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UC UC SF SF Disclosures: None Vessel Preparation is the Key - PowerPoint PPT Presentation

Dec 07, 2022 •529 likes •594 views

UC UC SF SF Disclosures: None Vessel Preparation is the Key Step For Successful DCB Revascularization Shant M. Vartanian, MD Assistant Professor of Surgery Division of Vascular and Endovascular Surgery VASCULAR SURGERY UC SAN

  1. UC UC SF SF Disclosures: • None Vessel Preparation is the Key Step For Successful DCB Revascularization Shant M. Vartanian, MD Assistant Professor of Surgery Division of Vascular and Endovascular Surgery VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Biology of Restenosis DCB Drug Delivery • Avoids metal/polymer induced restenosis • May distribute antiproliferative more homogenously than other methods • ~20% lost on the way to the target • Deposit ~20% at the target • Collect ~20% on balloon retrieval • ~40% is lost downstream as particulate Waksman R, Pakala R. Drug-eluting balloon: the comeback kid? Circ Cardiovasc Interv. Lippincott Williams & Wilkins; 2009 Aug;2(4):352–8. VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 1

  2. UC UC SF SF Principles of DCB Why Vessel Preparation • Semi-compliant balloon • Excipient with an anti- neoproliferative agent (paclitaxel) • Excipient allows for delivery of lipophilic paclitaxel to media and adventitia • Fractures and fissures in the plaque facilitate drug delivery to media and adventitia VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Why Vessel Preparation Balloon Angioplasty • 74 patients • Change compliance of the lesion • Randomized PTA of 30 sec vs. 180 sec - Long inflation time • Femoropopliteal lesions - Multiple inflations - Gentle balloon inflation gives time for the vessel to adapt to • Similar mix of occlusions, stenosis and lesion the balloon length • Prevent elastic recoil Zorger N, Manke C, Lenhart M et al. J Vasc Interv Radiol. 2002 Apr;13(4):355–9. • Prevent dissection VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 2

  3. UC UC SF SF Balloon Angioplasty Why Vessel Preparation • Change compliance of the lesion - Long inflation time - Multiple inflations - Gentle balloon inflation gives time for the vessel to adapt to the balloon • Prevent elastic recoil Zorger N, Manke C, Lenhart M et al. J Vasc Interv Radiol. 2002 Apr;13(4):355–9. • Prevent dissection VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF DCB Trials Calcium and Drug Delivery • 60 de novo SFA lesions treated with DCB • Stratified results by circumferential distribution of calcium • Calcium scoring method combined CTA, Fluoro and IVUS findings Fanelli F, Cannavale A, Gazzetti M, Lucatelli P, Wlderk A, Cirelli C, et al. Cardiovasc Intervent Radiol. Springer US; 2014 Aug;37(4):898–907. VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 3

  4. UC UC SF SF Calcium and Drug Delivery Methods of Vessel Preparation • Balloon Angioplasty • Atherectomy - Directional - Rotational • Cutting Balloon • Scoring Balloon Fanelli F, Cannavale A, Gazzetti M, Lucatelli P, Wlderk A, Cirelli C, et al. Cardiovasc Intervent Radiol. Springer US; 2014 Aug;37(4):898–907. VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Future Directions Future Directions • Turbohawk/Silverhawk atherectomy • Bayer Paccocath DCB • Stenosis, restenosis or occlusions • Lesion length 7-15 cm • Randomized 102 patients • Registry arm for severly calcified lesions that were • Directional atherectomy + DCB vs DCB alone exclusion criteria for randomization (n = 19) • Multicenter randomized trial Waksman R, Pakala R. Drug-eluting balloon: the comeback kid? Circ Cardiovasc Interv. Lippincott Williams & Wilkins; 2009 Aug;2(4):352–8. Waksman R, Pakala R. Drug-eluting balloon: the comeback kid? Circ Cardiovasc Interv. Lippincott Williams & Wilkins; 2009 Aug;2(4):352–8. VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 4

  5. UC UC SF SF Future Directions Future Directions Waksman R, Pakala R. Drug-eluting balloon: the comeback kid? Circ Cardiovasc Interv. Lippincott Williams & Wilkins; 2009 Aug;2(4):352–8. VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO UC UC SF SF Is Vessel Preparation Necessary? Conclusions • No vessel preparation steps in European IFU • Vessel prep facilitates delivery of drug to the target lesion • Prep the vessel in ways that maximize luminal gain with the least amount of trauma - Long inflation times • Lesions that are the most difficult to prep are the least likely to do well with DCB • New avenues of clinical research examining other means of vessel prep before DCB VASCULAR SURGERY • UC SAN FRANCISCO VASCULAR SURGERY • UC SAN FRANCISCO 5

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