Bifurcation Lesions Research Articles

Challenges in the Management of Dislodged Coronary Stent Embolization: A Case Report

AbstractAlthough device embolization is a rare complication in percutaneous coronary interventions (PCI), its mortality and morbidity are serious complications. With the increasing prevalence of complicated procedures, invasive cardiologists encounter device embolization daily. Different devices and techniques are utilized to retrieve these devices. Most devices used during PCIs are infection stents. More infrequently, the tip of diverting wires, angioplasty balloons, or balloon holders may break and embolize distally into the arteries. A 51-year-old man with non-ST elevation myocardial infarction was presented for restoration of the ring of the stent, which was stripped in the first diagonal ostium, with snare communication. The patient had an anterior myocardial infarction and underwent stent implantation in the left anterior descending artery (LAD) 1 month ago. While the stripped stent was being retracted, the LAD stent had been inserted, causing the stent implanted a month ago to be retracted. Additionally, the dissection was observed in the proximal LAD, and the procedure was terminated by stenting the LAD-Diagonal bifurcation lesion using the mini-crush technique. This case report highlights the importance of constant vigilance that invasive cardiologists must show when removing the embolized device. The maturity of the technique depends on the operator's experience with the methods of use and the material possibilities in the laboratory.

Drug-coated balloon versus provisional percutaneous transluminal coronary angioplasty to side branch in bifurcation lesions

Drug-coated balloon versus provisional percutaneous transluminal coronary angioplasty to side branch in bifurcation lesions

Safety and Efficacy of BioMime Sirolimus-Eluting Stent System in All-Comers Real-World Population With Coronary Artery Stenosis: MILES Global Registry.

This study evaluated the safety and efficacy of BioMime sirolimus-eluting stent (SES) system, with an ultra-low strut thickness (65 µm), in real-world all-comers population with coronary artery stenosis (CAD). This was a post-marketing, multicenter, single-arm, observational clinical registry among patients undergoing intervention for CAD. Patients were clinically followed up at 1, 9, 12, and 24 months after the index percutaneous coronary intervention. Four major indications, namely long stents of > 30 mm, stents with diameters of 4 and 4.5 mm, bifurcation subgroup, and chronic total occlusion (CTO) were evaluated as pre-specified subsets. A total of 771 patients (1,079 treated lesions) from 23 sites were included in this study. The mean length and diameter of the implanted stents were 25.57 ± 9.35 mm and 3.00 ± 0.44 mm, respectively. The mean minimum lumen diameter before and after the procedure was 1.00 ± 1.69 mm and 2.96 ± 1.35 mm, respectively. The cumulative rates of major adverse cardiovascular events (MACEs) and stent thrombosis (ST) at 1, 9, 12, and 24 months were 1.05%, 3.13%, 4.04%, 5.64% and 0%, 0.13%, 0.28%, 0.28%, respectively. In a subset with > 30 mm long stents, the cumulative rate of MACEs was 0.4%, 4.6%, 5.12%, and 7.01% at 1, 9, 12, and 24 months, respectively. The corresponding rates of ST were 0%, 0.42%, 0.43%, and 0.44%, indicating constant rate of ST after 9 months. In a subset of 4 and 4.5 mm diameter stents, the cumulative rate of MACEs was high (0%, 6.25%, 6.25%, and 10.41%) at 1, 9, 12, and 24 months, respectively. However, there was no case of ST until 24 months. In patients with bifurcation lesions, the cumulative rates of MACEs and ST were 2.46%, 6.32%, 11.53%, 16.21% and 0%, 1.27%, 1.28%, 1.35% at 1, 9, 12, and 24 months follow-up. In patients with chronic total occlusion, the cumulative rates of MACEs and ST were 0.79%, 5.04%, 6.83%, 7.07% and 0%, 0.84%, 0.85%, 0.88% at 1, 9, 12, and 24 months, respectively, indicating constant rate of ST after 9 months. The BioMime SES demonstrated good safety and efficacy outcomes at 24-month follow-up, with low rates of MACEs and ST in patients with CAD in the real-world setting.

Bifurcation lesion PCI with final 2-stent usage: Our No-stent crush & No-metal layer strategy, Feasibility, Procedural success and 6-month MACE

Bifurcation lesion PCI with final 2-stent usage: Our No-stent crush & No-metal layer strategy, Feasibility, Procedural success and 6-month MACE

One-Year Clinical Outcomes in Patients with Coronary Bifurcation Lesions: A Result from a Single Centre.

One-Year Clinical Outcomes in Patients with Coronary Bifurcation Lesions: A Result from a Single Centre.

Early and Long-term Outcomes of Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention to the Left Main Coronary Artery.

Patients undergoing percutaneous coronary intervention (PCI) to the left main (LM) coronary artery in the setting of acute coronary syndrome (ACS) were not adequately studied in the era of modern PCI. We investigated early and long-term outcomes of these patients, especially those with a true LM bifurcation stenosis. The Left Main Intervention in Acute Coronary Syndrome (LIMACS) is a multicenter registry that enrolled patients undergoing PCI to unprotected LM disease in the setting of ACS using a drug-eluting stent. The study included 360 patients (age, 65±12 years; male, 74%; STEMI, 65%). During index hospitalization, 25% of patients developed cardiogenic shock and 15% died. Cardiogenic shock (adjOR[95% CI]: 26[7-93]) and final TIMI grade <3 flow (adjOR[95% CI]: 7[1.6-31]) were associated with in-hospital mortality. Three-year mortality (37%) correlated with left ventricular ejection fraction≤40% (adjHR: 2.4[1.4-4.2]), Killip class II-IV at presentation (adjHR: 1.7[1.02-2.8]), LM culprit (adjHR: 1.7[1.04-2.8]), true LM bifurcation stenosis (adjHR: 1.8[1.1-2.9]), final TIMI grade <3 flow (adjHR: 3.2[1.7-5.8]), and radial access (adjHR: 0.58[0.38-0.99]). In patients with true LM bifurcation stenosis (n=127), two-stent strategy was adopted in 60% and was associated with lower 3-year mortality or repeat revascularization compared with one-stent strategy (48% vs. 69%, p=0.012). In conclusion, patients undergoing PCI to the LM in the setting of an ACS sustain high adverse event rates. Hemodynamic status, LM culprit lesion, femoral access, and failure to restore normal flow are major determinants of adverse outcomes. In patients with LM true bifurcation lesions, outcomes are impaired especially with one-stent strategy. Study Registration: ClinicalTrials.gov ID: NCT05701319.

Role of pre-procedure CCTA in predicting failed percutaneous coronary intervention for chronic total occlusions

PurposeThis study aimed to identify major lesion characteristics of chronic total occlusions (CTOs) that predict failed percutaneous coronary intervention (PCI) using pre-procedure coronary computed tomography angiography (CCTA) in combination with conventional coronary angiography (CCA). MethodsConsecutive patients with at least one CTO of the native coronary arteries received CCTA and CCA-guided PCI, with computed tomography performed before or during PCI. ResultsA total of 76 patients with CTO were included in this study. 76 patients were divided into successful and failed PCI groups based on their PCI outcome. There were 62 (81.58 %) patients in the successful PCI group and 14 (18.42 %) in the failed PCI group. The occlusion length ≥20 mm, ostial or bifurcation lesions, negative remodeling, microchannels, and good collateral vessels were the CCTA morphologic parameters associated with PCI outcome (P<0.05). In addition, the blunt stump, occlusion length ≥20 mm, and ostial or bifurcation lesions, were the CCA morphologic parameters associated with PCI outcome (P<0.05). The multivariate regression model showed that the three independent negative predictors: blunt stump on CCA (OR: 0.63; 95 % CI: 0.23–0.98; p =0.048), occlusion length ≥20 mm on CCTA (OR: 0.37; 95 % CI: 0.32–0.71; p <0.001) and negative remodeling on CCTA (OR: 0.26; 95 % CI: 0.28–0.44; p <0.001). ConclusionOur study demonstrated that combining CCTA and CCA morphologic characteristics could improve PCI outcome prediction in patients with CTO compared to CCTA morphologic features alone.

Impact of intravascular ultrasound for coronary bifurcations treated with last generations stents: insights from the BIFURCAT-ULTRA registry.

Bifurcation lesions are associated with higher rates of major adverse cardiovascular events (MACE). To investigate the impact of imaging-guided PCI in a real-world population with coronary bifurcation lesions. From the ULTRA-BIFURCAT registry, we compared IVUS vs. angiographic guidance in a cohort of 3486 propensity matched patients. MACE a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization (TLR) and stent-thrombosis was the primary endpoint. Subgroup analyses were performed for unprotected left main (ULM) and non-ULM disease. PSM generated 1743 pairs. MACE occurred in 154 (9%) patients in the IVUS guided group and in 199 (11%) patients in the angio-guided group (p=0.09). IVUS guidance was associated with lower MACE in the ULM population [HR 0.62, 95% CI 0.46-0.83], but had no impact in the non-ULM population [HR 1.12, 95% CI 0.83-1.51], p for interaction=0.006. IVUS was associated with reduction in all-MI [HR 0.32, 95% CI 0.16-0.64] in the ULM population and with lower ST in the non-ULM population [HR 0.24, 95% CI 0.08-0.71]. Provisional stenting was associated with lower MACE in the ULM population [HR 0.67, 95% CI 0.45-0.98], whereas kissing balloon [HR 0.75, 95% CI 0.56-0.99] and ultra-thin stents [HR 0.44, 95% CI 0.29-0.67] were protective factors in the non-ULM population. In a real-world scenario, IVUS guidance during DES implantation is associated with a lower rate of MACE in patients with ULM coronary bifurcation lesions. In non-ULM bifurcations, no difference was observed on MACE, while IVUS guidance was associated with a lower rate of ST.

Abstract 4140100: Outcomes of Percutaneous Coronary Intervention of the Left Main Coronary Artery Bifurcation: Insights from PROGRESS-BIFURCATION registry

Background: There is limited data on the long-term outcomes of percutaneous coronary intervention (PCI) in patients with left main coronary artery (LM) bifurcation lesions. Methods: This retrospective, observational, cohort study was performed across 6 centers in the United States, Russia, and Turkey between 2013-2024, as part of the Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). We examined procedural characteristics and follow-up outcomes of patients with versus without LM bifurcation lesions undergoing PCI. Multivariable adjusted hazard ratios (aHR) with 95% CI were calculated using Cox regression. Results: Of 1,089 patients who underwent bifurcation PCI, 289 (26.5%) underwent LM PCI. Patients in the LM group were older (70.1±11.9 vs 65.4±11.5 years; p&lt;0.001) and had more comorbidities, such as diabetes, heart failure, prior PCI, and prior coronary artery bypass graft surgery. Two-stent techniques were more commonly used in LM patients vs. non-LM patients (39.3% vs 26.5%, p&lt;0.001), with similar technical success (94.8% vs 95.9%, p=0.41) and procedural success (93.1% vs 93.1%; p=0.99). The incidence of in-hospital major adverse cardiovascular events (MACE) was higher in LM patients (7.9% vs 4.5%, p=0.04). During long-term follow-up LM PCI patients had higher mortality (aHR 3.17; 95% CI 1.22-8.18; p&lt;0.001), without significant differences in MACE (aHR 1.81; 95% CI 0.93-3.52; p=0.08), myocardial infarction (aHR 0.50; 95% CI 0.07-3.52; p=0.50), and target-vessel PCI revascularization (aHR 2.56; 95% CI 0.75-8.78; p=0.14). Conclusion: Follow-up mortality in patients undergoing bifurcation PCI, classified according to whether they underwent left main or non-left main PCI.

Abstract 4140163: Initial Experience with Mini-Crush Versus Double Kissing Crush in Bifurcation Percutaneous Coronary Intervention: Insights from PROGRESS-BIFURCATION registry

Background: There is limited data on use of the mini-crush technique in two-stent bifurcation percutaneous coronary intervention (PCI). Methods: This retrospective, observational, cohort study was performed across 6 centers in the United States, Russia, and Turkey between 2013-2024, as part of the Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). We evaluated procedural characteristics of patients who underwent bifurcation stenting using the mini-crush technique and compared it with those who were treated with double kissing (DK) crush. Results: Of 1,138 PCIs involving 1,499 lesions, 46 (4.04%) were performed using the mini-crush technique and 147 lesions (12.91%) using the DK crush technique. Baseline characteristics of the patients were similar in both groups. There was no difference between mini-crush versus DK-crush in technical success (100.0% versus 98.6%; p=0.99), procedural success (95.1% versus 97.1%, p=0.62), procedural complications (10.9% versus 14.7%, p=0.51), or in-hospital major adverse cardiovascular events (MACE) (6.5% versus 5.7%, p=0.73). In contrast, mini-crush technique was associated with shorter procedure time (79.00 vs 116.50 minutes; p&lt;0.001; Figure 1A), fluoroscopy time (23.50 vs 30.35 minutes, p=0.002; Figure 1A), and lower contrast volume (150 versus 109 milliliters; p&lt;0.001; Figure 1B), and air kerma radiation dose (1.11 vs 1.71 gray; p=0.024; Figure 1C). Conclusion: In patients undergoing PCI for bifurcation lesions, the mini-crush technique had similar rates of procedural complications and in-hospital MACE as compared with the DK crush technique but required less contrast volume, fluoroscopy time, radiation dose, and procedural time.

Abstract 4141481: Outcomes of the upfront two stent strategies for bifurcation percutaneous coronary interventions: Insights from PROGRESS-BIFURCATION registry

Background: Upfront two-stent techniques are often used in bifurcation percutaneous coronary interventions (PCI), but there is controversy about optimal strategy selection. Methods: We examined the clinical, angiographic characteristics, and long-term outcomes of 206 bifurcation PCIs using the double kissing (DK) crush or the culotte techniques in 192 patients between 2014-2023 from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (NCT05100992). For the long-term outcomes adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using the mixed effects Cox proportional hazards model. Results: DK crush was more commonly used (70.4%). Patients in the culotte group had similar baseline characteristics with the DK crush group. Lesions treated with culotte were more likely to be in the left anterior descending (54.1% vs. 35.9%, p&lt;0.001) and circumflex arteries (21.3% vs. 9.0%, p&lt;0.001), had smaller proximal (3.50 [3.00, 3.75] vs. 3.50 [3.30, 4.00] mm, p=0.032) and distal (3.00 [2.75, 3.00] vs. 3.00 [3.00, 3.50] mm, p=0.047) main vessel diameters, and were less likely to have severe calcification (6.6% vs. 32.4%, p&lt;0.001). Technical success (96.7% vs. 98.6%, p=0.583), procedural success (93.1% vs. 93.9%, p=0.758), and in-hospital major adverse cardiovascular events (MACE) (3.4% vs. 6.1%, p=0.726) were similar in both groups. During a mean follow-up of 38-month, 32 (28.3%) patients experienced MACE. On multivariable analysis, culotte was associated with similar MACE (aHR 1.19; 95%CI 0.78-1.80; p=0.680), mortality (aHR 1.11; 95%CI 0.68-1.79; p=0.810), and target vessel PCI revascularization (aHR 0.58; 95%CI 0.30-1.13; p=0.460) compared with DK crush (Figure). Conclusions: Bifurcation PCI with DK crush and culotte had similarly high technical and procedural success, low in-hospital MACE, and long-term outcomes.

Abstract 4141480: Gender differences in bifurcation percutaneous coronary interventions: Update from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION)

Background: Gender differences on short and long-term outcomes following bifurcation percutaneous coronary intervention (PCI) have received limited study. Research Questions: To examine gender differences in outcomes of bifurcation PCI. Methods: We examined the angiographic, procedural characteristics, and outcomes of 1084 bifurcation PCIs (1076 patients) performed at five centers between 2013-2024 from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION). Results: Women represented 25.19% of the entire study population. They were older (68.37±12.34 vs 66.09±11.54; p=0.001), less likely to be currently smokers (13.7% vs 20.4%; p=0.014), with higher left ventricular ejection fraction (%) (55.46±13.27 vs 53.16±12.55; p&lt;0.001) and lower baseline creatinine (0.85 vs 1.00; p&lt;0.001). Lesion characteristics were mostly similar, with slightly lower proximal and distal main vessel diameter in women. Their proximal main vessel was more likely to be left anterior descending artery (46.5% vs 39.4%; p=0.030) and less likely to be right coronary artery (10.3% vs 16.1%; p=0.030), compared to men. Technical success was similar (94.5% vs 94.6%; p=0.952), while procedural success was lower (89.6% vs 94.1%; p=0.011). In-hospital major adverse cardiac events (MACE) were more common in women (8.5% vs 4.2%; p=0.007), which presented with increased in-hospital mortality (4.1% vs 0.6%; p&lt;0.001), stroke (1.8% vs 0.1%; p=0.005) and bleeding (1.8% vs 0.2%; p=0.013). Their PCIs required equal procedure time, but lower fluoroscopy time, contrast volume and air kerma radiation dose. Female gender was independently associated with higher in-hospital major adverse cardiac events (MACE) (odds ratio (OR) 2.21; 95%CI 1.23-3.95; p=0.008) and lower procedural success (OR 0.56; 95%CI 0.32-1.00; p=0.044). Follow-up data were available for 733 patients (68.12%). The incidence of follow-up MACE was significantly higher in women (hazard ratio (HR) 1.36; 95%CI 1.02-1.81; p=0.038), while on adjusted mixed Cox proportional hazards analysis female gender was associated with higher follow-up MACE (HR 1.58; 95%CI 1.08-2.30; p=0.018). The incidence of follow-up mortality was similar between genders (HR 1.17; 95%CI 0.78-1.77; p=0.45). Conclusions: Bifurcation PCI can be accomplished with high technical success in women, but higher in-hospital and follow-up MACE, compared to men.

Prognostic value of computed tomography-derived fractional flow reserve in patients with diabetes mellitus and unstable angina

BackgroundCoronary artery calcification is commonly found in patients with type 2 diabetes mellitus (T2DM), which may compromise the diagnostic accuracy of coronary computed tomography angiography (CTA). Computed tomography-derived fractional flow reserve (CT-FFR), which integrates coronary anatomy with functional assessment, holds the potential to become a powerful diagnostic tool for evaluating calcified lesions.ObjectiveWe aim to assess the prognostic value of CT-FFR for calcific lesions in patients with T2DM and unstable angina (UA).MethodsWe conducted a retrospective study involving 3,392 patients who were diagnosed with T2DM and UA who underwent coronary CTA, with at least one visible calcification site. Of those, 1,091 patients and 1,372 vessels were recommended by cardiovascular specialists and completed invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR) measurements. Simultaneously, those patients also underwent CT-FFR measurements and were divided into two groups based on CT-FFR values: one group with CT-FFR > 0.80 and the other with CT-FFR ≤ 0.80. Demographics, clinical data, the diagnostic performance of CT-FFR, analysis of calcified lesions on CTA, and major adverse events during follow-up were recorded.ResultsThe diagnostic accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the area under the curve (AUC) of CT-FFR were 84.8%, 84.6%, 85.1%, 84.7%, 85.0%, and 84.8%, respectively, per patient, and 82.2%, 80.3.2%, 81.8%, 79.7%, 81.1%, and 82.9% respectively, per vessel. For lesion and calcification characteristics, the degree of stenosis, lesion length, rate of bifurcation lesions, diffusive lesions, occlusion, calcium volume, and coronary artery calcification score (CACS) were significantly higher in the CT-FFR ≤ 0.8 group compared to the CT-FFR > 0.8 group. In contrast, the minimum cross-sectional area was smaller in the CT-FFR ≤ 0.8 group than in the CT-FFR > 0.8 group. Major adverse cardiovascular and cerebrovascular events (MACCE) at the 3-year follow-up was significantly higher in the CT-FFR ≤ 0.8 group compared to the CT-FFR > 0.8 group. The CT-FFR value is an independent predictor of MACCE at the 3-year follow-up.ConclusionCT-FFR demonstrated significant diagnostic performance using invasive FFR as the reference standard and proved to be an important predictive tool for assessing prognosis not only in calcified lesions but also in lesions with a CACS score of zero in patients with T2DM and UA. CT-FFR may serve as a valuable tool for guiding treatment decisions in these patients.Graphical abstract

Long-Term Clinical Outcomes of Drug-Coated Balloon Following Directional Coronary Atherectomy for Bifurcated or Ostial Lesions in the DCA/DCB Registry.

The long-term efficacy of drug-coated balloon (DCB) angioplasty for large bifurcation lesions, particularly those involving the left main trunk (LMT), remains unclear. This study aimed to evaluate the long-term outcomes of directional coronary atherectomy followed by DCB (DCA/DCB) for large bifurcation lesions. This retrospective multicenter study analyzed 129 cases from the DCA/DCB registry, with 80.4% involving LMT bifurcation lesions. Building on previously reported 12-month outcomes, this study assessed long-term results. The primary endpoint was clinically driven (CD) target lesion revascularization (TLR) at 36 months. Secondary endpoints included CD target vessel revascularization (TVR); CD target vessel failure (TVF); and adverse events, such as all-cause mortality, cardiac death, target vessel acute myocardial infarction (AMI), and the need for coronary artery bypass grafting (CABG), at 24 and 36 months. The mean follow-up was 53.4 ± 23.9 months. The CD-TLR rate was 5.0% at 24 months, and the primary endpoint was 5.9% at 36 months. CD-TVR rates were 14.0% at 24 months and 15.0% at 36 months, while CD-TVF rates were 14.9% at 24 months and 16.7% at 36 months. Adverse events included all-cause mortality rates of 0.8% at 24 months and 1.8% at 36 months, and cardiac death rates of 0.8% at both 24 and 36 months. No target vessel AMI or CABG procedures were reported. The consistently low CD-TLR rate at 36 months supports the efficacy of the DCA/DCB strategy for large bifurcation lesions, including LMT, indicating its sustained effectiveness. These findings highlight the viability of this treatment approach.

Evaluation of Small Vessel Bifurcation Stenting Using the Double-Kissing Culotte and Culotte Technique in Acute Coronary Syndrome: 12-Month Clinical Outcomes.

Patients with small vessels who undergo percutaneous coronary intervention (PCI) with subsequent multiple implantation of drug-eluting stents remain at a higher risk of unfavorable outcomes. In complex cases where maintaining flow to all side branches is part of contemporary practice, using two-stent techniques may be appropriate. This study aims to evaluate the efficacy of double-kissing (DK) culotte technique in comparison to culotte technique in the context of small-vessel therapy in patients with acute coronary syndrome (ACS). This substudy of the Lower Silesia culotte Bifurcation Registry retrospectively analyzed patients who underwent ACS-PCI using DK culotte or culotte technique for bifurcation lesions in small vessels, defined as having at least one branch with a diameter of 2.75 mm or less. The primary endpoint was target lesion failure (TLF), a composite of cardiovascular death, target vessel myocardial infarction, or clinically driven target lesion revascularization (TLR) at 1-year follow-up. The secondary endpoint included major adverse cardiac events (MACE). The DK culotte group (n = 49) and the culotte group (n = 52) were compared, with 12-month follow-up showing lower TLF in the DK culotte group (8.2% vs. 19.2%, p = 0.082). Similar results were observed for TLR (6.1% vs. 13.5%; p = 0.161), stent restenosis (4.1% vs. 9.6%; p = 0.203), and MACE (18.4% vs. 25%; p = 0.344). For bifurcation lesions with a small-diameter artery, the DK culotte technique may reduce TLF and MACE compared to the culotte technique. However, given the limited sample size and the absence of statistical significance, these findings remain preliminary and require further investigation.

Ostial LCx: Achilles Heel of Left Main Bifurcation Angioplasty and How We Evolved in Its Management

In-stent restenosis (ISR) within bifurcation lesions of the left main (LM) coronary artery (LMCA) is challenging due to its complex anatomy and critical function. This case series highlights 3 patients with LM bifurcation ISR (Medina 1,1,1) post-index intervention using different stent strategies as follows: Case 1: A 58-year-old male developed distal LM bifurcation stenosis after ostial left anterior descending artery (LAD) stenting. Mini-culotte bifurcation angioplasty effectively managed this. Case 2: A 62-year-old male presented with neo-atherosclerosis-induced distal LM bifurcation ISR post-provisional LM-left anterior descending artery (LAD) stenting. A single-stent crossover with a drug-coated balloon in a large side branch achieved optimal flow restoration. Case 3: A chronic total occlusion in the right coronary artery and distal LM bifurcation ISR due to stent overhang into LMCA in a 72-year-old male was resolved with a string culotte technique. These cases underscore ISR management strategies tailored to patient-specific anatomy and clinical needs, advocating advanced imaging techniques like intravascular ultrasound and optical coherence tomography for procedural precision and safety.

Assessment of fractal ratio of vessel diameters in coronary bifurcation lesions by angiography and intravascular ultrasound.

Physiological coronary branching at the bifurcation has a constant fractal ratio (FR) of the diameter of the mother vessel to the sum of daughter vessels on quantitative coronary angiography (QCA). We sought to investigate the FR of diseased coronary bifurcations using QCA and intravascular ultrasound (IVUS) and its impact on late lumen loss after percutaneous coronary intervention (PCI). In multicentre prospective studies of the J-REVERSE and 3D OCT Bifurcation Registry, 402 and 109 bifurcations treated with stenting that completed QCAs and IVUS examinations, respectively were analysed. FR was investigated at the reference sites pre-PCI and the minimum lumen diameter (MLD) post-PCI. In the QCA analysis, constant FR was observed in the pre-PCI reference (0.62 ± 0.08) and in the post-PCI MLD site (0.74 ± 0.10), which was greater (p < 0.05). In the IVUS analysis, the constant FR in the post-PCI MLD site (0.67 ± 0.06) was similar to that in the pre-PCI reference (0.66 ± 0.06) and close to the physiological FR value (0.678). The fourth quintile of pre-PCI reference FR in the IVUS analysis showed numerically least late lumen loss in proximal main vessel (MV) (0.16 ± 0.22mm) and distal MV (0.13 ± 0.32mm) and significantly less in the side branch compared to higher FR quintile (-0.14 ± 0.27mm vs. 0.10 ± 0.19mm, p = 0.004), while no relationship was found in the QCA analysis. FR in the diseased coronary bifurcation was more accurately assessed on IVUS than on QCA, and the accomplishment of physiological FR might lead to less late lumen loss after bifurcation PCI.

“Kissing-Balloon” Angioplasty Associated Coronary Artery Perforation in Anterior STEMI: A Cautionary Tale

Introduction: Bifurcation technique angioplasty remains one of the most challenging procedures in interventional cardiology, up to 10% of patient with STEMI present with a bifurcation as the culprit lesion. Coronary artery perforation is a known complication of percutaneous coronary intervention and complex coronary anatomy is often posed as a risk factor. Interventional and surgical management of coronary artery perforation is indicated as soon as possible. Case presentation: A 55-year-old male was admitted to the emergency room with severe chest pain 12-hour prior to his admission. An anterior STEMI was diagnosed, and the patient underwent emergency coronary angiography with a bifurcation lesion of the mid LAD and D1, after transient loss of anterograde flow a secondary vessel a “kissing-balloon” technique was performed and type III coronary artery perforation in the Ellis classification of the side-branch was identified. Patient developed cardiogenic shock and urgent thoracotomy was performed. The patient was discharged in good conditions. Conclusion: Coronary artery perforation is a feared complication of percutaneous coronary intervention. Chest pain and hemodynamic deterioration can quickly lead to patient’s death. Identification as soon as possible and interventional or surgical management must be performed.

The risk factors for in-stent restenosis following drug-eluting stent implantation in end-stage renal disease patients receiving renal replacement therapy

Abstract Background Chronic renal disease is a recognized risk factor for in-stent restenosis (ISR) following percutaneous coronary intervention (PCI) with a drug-eluting stent (DES). However, the specific risk of ISR among individuals with end-stage renal disease (ESRD) remains unclear or insufficiently studied. Purpose It is imperative to identify the risk factors associated with ISR among patients with ESRD and coronary artery disease following the implantation of DES. This identification is crucial for generating evidence-based strategies aimed at preventing ISR. Methods ESRD patients undergoing renal replacement therapy with concomitant coronary artery disease who underwent PCI with their initial DES implantation at our hospital between January 2013 and December 2022 were included in the study cohort. Clinical data, laboratory test results, and PCI specifics were compared between patients with and without ISR. Univariate and multivariate analyses utilizing Cox proportional hazard regression were employed to identify independent risk factors for DES-ISR. Results Among the 321 patients with ESRD who underwent PCI with DES implantation, totaling 874.5 patient-years of follow-up, 53 cases of ISR occurred during this period, yielding an incidence rate of 6.1 per 100 patient-years. Several baseline characteristics, angiographic findings, and procedural details were found to elevate the risk of ISR significantly. These included underlying diabetes mellitus, peripheral artery disease (PAD), high serum parathyroid hormone levels, LDL-C levels, acute coronary syndrome as the clinical presentation, the presence of triple vessel disease, duration of dual antiplatelet therapy less than 1 year, target lesion involving the left main (LM) or left anterior descending (LAD) artery, target vessel size less than 3 mm, ostial lesion, bifurcation lesion, number of stents implanted equal to or more than 3, and stent size less than 3 mm. In the multivariate Cox proportional hazard model, bifurcation lesion (HR 14.70, 95% CI 4.66-46.38), PCI of LM or LAD (HR 5.29, 95% CI 1.14-24.60), target vessel size less than 3 mm (HR 4.10, 95% CI 1.77-9.50), PAD (HR 3.92, 95% CI 1.52-10.08), and ostial lesion (HR 2.92, 95% CI 1.16-7.38) were identified as independent risk factors for ISR (all p-values &amp;lt; 0.05). Conclusions Among ESRD patients with coronary artery disease, bifurcation lesion, PCI involving the LM or LAD, target vessel size less than 3 mm, PAD, and ostial lesion are identified as independent risk factors for ISR. These findings hold significance in enhancing risk stratification and decision-making concerning treatment planning for this population.Univariate analysis risk factors for ISR

Performance and safety of complex percutaneous coronary intervention in centres without on-site cardiac surgery: a multi-centre australian registry study.

Abstract Background Performing complex percutaneous coronary intervention (PCI) procedures in hospitals with no on-site cardiac surgery (NOSCS) remains controversial due to a lack of contemporary data and guideline support. Methods Victorian Cardiac Outcomes Registry data was analysed including all PCI cases in the state of Victoria, Australia, from 2014 to 2022. Patients were stratified by PCI at sites with on-site cardiac surgery (OSCS) or NOSCS. Complex PCI was defined as PCI to unprotected left main, bifurcation lesions, rotational atherectomy or intravascular lithotripsy use, severe left ventricular systolic dysfunction, chronic total occlusion, or vein graft PCI. The primary outcome was composite MACCE comprising all-cause mortality, stroke, non-fatal MI, emergency CABG, unplanned revascularisation, definite stent thrombosis and major bleeding (BARC 3 &amp; 5) at 30-days. Risk ratio for average treatment effect in the NOSCS cohort was estimated using inverse probability treatment weighting. Results 94,268 total PCI procedures (32.6% NOSCS) were analysed, including 12,459 complex PCI cases (28.7% NOSCS). Patients from NOSCS were younger (65.0 vs 67.4, p&amp;lt;0.001), less likely to have had previous PCI (29.5% vs 34.5%, p&amp;lt;0.001) or CABG (4.6% vs 8.0% p&amp;lt;0.001) and presented more frequently with acute coronary syndromes (NSTEMI [32.0% vs 28.0%, p&amp;lt;0.001; STEMI [23.3% vs 15.2%], p&amp;lt;0.001). A propensity weighted sample of 30,850 OSCS patients and 30,692 NOSCS patients demonstrated no difference in adjusted 30-day MACCE (risk ratio 0.93, 95% CI 0.87-1.01, p=0.051) for all PCI procedures. In a propensity-weighted subgroup of 3,638 OSCS and 3,576 NOSCS patients who underwent complex PCI, there was also no difference in adjusted 30-day MACCE (risk ratio 0.97, 95%CI 0.86-1.09, p=0.60). Unadjusted rates of CABG at 30-days were very low (0.1 vs 0.1%, p=1.00). Conclusion Patients undergoing PCI and complex PCI at NOSCS centres had comparable 30-day outcomes to those treated at OSCS centres. Newer percutaneous therapies such as intravascular lithotripsy and percutaneous left ventricular assist devices may further improve safety and efficacy of high-risk PCI in NOSCS centres as operator experience increases. Increasing PCI and complex PCI capabilities at NOSCS is likely to increase equitable treatment access for more patients.