Lesion Prep Treatment Strategies for Complex Cases

Meet coronary artery disease (CAD) with precise plaque modification.

No two lesions are the same

More patients are presenting with advanced disease and comorbidities.¹ Common challenges include bifurcation, severe calcium, and in-stent restenosis (ISR). Effective lesion preparation is crucial for optimal outcomes.

Chart: A 12-year study analyzing PCI procedures (N = 20,301) reveals a significant rise in complex PCI procedures (5,647, 27.8% of total cases), primarily driven by interventions for bifurcations and left main arteries (P < 0.01).

See the data

Optimal treatment for calcified lesions is necessary

Over 30% of patients treated for PCI in the United States have some degree of calcium, a 31% increase over the last two decades.² Calcium can make it difficult to dilate the artery, leading to complications such as dissection, inadequate stent expansion, and stent malapposition. Patients with moderate to severe calcium have a significantly higher risk of complications, including:

PRE-PCI

Dissection during balloon angioplasty or pre-dilation³

Balloon dog boning³

PERI-PCI

Prevention of stent delivery of target lesion⁴

Stent under expansion or deformation⁵

POST-PCI

Insufficient drug penetration⁶

Subsequent restenosis⁶

A simplified calcium solution

The Calcium Lesion Modification Strategy (CLMS)⁷ is a simplified and highly effective approach to modifying calcific lesions. Based on proven research and clinical evidence, and vetted by expert interventional cardiologists, the CLMS is built on three key components shared by successful calcium algorithms:

Download a copy of CLMS (PDF)

IMAGE

Examine the lesion's severity and location using intravascular ultrasound (IVUS).

ASSESS

Utilize IVUS imaging to determine lesion morphology to help inform device selection.

MODIFY

Select the optimal therapy to effectively modify the lesion.

A step-by-step guide

If the device does not pass, treat with rotational atherectomy. If the device passes or the vessel is undilatable (1:1 size), begin to IVUS.

Measure: lesion location (ostial; establish lesion length and define landing zones), plaque morphology (arc: <270° vs. >270°; extent of disease: focal vs. diffuse), and vessel size MLD (<2mm vs. > 2mm).

If larger MLD device delivers eccentric arc <180°: modify calcium with a Cutting Balloon, if a smaller MLD ostial/diffuse preferred concentric arc >270°: modify calcium with Rotational Atherectomy; if a larger MLD ostial/focal preferred concentric arc >270°: modify calcium with Intravascular Lithotripsy.

See clearly to prep precisely

Using HD IVUS in every case allows for precise visualization, aiding in faster healing, better procedural efficiency, and stronger long-term outcomes.

Key lesion features:

The ability to identify key lesion features is a critical component of your imaging and treatment decision-making process. By understanding these depth, arc, and thickness characteristics, you can leverage HD-IVUS findings to guide treatment decisions for optimal patient outcomes.

To learn more, visit IVUS 123 Essentials, a step-by-step guide to interpret images and simplify IVUS workflow.

Tips for ISR prep before drug-coated balloon (DCB) treatment

Before proceeding with a DCB treatment for ISR lesions, ensure success by asking yourself these crucial questions:

Neointimal modification: Has the neointimal tissue been adequately addressed? (Figure A)
Calcium modification: Is the calcium burden appropriately modified? (Figure B)

Confidently proceed with DCB delivery when these criteria are met:

Angiography: Ideally, less than 30% residual stenosis should be observed
Flow: No significant flow-limiting dissection should be present on angiography
Intravascular imaging: Adequate lumen area is confirmed using IVUS or OCT (goal: minimum stent area ≥ 80% of the distal reference)

By incorporating these key steps, HD IVUS empowers you to make informed treatment decisions and optimize patient outcomes. Dive deeper into your treatment approach with Drug-Coated Balloons (DCBs).

Have the right tools for lesion-centric prep

Do you need to crack, cut, debulk, or abate? You must match method to morphology. How a prep therapy interacts with a lesion directly influences the efficacy and safety of the procedure. Prep toolkits must include a variety of tools to consistently facilitate optimal stent deployment on a case-by-case basis.

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