Cutting balloon ascending.

Catheterization and Cardiovascular Interventions 54:482– 483 (2001) Editorial Comment Cutting Balloon Ascending Jonathan Tobis, MD Interventional Cardiology Research, UCLA School of Medicine, Los Angeles, California Andreas Gruntzig recognized the paradox inherent in inflating a balloon under high pressure within an atherosclerotic artery. He cautioned that the key for a successful angioplasty was to find a way of “balancing optimally, arterial dilatation and arterial damage.” Although balloon dilatation often was successful, he realized that the results were also unpredictable because the mechanical characteristics of the plaque were variable. This could lead to excessive tearing where the plaque could be ripped from its adhesion with the media. A large dissection might occlude the lumen. Barath et al. [1] addressed this paradox by suggesting that razor-sharp blades, bonded along the length of an angioplasty balloon, could act to score the plaque and produce a more controlled cut. There are now several studies to suggest that the initial results with the cutting balloon are superior to those obtained with balloon dilatation alone (also referred to as plain balloon dilatation)[2–4]. In the majority of cases, the subsequent deployment of a coronary artery stent makes the use of a specialized (and expensive) cutting balloon unnecessary. However, there are several situations where the use of the cutting balloon appears to offer significant technical ad-vantages over plain balloon dilatation. First, the cutting balloon does not squeeze out of an arrowed arterial segment in a manner that has been described gastronomically as watermelon seeding. This can be a frustrating situation with plain balloon dilatation of fibrotic plaques and is especially common when treating restenotic lesions such as in-stent restenosis. The cutting balloon has shown that it is predictable in not moving from the intended target despite the presence of glistening connective tissue. Second, the cutting balloon is effective when treating ostial lesions. These are often extremely resistant to plain balloon dilatation and can also be associated with the watermelon seed effect. Third, bifurcation lesions remain a difficult subset to treat effectively with balloon dilatation or even with coronary stents. Scoring the plaque and dilating the major branch as well as the ostium of the side branch with the cutting balloon appears to provide a better initial result compared to kissing balloons or kissing stents. Since the adverse clinical event rate of placing a stent in both branches of a bifurcation is high (approximately30%), the cutting balloon may be useful in adequately expanding the ostium of the side branch and thereby avoiding the necessity of a second stent. Fourth, heavily calcified plaque has the greatest bio-mechanical resistance of atheromatous tissues, and understandably, it is extremely resistant to balloon dilatation. Over the past decade, it became axiomatic that intensely calcified arteries should be treated with rotational atherectomy. This clever method of boring through calcium with a high-speed diamond drill produced an effective means of obtaining a