Abstract
Stent implantation in bifurcated coronary lesions is technically challenging so that procedural refinements are continuously investigated. Novel procedure modeling and intracoronary imaging techniques may offer critical insights on stent deformations and stent-wall interactions during bifurcation stenting procedures. Thus, we assessed coronary bifurcation stenting techniques using multimodal imaging and 3D modeling in reanimated swine hearts. Harvested swine hearts were reanimated using Visible Heart® methodologies and (under standard fluoroscopic guidance) used to test 1-stent (provisional and inverted provisional) and 2-stent (culotte, TAP and DK-crush) techniques on bifurcations within various coronary vessels using commercially available devices. Intracoronary angioscopy and frequency-domain optical-coherence-tomography (OCT) were obtained during the procedures. 3D OCT reconstruction and micro-computed tomography 3D modeling (post heart fixations) were used to assess stent deformations and stent-wall interactions. We conducted multiple stenting procedures and collected unique endoscopic and OCT images (and subsequent computational models from micro-CT) to assess stent deformations and device/wall interactions during different steps of bifurcation stenting procedures. Endoscopy, micro-CT and virtual reality processing documented that different 1- and 2-stent techniques, practiced according to experts’ recommended steps, achieve optimal post-intervention stent conformation. As compared with intra-procedural endoscopy, software-generated 3D OCT images accurately depicted stent deformations during 1-stent techniques. On the opposite, during more complex 2-stent techniques, some defects were appreciated at 3D OCT reconstruction despite optimal 2D OCT images. This study provided unique insights regarding both stent deformations occurring in the course of bifurcation stenting and the efficacy of OCT to visualize them.
Highlights
Atherosclerosis can develop anywhere within human coronary arteries and branching points are commonly affected, likely due to shear stress issues [1]
◂Fig. 1 a–c Angioscopic visualization and 3D optical coherence tomography (OCT) reconstruction of a representative coronary bifurcation. a Angiographic image shows guidewire placement in descending posterior and angioscopy device in distal right coronary. b Distal right coronary bifurcation with guidewire in descending posterior artery. c Distal right coronary bifurcation obtained with 3D OCT reconstruction. d–i Multimodal assessment of results achieved after crossover stenting in provisional
Perfect 3D OCT reconstructions show stent malapposition in proximal main vessel, side branch “jailing” due to floating stent struts, and side branch ostium shape preservation. d Direct visualization of proximal malapposition of stent with OCT catheter following the main vessel guidewire. e Abluminal guide wire crossing is clearly identified in the 2-D OCT image
Summary
Atherosclerosis can develop anywhere within human coronary arteries and branching points are commonly affected, likely due to shear stress issues [1]. D Direct visualization of proximal malapposition of stent with OCT catheter following the main vessel guidewire. I Visualizing the guidewire rewiring through the proximal stent struts was difficult to interpret via the 3-D OCT image. Relative to the implantation of drug-eluting metallic stents, 1- or 2-stent techniques are the standard approaches for PCIs within bifurcation lesions [3–5]. In the setting of procedure simulations, microcomputed tomography imaging is becoming a popular method to analyze stents implanted both in-vivo and in-silico models to assess restenosis [8] and CFD modeling [9], respectively. These methodologies have yet to be applied for the analysis of technique specific procedural steps
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