks” are needed to achieve optimum results with drug-coated balloons.
Firstly, you have to plan the percutaneous coronary intervention (PCI) in depth and consider eventual proximal tortuosities, calcifications and lesions. Secondly, you have always to prepare your lesion. I recommend using a semi-compliant balloon because they are better than the non-compliant balloons at showing how the lesion reacts to dilation (20 seconds is usually sufficient). The measure of the balloon should be in the range of -0.5/-0mm of the drug-coated balloon you want to use. Downgrade to a stent if you observe a large flow-limiting dissection, but otherwise—even in the case of a small (type A-C) dissection—use your preferred choice of drug-coated balloon (there is a vast amount of drug-coated balloons on the market in Europe, but that is another story!).
The device requires careful handling from the moment that it is taken out of its packaging—do not attempt to touch the drug or try to scratch it, which I have actually seen happen! Also, be careful when crossing the Y-connector and navigating through the guiding catheter and, therefore through the proximal parts of the coronary artery, up to the lesion. Once you have reached the lesion, I suggest a gentle inflation that should be increased step-by-step up to the nominal pressure (or even a little bit more) and keeping at that pressure for a while. Many ask for how long. I answer it depends.
For drug delivery, 30 seconds are always enough with current devices. However as you do not want to have big dissections or vessel recoil, sometimes—especially in native calcific or fibrotic vessels—two minutes may be necessary.
The rate of stenting should be kept low (below 10%) for the following reasons: data for bare metal stents are not good; data for drug-eluting stents are insufficient, and you do not want to denaturalise the drug-coated balloon technology by putting metal on. However if stenting is required, you should always avoid geographical mismatch—ie. putting metal into the coronary lesion that has been pre-treated with paclitaxel.
Before assessing the final result, take a moment to relax. PCI with a drug-coated balloon is not the same as PCI with a stent—you have to wait for 5–10 minutes before removing the guidewire because acute vessel recoil—although rare—can still occur. In my view, these “tips and tricks” are all you need to know about drug-coated balloon angioplasty. Trust me, it is a matter of philosophical adaptation and time, but finally drug-coated balloon-angioplasty will conquer you!