Cutting Balloon Angioplasty — Teaching the Old Dog New Tricks!

The recent article in this issue of the Journal of Invasive Cardiology by Kawaguchi et al. continues to stimulate my fascination with cutting balloon angioplasty. I can remember when we first started using the cutting balloon on an investigational basis in the United States in about 1995. It would be an understatement to say no one believed in the concept of “atherotomy”. Surely, these razor blades would “filet” the artery in two or four different pieces! Perforations would be unacceptably high, and no one in their right mind would dare to use something so high-profile and so sharp. Well, I guess we have come a long way from those early years of skepticism, to a point where most interventional cardiologists actually believe this technology is applicable to real world angioplasty. See Kawaguchi et al. on pages 515–519 If there is one thing we have learned after 22 years of PTCA, it is that restenosis is a complex and still mysterious process.1 Our understanding of the morphologic changes has long been known. How to modify the healing is another story. Stents have altogether eliminated the “recoil factor” in this equation, but has, in turn, exaggerated the neointimal response. I applaud the authors of this article, because they have systematically and quantitatively confirmed what I have observed clinically in my seven years of cutting balloon angioplasty. In others words, cutting balloon angioplasty reduces recoil by doing more cutting and less tearing. Past studies have documented the mechanisms of conventional balloon angioplasty.2 Fissuring, dehiscence, disruption and stretching of the plaque and the relatively non-diseased segment have been well documented. Much more needs to be done to further understand this newer technology: • Does cutting balloon angioplasty reduce smooth muscle infiltration by doing less tearing of the external elastic lamina? • Does cutting balloon angioplasty reduce restenosis by promoting more symmetrical expansion of fibrodense eccentric plaques? • When used in conjunction with stents, is pre-dilatation cutting balloon angioplasty better, worse or no different than direct stenting or POBA pre-dilatation? • Can the “cut and drug infiltration” technique rival the up and coming drug-coated stents? All of these questions are ones I never thought of until the last two or three years. I do know that nearly the entire interventional community has embraced this technology with cautious enthusiasm. Where does cutting balloon angioplasty work? The “short” of it is that anywhere that stents have shortcomings, one should consider cutting balloon angioplasty! The “long” of it is the following: • Ostial bifurcation lesions (Less recoil); • Smaller vessels not suitable for stenting; • Fibrodense plaques requiring severe barotrauma with POBA; • Spot stenting in diffuse disease; • Proximal or distal bypass graft lesions; • Peripheral applications (infrapopliteal, renal, carotid) Although I cannot assuredly say these indications are accurate, they have served me well over the past several years. Cutting balloon angioplasty has added a new weapon for several of these commonly encountered anatomic situations. With the advent of drug-eluting stents, I anticipate the entire treatment paradigm for coronary artery disease to change radically. Much of our present technology will literally “go by the wayside”. I doubt if cutting balloon angioplasty will have that fate because of it is utility as a viable stent substitute. Combine it with drug infiltration and you may have something! The “old dog” (elastic recoil) just got a new lesson. Can we learn from it and teach that “old dog” newer tricks?

1. Zarins CK, Lu CT, Gewertz BL, et al. Arterial disruption and remodeling following balloon dilatation. Surgery 1982;92:1086–1095. 2. Waller BF. Crackers, breakers, stretchers, drillers, scrapers, shavers, burners, welders and melters — The future treatment of atherosclerotic coronary artery disease? A clinical morphologic assessment. J Am Coll Cardiol 1989;13:969–987