Coronary Artery Dissection Series – Back to the Future II: The ARM Strategy (Avoid, Recognize and Manage Dissections) in Drug-coated Balloon Angioplasty

Drug-coated balloon (DCB)-only angioplasty is a ‘leave nothing behind’ approach, necessitating a modified percutaneous coronary intervention strategy and mindset to accept coronary dissection during lesion preparation while simultaneously achieving an optimal angiographic outcome. Drawing from the lessons learned during the plain old balloon angioplasty era, it is imperative to re-familiarize ourselves with the strategies of dissection avoidance, recognition and management. With our increasing clinical and research experience in DCB angioplasty, we present our approach to managing dissections, emphasizing the distinction between safe and unsafe dissections, techniques for modifying unsafe or indeterminate dissections into a safe category and the appropriate consideration of bailout stenting (BOS). We provide examples of each dissection category, including those that can be safely left, those requiring BOS and those that necessitate modification through techniques such as further dilatation with specialized balloons (such as non-compliant, scoring and cutting balloons) and prolonged balloon inflation.