A Closer Look at Stentless Angioplasty: Who Should Consider It and Why? – Expert Insights by Dr. Mayur Jain
Overview
In Part 1 of this series, we explored the basics of stentless angioplasty, the procedure itself, and its long-term benefits. Now, in Part 2, we explore the advantages, indications, and contraindications of this innovative procedure in greater depth.
In this conversation with The Aartery Chronicles (TAC), Dr. Mayur Jain, a leading cardiologist and director of Gene Crucial Cardiac Care and Super Speciality Hospital, shares his insights on the ideal patient populations for stentless angioplasty and the potential risks and challenges associated with the technique.
With over 14 years of experience in cardiology, Dr. Jain brings a wealth of knowledge to the field. He completed his MBBS, MD, and DM at JJ Hospital and Jain Medical College in Mumbai and further honed his expertise by training in structural heart disease and complex angioplasty at Fluid Clinic in Ohio, USA. Additionally, Dr. Jain has undergone multiple training sessions in Transcatheter Aortic Valve Implantation (TAVI).
In this segment, he discusses the prognosis of patients following stentless angioplasty and presents a real-world case study to highlight the procedure’s effectiveness. This comprehensive conversation provides a nuanced understanding of stentless angioplasty and its growing role in modern cardiac care.
Advantages of Stentless Angioplasty
Dr Mayur Jain highlighted several key benefits of stentless angioplasty over traditional stent placement:
1. Minimally Invasive: Dr Jain explained that the procedure involves a small incision, usually just 3-4 mm in diameter, making it less invasive compared to stent placement, which involves inserting a metal device into the artery.
2. Shorter Duration of Blood Thinners: Dr Jain elucidated that following traditional angioplasty, patients must take blood thinners for at least a year to prevent blood clots from forming around the stent. With stentless angioplasty, blood thinners can be discontinued after about 3 months. This is especially beneficial for patients who are at high risk of bleeding, such as those with bleeding disorders or elderly individuals.
3. Preserving Artery Motion: Stentless angioplasty helps maintain the natural vasomotion of the arteries. Arteries naturally expand and contract, but placing a stent can disrupt this motion. By using a drug-coated balloon instead of a metal stent, the normal function of the artery is preserved, reducing the risk of re-stenosis (the artery becoming blocked again).
- Effective for In-Stent Restenosis: Dr. Mayur Jain pointed out that one of the most important applications of drug-coated balloons is in cases where a blockage develops within a previously placed stent. This condition, known as “in-stent restenosis,” occurs in about 8-12% of patients who have undergone angioplasty with stent placement. In such cases, the drug-coated balloon helps reduce this risk without the need for another stent.
Indications for Stentless Angioplasty
Dr Mayur Jain explained that stentless angioplasty is particularly indicated for specific patient populations, as it offers significant benefits in certain circumstances:
- Young Patients:
Dr. Jain emphasized that stentless angioplasty is especially beneficial for younger individuals. This procedure is indicated for young patients because it avoids long-term stent placement, which can help preserve normal arterial function over time. As these individuals are expected to live many more years, stentless angioplasty helps prevent long-term complications associated with permanent stent placement. - Elderly Patients:
Dr. Jain also highlighted a common challenge with traditional stent angioplasty in elderly patients. After undergoing stent placement, these patients may require additional surgeries like knee replacements or may develop fractures, which complicates the management of blood thinners. If blood thinners are stopped too soon, there is a risk of stent thrombosis (blood clots forming in the stent), which could lead to a heart attack. On the other hand, continuing blood thinners for too long can cause bleeding complications. In these cases, stentless angioplasty is indicated as a safer and more manageable option, minimizing risks related to blood thinner management and preventing complications.
Contraindications for Stentless Angioplasty
Despite the benefits, there are specific contraindications for the use of drug-coated balloons. Dr Jain explained that it is important for the operator to have enough experience to identify when it is not suitable to use them. Here are some key contraindications:
- Highly Calcified Arteries:
The success of a drug-coated balloon procedure largely depends on the preparation of the “bed,” meaning the proper dilatation of the blockage area. If there is a significant amount of calcium in the arteries, it may be difficult to achieve adequate dilation, even after cracking the calcium. In such cases, the patient may not be a good candidate for the drug-coated balloon. - Dissection After Balloon Angioplasty:
Before using a drug-coated balloon or stent, the artery is often dilated with a simple non-drug-coated balloon. If, after this dilation, the artery experiences a dissection (a tear or split in the arterial wall), the degree of dissection must be evaluated. The artery has three layers, and if the dissection is more than grade C (on a scale from A to F), it is generally not recommended to use a drug-coated balloon. - Acute Coronary Syndromes (ACS):
In acute coronary syndromes, where there are a lot of blood clots present, there is not enough clinical trial data to confirm that drug-coated balloons are safe in these situations. Therefore, extra caution is required when considering their use for patients with ACS. However, ongoing trials are expected to provide more data on the use of drug-coated balloons in ACS within the next 2-3 years. - Left Main Coronary Artery:
In India, the use of drug-coated balloons in the left main coronary artery, which divides into the left anterior descending (LAD) artery, is still not common practice. However, there is encouraging data from the US showing that drug-coated balloons have been used successfully in the left main artery with excellent results.
Case Studies and Treatment Outcomes
Over the past six months, Dr. Jain and his team have completed more than 50 procedures, treating a diverse mix of patients, including those with acute coronary syndrome and complex vascular issues. A key focus of their treatment approach has been the use of drug-coated balloons, a less invasive alternative to traditional stent placement.
Case Study 1: A 40-Year-Old Lady with a Strong Family History of Amputation
Dr Jain recalled a case of a 40-year-old woman who presented with a strong family history of amputations related to cardiovascular disease. In her case, she had only one blockage at the LAD osteum, while the rest of her coronary arteries were normal. Despite the genetic predisposition, the limited nature of her disease prompted Dr. Jain and his team to opt for a drug-coated balloon instead of a stent.
According to Dr. Jain, using a stent, in this case, would have involved placing it from the left main to the LAD, potentially causing a decrease in blood flow due to plaque shift or stent strut interference. The plaque shift could lead to further blockage at the circumference of the artery, while the stent struts could obstruct the opening of the vessel, reducing blood flow. This scenario could also result in long-term complications, as side branches may become problematic over time by developing stenosis, thus requiring additional interventions.
In such situations, Dr. Jain emphasized that a drug-coated balloon (DCB) provides an ideal alternative. Unlike stents, which can lead to long-term complications, DCBs are effective in reducing plaque buildup without causing issues at the side branches or the vessel’s opening.
Case Study 2: 68-Year-Old Woman with Severe Calcification
Dr. Jain also highlighted the importance of advanced technologies such as intravascular ultrasound (IVUS) in treating complex cases. One such case involved a 68-year-old woman with severely calcified coronary arteries and compromised renal function (haemoglobin of 8 and creatinine of 4). In this situation, Dr. Jain and his team utilized IVUS technology to evaluate the extent of the calcification and determine the most suitable treatment approach.
Given the severity of the calcification, Dr. Jain and his team resorted to multiple balloon options, including cutting balloons, intravascular lithotripsy (IVL) balloons, and ostial post-dilatation (OPN) balloons, to crack the calcium and achieve an adequate result. While the result was moderate rather than optimal, Dr. Jain pointed out that placing a stent in such a case could have led to mal-opposition, where the stent does not open uniformly. This could cause even more harm than leaving the artery untreated.
In this case, a drug-coated balloon was chosen to treat the blockage, and the patient showed good progress. Dr. Jain noted that the patient’s condition remained stable, with her creatinine levels unchanged. She was expected to be discharged the following day. The procedure was also done without contrast, thanks to the use of IVAS technology, which enabled the team to guide the procedure safely.
The Role of Imaging Technology in DCB Procedures
Dr. Jain emphasized the importance of advanced imaging technologies, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT), in the use of drug-coated balloons. These technologies help doctors assess the condition of the arteries, determine the extent of blockages, and optimize treatment outcomes.
He shared an example where a 38-year-old male patient with an 80% lesion in the left anterior descending (LAD) artery underwent angioplasty using a drug-coated balloon with the assistance of OCT (Optical Coherence Tomography). OCT is an advanced imaging technology that provides highly detailed images of the artery, helping doctors make precise decisions during procedures. In this case, using OCT enabled the team to create optimal cuts in the intima up to the media layer of the artery, ensuring better drug delivery into the artery’s medial layer.
Dr. Jain noted that recent studies, including one published in December 2024, have demonstrated that using OCT-guided medial cuts before deploying a drug-coated balloon significantly improves long-term results compared to procedures where imaging is not used.
Prognosis and Follow-Up
When asked about the prognosis for patients who undergo drug-coated balloon procedures, Dr. Jain explained that most patients are discharged either the next day or after two days, provided the angiography results are satisfactory. He emphasized that imaging technology is essential for ensuring optimal results with drug-coated balloons and that physicians need to be well-trained in using IVUS and OCT for these procedures.
Looking ahead, Dr. Jain and his team are planning follow-up angiographies for their patients who have received drug-coated balloon treatment, aiming to learn more about how Indian patients respond to this technology over time. This ongoing research will help refine treatment strategies and improve patient outcomes.
Conclusion
Dr Mayur Jain’s insights highlight the growing role of drug-coated balloons in the treatment of coronary artery disease, particularly in complex or high-risk cases where traditional stents may not be ideal. By combining advanced imaging technologies like IVUS and OCT with drug-coated balloon therapy, his team can provide patients with safer, more effective treatments, improving both short-term and long-term outcomes. As research continues and follow-up data is gathered, the role of drug-coated balloons in coronary interventions is likely to expand, offering new hope for patients with challenging cardiovascular conditions.
