Balloon Angioplasty Versus Shockwave Intravascular Lithotripsy in Calcified Coronary Arteries: The BASIL Study
An Interview With Bernard Wong, MBChB
An Interview With Bernard Wong, MBChB
Dr Bernard Wong shares background and insights on his article, “Balloon Angioplasty Versus Shockwave Intravascular Lithotripsy in Calcified Coronary Arteries: The BASIL Study.”
Hi, my name is Bernard Wong. I'm an interventional cardiologist at North Shore Hospital, Auckland, New Zealand. I've been a specialist for about 3 years now; I studied in Auckland and did overseas training in Hong Kong before returning back home.
What motivated your group to explore intravascular lithotripsy as an alternative to conventional balloon angioplasty in this patient population?
Well, New Zealand was actually very fortunate in obtaining the availability of intravascular lithotripsy very early on; we were able to use the device in 2018, before many countries in the world, and it was almost revolutionary to the doctors in our hospital—how effective it was and easy to use, it didn't require much additional learning. Calcium has always been a struggle for interventional cardiologists to deal with, and each device has its nuances, limitations, and potential risks, and this novel technology was very attractive for operators.
Despite the higher procedural success in the IVL group, the difference was not significant. Do you believe this result was due to sample size limitations, or does it reflect a larger trend?
I think it was almost certainly due to the small sample size in the BASIL study of 60 patients. We designed this trial back in 2019, and it was designed as a single-center, randomized controlled study. And, as you can imagine, there were not many centers around the world that had IVL available at the time, so it was almost impossible to design a multicenter trial, and we could only do a small pilot single-center study of a small number. Therefore, the results being negative is a reflection of the small sample size rather than the effectiveness of the device.
Were there any unexpected observations during the study, either technical or patient-related that could inform future trials or guide operator decisions?
In our study we tried to be as inclusive as possible, including patients who had acute coronary syndromes unprotected left mains, reduced ejection fractions. With the prolonged balloon inflations of the lithotripsy cycles, we learned that some patients had a tendency to be hemodynamically unstable or hypotensive during balloon inflations, particularly in the treatment of left main lesions. And as we became more experienced with the device, we learned techniques, such as withdrawing the balloon between cycles of lithotripsy back into the guide catheter to allow the patient to stabilize before delivering the next cycle. These small nuances aren't taught by the device reps, and this was a reflection of increasing experience over time.
Based on your findings, do you see the potential for IVL becoming the preferred method for the pretreatment of severely calcified lesions?
I think it already has in many observational studies worldwide. Looking at the amount of IVL use vs rotational and orbital atherectomy in recent years, IVL has overtaken rotational atherectomy as the preferred advanced calcium modification device in the UK and many other countries purely based on the simplicity of usage and the lower risk profiles compared with some of the other devices. However, there's no one-size-fits-all device, and I think it's important for operators to be comfortable using multiple devices so that you can pick the right one for the right situation.
Is there anything else you'd like to share with our audience?
Firstly, I'd like to acknowledge my co-authors and my colleagues who were involved with this trial, the cardiovascular team at North Shore Hospital. Also, I'd like to acknowledge the Journal of Invasive Cardiology, who was very proactive in publishing all of our manuscripts on intravascular lithotripsy all the way back from 2019 on the first real-world experience on the device and a subsequent case series looking at patients treated with left main lesions and STEMI situations, and also combination of atherectomy and intravascular lithotripsy, culminating in the BASIL trial, which is the highlight of our group's experience with the device.
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