Percutaneous Coronary Intervention in the Elderly: Are Drug-coated Balloons the Future?

Abstract

Background: Balloon angioplasty revolutionised percutaneous treatment for coronary artery disease four decades ago, but vessel-threatening dissections, elastic recoil and restenosis were major drawbacks to an otherwise successful long-lasting intervention. Subsequent advances with bare metal stents and then drug eluting stents followed, aiming to mitigate the risks of acute vessel closure and restenosis. However, stent implantation often necessitates dual antiplatelet therapy for a prolonged period of time, which in itself can lead to adverse outcomes, especially in the frail elderly population at higher risk of bleeding. More recently, bioabsorbable stents have been implemented in clinical practice enabling earlier intimal coverage of the stent and apposition. However, another addition to the armamentarium of percutaneous coronary intervention is the use of drug-coated balloons without the need for deploying any coronary stents or scaffolds. Drugcoated balloons are semi-compliant balloons coated with an antiproliferative agent that is rapidly released on contact with the vessel intima exerting an anti-restenotic effect. The absence of a metallic scaffold means that the need for antiplatelet therapy can potentially be negated in the longer term if required. In this article, we will review the history of percutaneous coronary intervention and the available evidence for the appropriate use of drug-coated balloons especially in the elderly population.

Conclusion: We will conclude this review by demonstrating the potential use of drug-coated balloon rather percutaneous stenting through case examples.

Keywords: Coronary artery disease; drug-coated balloons; elastic recoil; elderly; restenosis.; vessel-threatening dissections.

Fig. (1)

Coronary angiograpghy in a patient with stable angina showing significant calcific LAD disease (panel A, arrow) which was treated with DCB showing immediate (panel B) result and result at six months (panel C).

Fig. (2)

A patient with severe circumflex lesion (panel A, arrow) was treated with DCB in view of bleeding history showing good result post DCB (panel B) and at 42 months (panel C).

Fig. (3)

shows an occluded LAD (panel A, arrow) which was treated with DCB with good result (panel B during procedure, panel C post-procedure) which was maintained 3 months later when the patient returned for a staged procedure to his by-stander circumflex disease.