1977 : Andreas Grüntzig’s made history and stunned the world by opening up a coronary stenosis with a hand made balloon in his now iconic Zurich cath lab .No stent, no drugging. It was called POBA then. His famous patient had a patent coronary artery for the next 18 years. This is the beginning of the era of PTCA. By 1990s stents were made almost mandatory fearing reocclusion. They were bare metals then . By year 2002, stents were drugged to prevent restensois. That was the era of DES. The bare metal stents died a premature death. Curiously, by mid 2010, DES also became a suspect , Bio absorbable scaffold came in (A short lived self demising stent) It got into serious problem of patchy reabsorbtion and prohibitive events.Thus,again DES became the undisputed tool in PCI.
Fast-forward to 50 years: Some good samaritans decided to take on the fight with stents , and are trying to restore the bygone, balloon era now.But, they didn’t have courage to use Gruntzig’s POBA. They wanted something more. It came in the form of DEB. Now, it has become omnipresent. Suddenly, even in complex lesions including left main, bifurcations, ACS, and distal lesions, DEBs are rendering stents as “enemy.”
The real question to the cardiology community should be this . Is DEB truly revolutionary, or is it just a DOBA (drug-on-balloon angioplasty) a plain old balloon angioplasty (POBA) with a false crown ?
Logically and realistically ,every DEB transforms into POBA within 24 hours as the anti-proliferative drug dusted over the coronary lesion get washed away. There may be a dozen studies , that vouch for the DEB’s ability to prevent restenosis. But , the true efficacy of the DEB-PCI is accrued from the “B not from the D”. What we require is , an astute , discrete balloon dilatation at the right place and time. Yet in India, we have fallen for the DEBs that cost ₹3,0000 more to shed its metal jacket.
Final message
DEB has some evidence for benefit only in ISR. There is no single large one to one study that compared POBA vs DEB in denovo coronary lesions.So,the apparently provocative title of this post, is largely a fact.
False science coated with commerce can be as addictive as a narcotic. The cardiology community is experiencing this on a regular basis. At the least, one must realise this , forget about coming out of it.
Post-amble
Distal D-Wash after a POBA a perfect new PCI
A cheaper ,unconventional coronary intervention is proposed by the author, called Distal D wash. After performing a POBA over an intermediate lesion, push and inflate the same balloon distally to the maximum in the RCA/LAD, inject sirolimus locally with a dwell time of 1-2 minutes to allow a rinse*. This method could treat not only the lesion and protect entire vessel from future atherosclerosis , at a fraction of the cost of DEB.(A truly cranky Idea, but might be perfect for a new start up)
*Like surgeons wash the wounds while dressing with mixture of antibiotics etc.
Dr.S.Venkatesan MD 