The DCB Playbook: Imaging, Vessel Prep, and Complex Coronary Decisions

The DCB Playbook: Imaging, Vessel Prep, and Complex Coronary Decisions

Drug-coated balloons are creating new options in complex coronary intervention, but only when the lesion is prepared correctly. In this MurmurMD discussion, Dr. Nyal Borges and Dr. Pratik Sandesara walk through a practical, case-based approach to contemporary DCB use, focusing on ISR, calcific neoatherosclerosis, underexpanded stents, and bifurcation disease. The conversation starts with a severe LAD ISR case involving jailed diagonal branches and an under expanded stented segment. The operators discuss how imaging guides the diagnosis, why calcific atherosclerosis often requires atherectomy, when OPN and high-pressure balloons matter, and why DCB may be preferable to adding another layer of metal. They then move into a challenging LAD/diagonal bifurcation case, where the strategy becomes a hybrid approach: DES for the main LAD and DCB for the diagonal branch. Key topics include: • A practical framework for treating ISR • Differentiating tissue ISR, stent fracture, and mechanical under expansion • Why calcific atherosclerosis is so difficult to treat • Rotational atherectomy inside a stent • OPN and high-pressure balloon optimization • Imaging-guided vessel preparation before DCB • When to avoid adding another stent layer • DCB for jailed side branches and bifurcations • Cutting balloon strategy for de novo vessel prep • Using physiology to assess side branch stability after DCB • Why DES and DCB may be complementary rather than competitive This is a detailed, operator-level conversation on where DCB fits today — and why the success of DCB depends less on the balloon itself and more on diagnosis, imaging, and meticulous vessel preparation. 🔔 Subscribe for more insights from interventional experts and real-world program builders. 📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687 📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA Chapters: 00:00 – Introduction: DCB in contemporary complex PCI 00:51 – Case 1: Severe LAD ISR with jailed diagonal branches 01:48 – A practical framework for image-guided ISR treatment 02:25 – Calcific neoatherosclerosis vs neointimal hyperplasia 03:20 – Mechanical underexpansion and calcium behind the stent 04:20 – Why imaging matters before choosing a DCB strategy 06:00 – DCB after vessel prep: when another stent layer is avoidable 08:00 – Why this ISR lesion is high risk for recoil 10:17 – Why OPN or IVL may not be enough in dense ISR calcium 11:35 – Rotational atherectomy inside a stent 15:09 – Long NC balloons, OPN, and confirming expansion 16:26 – Wire strategy and practical OPN considerations 18:00 – Post-treatment imaging and deciding whether to use DCB 20:04 – Why DCB may be attractive in LAD ISR with jailed branches 21:30 – What if you need to extend the stent? 25:24 – Case 2: Complex LAD/diagonal bifurcation disease 30:07 – IVUS assessment of LAD/diagonal anatomy 31:09 – Hybrid strategy: LAD stent plus diagonal DCB 31:46 – Cutting balloon and vessel prep for de novo DCB 36:10 – Using pressure wire to assess side branch stability 40:05 – When DES still makes sense in high-jeopardy anatomy 42:00 – DCB timing in bifurcation workflows 45:06 – Should you evaluate the side branch after provisional stenting? 46:02 – Final angiogram and optimization 47:10 – Future role of hybrid DES + DCB strategies #DCB #ComplexPCI #DrugCoatedBalloon #ISR #InStentRestenosis #CoronaryCalcium #BifurcationPCI #IVUS #RotationalAtherectomy #InterventionalCardiology #MurmurMD

Aero IVL: The Device Upgrade Changing Coronary Calcium Modification- Case Reviews

For years, the biggest limitation of coronary IVL wasn’t its ability to modify calcium- it was deliverability. In this MurmurMD discussion, Dr. Yousif Ahmad and Dr. Chris Brown review early real-world experience with Aero, ⁨@ShockwaveMedical⁩ IVL platform designed to improve crossability, flexibility, rewrap, and treatment efficiency in calcified coronary anatomy. The discussion focuses on how Aero changes day-to-day decision-making around calcium modification, including: • Why deliverability has historically limited IVL use • How Aero’s tapered tip, redesigned shaft, flexible balloon material, and longer hydrophilic coating improve performance • Why 120 pulses matter for longer calcified segments • Delivering Aero through tortuous LAD/diagonal anatomy • Using Aero in heavily calcified distal left main bifurcation anatomy • When atherectomy is still needed before IVL • Why rewrap performance may be one of Aero’s biggest advantages • Treating multiple vessels with the same IVL balloon • Reduced need for guide extension, repeat balloons, and device exchanges • How Aero may shift IVL earlier in the calcium-modification algorithm This is a practical device-focused discussion on how a seemingly incremental design change may meaningfully change how operators approach complex coronary calcium. 🔔 Subscribe for more insights from interventional experts and real-world program builders. 📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687 📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA Chapters: 00:00 – Why Aero matters: IVL’s deliverability limitation 01:00 – What changed: tip, shaft, coating, and balloon design 02:00 – Tortuous LAD/diagonal anatomy and Aero deliverability 04:00 – When Aero may reduce the need for atherectomy 04:30 – Distal left main bifurcation calcium: atherectomy plus Aero 06:30 – Rewrap performance and multivessel treatment 08:00 – Fewer guide extensions, fewer exchanges, fewer ruptures 09:30 – How Aero may change the coronary calcium algorithm 11:00 – Final thoughts: why this upgrade surprised operators #Aero #IVL #IntravascularLithotripsy #CoronaryCalcium #CalcifiedLesions #LeftMain #Atherectomy #InterventionalCardiology #MurmurMD

How Transcatheter Arterialization of Deep Veins Saves Limbs with Dr. Vargas Estrada

What happens when a patient has critical limb-threatening ischemia, severe calcification, no distal targets, and has failed traditional endovascular therapy? In this MurmurMD discussion, Dr. Andres Vargas Estrada and Dr. Sameh Sayfo explain the evolution of Deep Vein Arterialization (DVA/TADV) and why it has become a powerful option for patients previously considered "no-option" candidates. The conversation explores the changing landscape of peripheral artery disease, the rise of small artery disease and medial arterial calcification, and why conventional therapies often fail in advanced CLTI patients. Key topics include: • Why today's CLTI patients are different than those of the past • The impact of diabetes, dialysis, and severe calcification • Understanding the MAC score and predicting treatment failure • Why traditional tibial interventions often fall short • The role of vessel preparation before advanced therapies • How Javelin, IVL, and bioresorbable scaffolds fit into modern limb salvage • The history and evolution of Deep Vein Arterialization • How DVA reroutes blood flow to preserve limbs when no arterial options remain This discussion highlights one of the most innovative shifts in peripheral intervention: when arteries can't be reopened, use the veins. 🔔 Subscribe for more insights from interventional experts and real-world program builders. 📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687 📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA Chapters: 00:00 – Why CLTI remains one of the biggest challenges in vascular care 03:00 – The shift from large artery disease to small artery disease 05:00 – Using the MAC score to identify no-option patients 07:00 – Modern tools: Javelin, IVL, and bioresorbable scaffolds 10:00 – The origins and evolution of Deep Vein Arterialization 13:00 – How DVA works and why it can salvage limbs 18:00 – Patient selection and practical considerations 22:00 – Future directions in limb salvage #DeepVeinArterialization #DVA #CLTI #LimbSalvage #PeripheralArteryDisease #Endovascular #PeripheralIntervention #CriticalLimbIschemia #MurmurMD

Removing Intracardiac Masses Without Surgery: Transcatheter Techniques Explained

Intracardiac masses have traditionally meant high-risk surgery — but transcatheter approaches are changing what’s possible in structural and endovascular intervention. In this MurmurMD discussion, Dr. Abdallah El Sabbagh and Dr. Andrei Pop review the evolving role of transcatheter removal of intracardiac masses, focusing on procedural planning, imaging guidance, device strategy, and patient selection. Key discussion points from the transcript include: • Types of intracardiac masses considered for transcatheter removal • Imaging strategies for procedural planning and guidance • Access considerations and device positioning • Managing embolic risk during extraction • Technical challenges unique to intracardiac mass removal • Patient selection and procedural decision-making • Real-world lessons from complex intracardiac cases • The expanding role of minimally invasive intracardiac intervention This discussion provides a practical look at how transcatheter techniques are creating new options for managing intracardiac masses without open surgery. 🔔 Subscribe for more insights from interventional experts and real-world program builders. 📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687 📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA Chapters: 00:00 – Why transcatheter intracardiac mass removal is evolving 01:30 – Imaging and procedural planning 03:30 – Access strategy and device positioning 05:30 – Managing embolic risk and technical challenges 07:30 – Patient selection and case considerations 09:00 – Key lessons and future direction #StructuralHeart #IntracardiacMass #TranscatheterIntervention #InterventionalCardiology #CardiacImaging #Endovascular #MurmurMD

How Top LAAO Programs Scale Faster: Efficiency, Workflow, and Growth Strategies

Building a successful LAAO program requires more than procedural skill — it depends on workflow efficiency, team coordination, and scalable systems. In this MurmurMD discussion, Dr. Vijay Iyer and Dr. Joe Walsh break down the key drivers behind LAAO program efficiency and growth, focusing on how high-performing programs optimize patient flow, referrals, procedural planning, and long-term expansion. Key discussion points from the transcript include: • Improving workflow efficiency in LAAO programs • Referral pathways and program growth strategies • Streamlining patient evaluation and scheduling • Building coordination across the heart team • Procedural efficiency and lab workflow optimization • Managing follow-up and longitudinal patient care • Identifying bottlenecks that slow program growth • Lessons learned from scaling successful LAAO programs This discussion provides practical insights into how structural heart teams can grow LAAO programs while improving efficiency and patient care. 🔔 Subscribe for more insights from interventional experts and real-world program builders. 📱 Download the app: https://apps.apple.com/app/apple-store/id1586692687 📺 Follow us on YouTube: https://www.youtube.com/channel/UCfrLYhAhliQ2ZvXinkDCZvA Chapters: 00:00 – Why LAAO program efficiency matters 01:30 – Referral pathways and program growth 03:30 – Streamlining workflow and patient evaluation 05:30 – Team coordination and procedural efficiency 07:30 – Managing follow-up and long-term care 09:00 – Lessons learned from scaling LAAO programs #LAAO #StructuralHeart #Watchman #LeftAtrialAppendageClosure #ProgramGrowth #HeartTeam #InterventionalCardiology #MurmurMD