Drug-eluting balloon versus second-generation drug-eluting stent for the treatment of restenotic lesions involving coronary bifurcations

Selected in EuroIntervention by S. Brugaletta

References

Authors

Naganuma T, Latib A, Costopoulos C, Oreglia J, Testa L, De Marco F, Candreva A, Chieffo A, Naim C, Montorfano M, Bedogni F, Colombo A

Reference

EuroIntervention. 2015 Nov 22;11(8):793-8

Published

22 January 2016

Link

Read the abstract

My Comment

What is known 

Percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) is associated with high rates of recurrent restenosis and repeat revascularisation. Although drug-eluting stents (DES) are currently considered the default approach for ISR, previous papers have reported that drug-eluting balloon (DEB) use for BMS-ISR is feasible and effective, as compared with uncoated balloon or paclitaxel-eluting stents. DEB for ISR at bifurcations can be a beneficial and attractive approach in order to suppress further neointima growth and avoid further metal layers. The aim of this study was to evaluate clinical outcomes following treatment with DEB for bifurcation ISR, as compared to second-generation DES. 

Major findings 

  • Between February 2007 and November 2012, 167 bifurcation ISR in 158 patients were treated with either DEB (n=73) or second-generation DES (n=85).
  • The EuroSCORE was significantly higher in the DEB group (4.2±3.8 vs. 2.8±2.1, p=0.004). Regarding restenosed stent type, second-generation DES was more frequently seen in the DEB group (26.9% vs. 6.7%, p<0.001).
  • Over a median follow-up period of 701 days, there was no significant difference in major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction including periprocedural myocardial infarction, target vessel revascularisation, between the two groups (p=0.585).
  • Independent predictors of MACE on multivariate Cox regression analysis included stent-in-stent (HR: 2.16; 95% CI: 1.11 to 4.20; p=0.023) and true bifurcation lesions (HR: 2.98; 95% CI: 1.45 to 6.14; p=0.001). 

My comment

The use of DEB is currently increasing especially for the treatment of ISR. Overall, in the treatment of ISR, the interventional cardiologist should keep in mind that the use of DEB in this context reduces the amount of metal, potentially reducing events related to the excess of metal, such as thrombosis. In addition, the treatment of a restenosis either with a DES or with a DEB should be based on identification of the restenosis cause by means of an intracoronary imaging technique, which use should be encouraged: in this sense a stent under-expansion or malapposition as cause of restenosis could be better treated by a DEB than a DES. DEB use and value in bifurcational ISR has not been investigated previously. The present study suggests that DEB for bifurcation ISR may be an acceptable treatment option, with good results at 2-year follow-up, despite a worse Euroscore.
Some points are open for discussion within the community. Firstly, which DEB should be used? It is well known that DEBs differ a lot from each other so a class effect cannot be generalized. Secondly, is ISR of the side branch better treated by DEB than ISR of the main branch? Please share your opinion.

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