An alternative strategy for coronary artery lesions with an extra-large reference diameter using a perfusion balloon

Although drug-eluting stents (DES) have dramatically reduced the target vessel revascularization in contemporary percutaneous coronary interventions (PCI), revascularization to a lesion with an extra-large reference diameter is still challenging. Since the maximum size of DES is limited to 4.0 mm in Japan, stent malapposition would be inevitable if we used a DES for a lesion with a reference diameter of ≥ 5.5–6.0 mm. The stent-less strategy such as the drug-coated balloon (DCB) following scoring balloon dilatation may be a good substitute for lesions with an extra-large reference diameter. However, bailout stenting is sometimes necessary even in the planned stent-less strategy [1]. Therefore, further refinements and discussions are needed for such lesions. In this case report, we show the utility of the perfusion balloon for lesions with an extra-large reference diameter.
An 80s-year-old man was referred to our hospital for PCI. Coronary angiography showed a stenosis in the proximal segment of the right coronary artery (RCA), which had an extra-large reference diameter (Figure 1 A). Intravascular ultrasound (IVUS) revealed that the proximal reference diameter, the minimum lumen diameter and distal reference diameter were 5.3 mm, 2.3 mm, and 6.7 mm, respectively (Figures 1 B–D). We performed a prolonged period of balloon dilatation to the lesion for 10 min using a 4.0 × 20 mm perfusion balloon with 6 atm (Ryusei: Kaneka, Osaka, Japan) (Figures 1 E, F). After 10 min of dilatation, a sufficient lumen area was obtained without significant dissections (Figure 1 G). After an additional 10 min of observation, we finished the procedure without DES or DCB (Figure 1 H). After 6 months, follow-up coronary angiography revealed good patency of the lesion (Figure 1 I).
The perfusion balloon has been used as a bailout device in cases of vessel perforation, occlusive dissections, and thrombotic occlusions [2]. A unique characteristic of the perfusion balloon is to maintain blood flow during balloon inflation, which allowed us to perform a prolonged period of balloon dilatation for 10 min. Recently, Horie et al. reported that prolonged balloon dilatation (7.8 ±2.7 min) was inversely associated with severe dissection in the revascularization of femoropopliteal lesions [3]. However, unlike femoropopliteal lesions, such prolonged inflation to coronary lesions is difficult to perform except by perfusion balloon. Although we obtained an optimal result, we should...


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