Branch Ostium Research Articles

Pulmonary Vein Anatomy is Associated with Cryo Kinetics during Cryoballoon Ablation for Atrial Fibrillation.

BackgroundThe influence of pulmonary vein (PV) anatomy on cryo kinetics during cryoballoon (CB) ablation is unclear.ObjectiveTo investigate the relationship between PV anatomy and cryo kinetics during CB ablation for atrial fibrillation (AF).MethodsSixty consecutive patients were enrolled. PV anatomy, including ostial diameters (long, short and corrected), ratio between short and long diameters, ostium shape (round, oval, triangular, and narrow), and drainage pattern (typical, with common trunk, common antrum, ostial branch and supernumerary PV) were evaluated on multi-detector computed tomography (MDCT) images pre-procedure. Cryo kinetics parameters [balloon freeze time from 0 to -30ºC (BFT), balloon nadir temperature (BNT) and balloon warming time from -30 to +15ºC (BWT)] were recorded during procedure. All p values are two-sided, with values of p < 0.05 considered to be statistically significant.Results606 times of freezing cycle were accomplished. Moderate negative correlation was documented between BNT and corrected PV diameter (r = -0.51, p < 0.001) when using 23-mm CBs, and mild negative correlation (r = - 0.32, p = 0.001) was found when using 28-mm CBs. Multivariate logistic regression analysis revealed that PV corrected ostial diameter (OR, 1.4; p = 0.004) predicted a BNT < -51ºC when using 23-mm CBs, while PV ostium oval shape (OR, 0.3; p = 0.033) and PV locations (left inferior PV: OR, 0.04; p = 0.005; right superior PV: OR, 4.3; p = 0.025) predicted BNT < -51ºC when using 28-mm CBs.ConclusionsMDCT can provide PV anatomy accurate evaluation prior CB ablation. PV anatomy is associated with cryo kinetics during ablation.

Automatic Side Branch Ostium Detection and Main Vascular Segmentation in Intravascular Optical Coherence Tomography Images.

Intravascular optical coherence tomography is the state-of-the-art imaging modality in percutaneous coronary intervention planning and evaluation, in which side branch ostium and main vascular measurements play critical roles. However, manual measurement is time consuming and labor intensive. In this paper, we propose a fully automatic method for side branch ostium detection and main vascular segmentation to make up manual deficiency. In our method, side branch ostium points are first detected and subsequently used to divide the lumen contour into side branch and main vascular regions. Based on the division, main vascular contour is then smoothly fitted for segmentation. In side branch ostium detection, our algorithm creatively converts the definition of curvature into the calculation of the signed included angles in global view, and originally applies a differential filter to highlight the feature of side branch ostium points. A total of 4618 images from 22 pullback runs were used to evaluate the performance of the presented method. The validation results of side branch detection were TPR = 82.8 $\%$, TNR = 98.7$\%$ , PPV = 86.8$\%$, NPV = 98.7$\%$. The average ostial distance error (ODE) was 0.22mm, and the DSC of main vascular segmentation was 0.96. In conclusion, the qualitative and quantitative evaluation indicated that the presented method is effective and accurate.

Use of Synchrotron Radiation to Accurately Assess Cross-Sectional Area Reduction of the Aortic Branch Ostia Caused by Suprarenal Stent Wires

Purpose: To compare in vivo the use of synchrotron radiation to computed tomography angiography (CTA) for the measurement of cross-sectional area (CSA) reduction of the aortic branch ostia caused by suprarenal stent-graft wires. Methods: This study was performed with a Zenith stent-graft placed in a phantom of the human aorta to simulate treatment of abdominal aortic aneurysm. Synchrotron radiation scans were performed using beam energies between 40 and 100 keV and spatial resolution of 19.88 μm per pixel. CSA reduction of the aortic branch ostia by suprarenal stent wires was calculated based on these exposure factors and compared with measurements from CTA images acquired on a 64-row scanner with slice thicknesses of 1.0, 1.5, and 2.0 mm. Results: Images acquired with synchrotron radiation showed <10% of the CSA occupied by stent wires when a single wire crossed a renal artery ostium and <20% for 2 wires crossing a renovisceral branch ostium. The corresponding areas ranged from 24% to 25% for a single wire and from 40% to 48% for double wires crossing the branch ostia when measured on CT images. The stent wire was accurately assessed on synchrotron radiation with a diameter between 0.38±0.01 and 0.53±0.03 mm, which is close to the actual size of 0.47±0.01 mm. The wire diameter measured on CT images was greatly overestimated (1.15±0.01 to 1.57±0.02 mm). Conclusion: CTA has inferior spatial resolution that hinders accurate assessment of CSA reduction. This experiment demonstrated the superiority of synchrotron radiation over CTA for more accurate assessment of aortic stent wires and CSA reduction of the aortic branch ostia.

Abstract 473: Dissecting Aortic Aneurym in Angiotensin II - Infused Mice: The Mechanisms Behind Lesion Variability

Angiotensin II-infused mice develop dissecting aneurysms, characterized by intramural rather than intraluminal thrombus, suprarenal rather than infrarenal lesions, medial dissections rather than circumferential elastin degradation and a variability in lesion shape that remained as yet unexplained. In order to provide insight into these intriguing lesions we scanned murine aortas at baseline and after 10, 18 and 29 days of Angiotensin II infusion, both in vivo (ultrasound, micro-CT) and ex vivo (phase-contrast X-ray tomographic microscopy). Dissecting aneurysms of varying severity occurred in 31/34 mice. All of these were characterized by a medial tear near the ostium of thoracic and abdominal aortic side branches, with a predilection for the left and ventral aspects of the ostium of the celiac artery. In 25/31 animals an intramural hematoma was formed. Fully ruptured branch ostia occurred significantly more often in the supraceliac aorta, affecting in particular the left suprarenal artery (the first branch cranial to the celiac artery, 23/25). Animals with a thoracic tear (6/31) had significantly larger intramural hematoma than animals with an abdominal tear (p&lt;0.05), and the length of the hematoma correlated to the number of ruptured side branches (r 2 =0.78). In 11 mice a parallel false channel was formed. The volume of free-flowing intramural blood in the false channel was significantly larger for left than for ventral tears, but was not related to the length of the tear. Our data suggest that (i) medial tears are the primary event in dissecting AAA formation, (ii) an intramural hematoma is formed if the adventitia covering the medial tear dissects and leads to the accumulation of intramural blood from ruptured side branches, (iii) adventitial dissection and hematoma formation progress in the direction of least resistance/smallest side branches (i.e. cranial of the celiac artery) and (iv) a false channel is formed if the radial expansion of the adventitia due to blood flowing out of the medial tear acts in the same (leftward) direction as the expansion due to a ruptured left suprarenal artery. We conclude that Ang II-infused mice can be a valuable model to study the under-researched role of side branches in the formation and progression of aortic dissections.

Angiographic study of the clinical liaison of drug-eluting stent and paclitaxel-eluting balloon in unifocal side branch ostium stenosis (ASCLEPIUS).

A reliable stenting strategy for treating isolated side branch (SB) ostium stenosis is not well established. The purpose of this study was to examine the 6-month angiographic outcome of a novel technique, called the shoulder technique, on this lesion subtype. Symptomatic patients with isolated SB ostium stenosis, defined as ≥75% diameter stenosis at SB ostium and <50% diameter stenosis in main vessel (MV), were treated with paclitaxel-eluting balloon in MV and drug-eluting stent in SB using the shoulder technique. Angiographic restudy was performed at 5-9months and clinical follow-up was scheduled regularly every 3months. There were 46 patients of age 66 ± 12years with male predominance (76%) recruited. Diagonal ostium (67%) was the most frequent target lesion site. The size and length of paclitaxel-eluting balloon and drug-eluting stent used in MV and SB were 3.01 ± 0.25 and 20 ± 4mm, and 2.39 ± 0.25 and 17 ± 6mm, respectively. Angiographic restudy was performed on 43 (93.5%) patients at 6.5 ± 1.6months. The late loss in MV and SB were 0.04 ± 0.19 and 0.19 ± 0.32mm, respectively. Angiographic restensosis was seen in 2 (4.7%) patients at SB, whereas no stenosis was induced in MV. Improvement of symptom was reported in 36 (78%) patients. At 1-year follow-up, no death, myocardial infarction, and stent thrombosis was observed; target vessel revascularization was performed on 3 (6.5%) patients. Treatment of isolated SB ostium stenosis using the shoulder technique is associated with a favorable short-term angiographic outcome.

Difference in vascular response between sirolimus-eluting- and everolimus-eluting stents in ostial left circumflex artery after unprotected left main as observed by optical coherence tomography

BackgroundKissing-balloon technique (KBT) is commonly performed during percutaneous coronary intervention of distal unprotected left main coronary artery (ULM) aiming at obtaining optimal opening of the side branch (left circumflex artery; LCX) ostium. Nonetheless, detailed evaluation of vascular response to stents in LCX ostium is lacking. We therefore evaluated the vascular response to different drug-eluting stents (DES) in ostial LCX after ULM by means of optical coherence tomography (OCT). MethodsWe prospectively enrolled 38 consecutive patients with ULM disease, who were treated with single-stent procedure using DES, crossover the ULM-left anterior descending artery (LAD) followed by KBT. Twelve patients were treated with sirolimus-eluting stents (SES) and 26 patients were treated with everolimus-eluting stents (EES). OCT was conducted at post-PCI and 9-month follow-up. We evaluated the DES–vessel interactions and number of stent struts at the side branch (LCX) ostium (SO) at post-PCI, and compared the narrowing of ostial area at LCX between SES and EES. ResultsPost-procedure, the number of stent struts at SO was significantly higher in SES compared to EES (median 14.47% vs 0.19%, p<0.001). The narrowing of LCX ostial area at follow-up was more pronounced in SES compared with EES (29.16% vs 2.46%, respectively, p<0.001). Linear regression analysis showed a high correlation between the number of stent struts in LCX ostium and ostial area narrowing (r=0.771, p<0.001). ConclusionsOCT showed differences between EES– and SES–vessel interactions at ULM bifurcation PCI. Number of LCX ostium struts at post-PCI impacted the narrowing of ostial area at 9-month follow-up.

Impact of branching angle on neointimal coverage of drug-eluting stents implanted in bifurcation lesions

To investigate the impact of branching angle (BA) on neointimal coverage of drug-eluting stents (DESs) in bifurcation lesions. Previous experimental studies indicated that BA influences the local flow turbulence and wall shear stress, which are associated with neointimal coverage of DESs. Fifty-five bifurcation lesions in 47 patients were evaluated by serial optical coherence tomography (OCT) before DES implantation and at follow-up. Neointimal coverage was assessed in cross-sectional OCT images containing the side branch; regions including the side branch ostium (SO) and vessel wall (VW) were assessed separately. BA was measured using angiography (Angio-BA) and longitudinal OCT imaging (OCT-BA). In the SO region, a significant negative correlation was found between the uncovered strut percentage and Angio-BA or OCT-BA (r=-0.41, P=0.0024; r=-0.33, P=0.0167, respectively) and a significant positive correlation was found between Angio-BA and average neointimal thickness (r=0.31, P=0.025), whereas no correlation was observed between OCT-BA and average neointimal thickness (r=0.20, P=0.158). In the VW region, no correlation was found between Angio-BA or OCT-BA and the uncovered strut percentage or average neointimal thickness. BA influence the neointimal coverage over DES struts in the SO at coronary bifurcation lesions, but not in those attached to the VW.

Neointimal response to everolimus-eluting bioresorbable scaffolds implanted at bifurcating coronary segments: insights from optical coherence tomography.

Heterogeneity of neointimal thickness is observed after drug-eluting stents implantation in bifurcation lesions (BL). We evaluated the vascular response of everolimus-eluting bioresorbable scaffold (BRS) struts deployed at BL using optical coherence tomography (OCT). 50 patients (64 scaffolds) underwent follow-up OCT after BRS implantation. Cross-sectional areas of each BL with a side branch more than 1.5mm were analyzed using OCT every 200µm. All images were divided into three regions according to shear stress: the 1/2 circumference of the vessel opposite to the ostium (OO), the vessel wall adjacent to the ostium (AO) and the side-branch ostium (SO). The %uncovered strut and the averaged neointimal thickness (NIT) were calculated. Overall, there were significant differences in both NIT and %uncovered strut among the three regions (OO, 119.2 ± 68.5μm vs. AO, 94.2 ± 35.7μm vs. SO, 80.5 ± 41.4μm, p = 0.03; OO, 0.4 %vs. AO, 1.4 %vs. SO, 4.8 %, p = 0.02). Scaffolds were divided into two groups: a large-ratio side-branch group (LRSB; n = 32) and a small-ratio side-branch group (SRSB; n = 32), based on the median value of the ratio of the diameter of side branch ostium (Ds) to that of the main branch (Dm). In the LRSB alone, there were significant differences in both NIT and %uncovered strut among the three regions (OO, 128.0 ± 61.1μm vs. AO, 97.3 ± 34.3μm vs. SO, 75.9 ± 39.4μm, p < 0.01; OO, 0.3 % vs. AO, 2.3 % vs. SO, 8.7 %, p < 0.01). After BRS implantation in BL, neointimal response was pronounced at the vessel wall opposite to the side branch ostium, especially in those with large side branches.

A Combination of Drug-Eluting Stents and Bioresorbable Vascular Scaffolds in the Treatment of Multivessel Coronary Artery Disease.

Optimal management of multivessel coronary artery disease can be complex. We report a 67-year-old male patient who was admitted to the Padua University Hospital, Padua, Italy, in 2014 with a non-ST-elevation myocardial infarction. Coronary angiography showed diffuse multiple sub-occlusive lesions of the proximal and distal left coronary vessels involving a long segment of the vessel. On intravascular ultrasonography (IVUS), the left main artery was moderately diseased with critically stenotic and calcified branch ostia. A successful percutaneous coronary intervention using the T-stenting and small protrusion technique with two drug-eluting stents (DES) was performed on the left main artery and its main branches. Two bioresorbable vascular scaffolds were also deployed in overlap at the mid to distal segments of the left anterior descending artery and overlapping a previous DES at the proximal segment. The full expansion and apposition of the struts and scaffolds to the vessel wall without residual stenosis was confirmed by IVUS.

The fate of small side branches following drug eluting stent implantation

ObjectivesAlthough drug eluting stents (DES) have documented convenience in bifurcation lesions, possible unfavorable effects on small side branch ostium (SBO) remain a question. We aimed to explore the effects of DES on small jailed SBs (1.5–2.25mm) which originated from the lesion on the main vessel and were not treated with either stenting or balloon dilatation. MethodsAngiographic data of 107 consecutive patients (129 SB) with Medina 1,1,1 or 1,1,0 lesions were evaluated at the time of procedure and at the follow-up. ResultsOf all DES used, 70 (54.7%) was sirolimus-eluting, 39 (30.5%) was paclitaxel-eluting and 20 (14.8%) was zotarolimus-eluting. The diameter of SBs was 1.84±0.41mm with a stenosis of 20.7±26.6% at SBO at baseline. The lesion at the SBO had progressed after the procedure when the pre vs postprocedure values and follow-up vs pre-procedure values are compared (20.7±26.6% vs 29.4±27.4%; p<0.0001 and 25.4±25.1 vs 20.7±26.6%; p=0.004 respectively). A significant reduction in stenosis was revealed over the follow-up (29.4±27.4 vs 25.4±25.1 respectively; p=0.013). The severity of the disease at the SBO at baseline was the only parameter that affected the severity of SB stenosis in acute, longterm and follow-up. Additional parameters with influence on SB patency at different times were female gender, stent deployment with low pressure, cTFC of the main lesion, age, cTFC of the lesion, late loss index and the preprocedure TIMI flow grade of the SB. ConclusionsAlthough there was a significant deterioration of SBO immediately after stenting, follow-up data showed that the lesion at SBO improved but remained worse than baseline.

Practical based approach to left main bifurcation stenting.

Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method.

Differences of side branch jailing between left main-left anterior descending artery stenting and left main-left circumflex artery stenting with Nobori biolimus-eluting stent.

The aim of this study is to indicate differences of side branch jailing between the left main (LM)-left anterior descending artery (LAD) stenting and the LM-left circumflex artery (LCx) stenting. Thirty-one patients who underwent single-stenting using a two-link ten-crowns biolimus-eluting stent (Japanese design of BES, J-BES) and subsequent kissing balloon dilation (KBD) on an LM bifurcation with optical coherence tomography (OCT) were divided into two groups according to the stented vessel. Bifurcation angles were measured by three-dimensional (3D) quantitative coronary analysis. The jailing pattern on a side branch ostium was evaluated by stent-enhanced 3D-OCT. Incomplete stent apposition (ISA) after KBD was compared between the stented vessels. The to-be-stented angle of the LM-LCx stenting (n=11) was significantly steeper than that of the LM-LAD stenting (n=20) (132.6°±16.9° vs. 150.7°±10.6°, p<0.01). The incidence of the free carina type, which has no stent links bridging from a carina, in the LM-LCx stenting was significantly higher than that in the LM-LAD stenting (90.9 vs. 45.0%, p=0.02). The percentage of ISA at the bifurcation segment in the LM-LCx stenting was significantly smaller than that in the LM-LAD stenting (4.4±8.2 vs. 12.7±9.2%, p=0.0003). This study showed, by higher incidence of the favorable configuration, that the LM-LCx stenting achieved a smaller percentage of ISA than the LM-LAD stenting. These insights may help guide LM bifurcation stenting with J-BES.

Recent Perspectives on Left Main Bifurcation Interventions

For several decades, coronary bypass grafting has been considered as the gold standard treatment of unprotected left main (LM) disease. However, because of large vessel caliber and anatomic accessibility, percutaneous coronary intervention (PCI) for LM has been attractive option for interventional cardiologists. PCI of LM bifurcation can be technically demanding that warrants reinforcement of integrated approach combining advanced devices, tailored techniques, adjunctive support of physiologic evaluation, and adjunctive pharmacologic agents. The provisional one -stent approach has shown more favourable outcome than two-stent technique, making the former the preferred strategy in most types of LM bifurcation lesions. In complex lesions, two-stent technique may be required and may yield superior results. Selecting the proper strategy using intravascular ultrasound for ostium of the side branch (SB) is critical for reducing the risk for SB occlusion and for improving patient's outcome. Even unnecessary complex interventions can be deferred by measuring fractional flow reserve in angiographic isolated SB. Importantly, final successful procedure is more important than the type of stenting technique., emphasizing the greater importance of optimizing the selected technique rather than choice of method. Alongside the evolution of bifurcation techniques, there has been development of several dedicated bifurcation stents which are safe and effective in LM bifurcation PCI both at short and mid-term follow up.

0531: Retrospective monocentric study of coronary bifurcation lesions treated with a dedicated stent Nile Pax

To demonstrate the acute and early outcomes of the Nile PAX dedicated polymer-free paclitaxel-coated stents in the treatment of the coronary bifurcation lesions. The Nile PAX device incorporates a cobalt-chromium alloy with a side aperture in the mid-stent designed to optimize scaffold at the bifurcation carina and side branch (SB) ostium, while maintaining SB access during procedure. From January 2012 to December 2014, 36 patients were included in a retrospective, monocentric study. Lesion criteria were: vessel size 2.5-3.5mm in the parent vessel (PV) and 2.0-3.0mm in the SB, regardless of the lesion length. Average age was 63,1 years, 22% of patientshad diabetesand 51% had acute coronary syndrome, while LAD/Dg was involved in 67% of cases. Percutaneous coronary intervention (PCI) Ad-Hoc was done for 40%of lesions. SB received additional stent in 8% of procedures and final kissing-balloon inflation was performed in 89% of procedures. There was three non-Q myocardial infarctions: one during hospitalization, and two up to 6 months.In addition to these three Major adverse cardiacevents (MACE), two other patients underwent a target lesion revascularization due to astable angina. Preliminary results of this retro-prospective monocentric study demonstrated encouraging results with the Nile PAX bifurcation DES in the treatment of coronary bifurcation lesions, including high device and procedural success.

Abstract 9908: Three-dimensional Optical Coherence Tomographic Analysis of Eccentric Morphology of the Jailed Side-branch Ostium in Coronary Bifurcation Lesions

Introduction: Using the 3D-OCT, morphologic changes in the jailed side- branch ostium were evaluated before and after a single stent crossover at coronary bifurcation lesions. Hypothesis: The severity of angiographic diameter stenosis of the jailed side-branch ostium is usually overestimated over the three-dimensional (3D) optical coherence tomography (OCT)-measured actual stenosis. Methods: In 109 patients who received a single stent crossover at coronary bifurcation lesions, the pre- and post-intervention minimal lumen area (MLA) and the eccentricity of the jailed side-branch ostium were measured with 3D-OCT. The eccentricity index was defined as the ratio of maximal diameter/minimal diameter of the jailed side-branch ostium. When the eccentricity index was &lt;1.5, the shape of the jailed side-branch ostium was defined as circular. The MLA of the jailed side-branch ostium was also calculated from the quantitative coronary angiography (QCA) minimal lumen diameter assuming a circular lumen. Results: The 3D-OCT-measured MLA of the jailed side-branch ostium decreased from 2.91±1.65 mm2 pre-intervention to 2.37±1.48 mm2 post-intervention (p&lt;0.01). The QCA- derived MLA also decreased from 2.35±1.71 mm2 pre-intervention to 1.68±1.56 mm2 post- intervention (p&lt;0.01). However, the 3D-OCT-measured MLA was significantly larger than the QCA-derived MLA (p&lt;0.01). The shape of the jailed side-branch ostium changed from circular to elliptical after the stent implantation (eccentricity index: 1.40±0.33 pre- intervention; 1.71±0.60 post-intervention, p&lt;0.01). Conclusions: Compared to QCA measurements, 3D-OCT analysis could be useful to guide decision for additional intervention or not after stent implantation across coronary bifurcation lesions.

Abstract 18189: Neointimal Response to Everolimus-eluting Bioresorbable Scaffolds Implanted at Bifurcating Coronary Segments: An Optical Coherence Tomography Study

Background: Previous studies have described different patterns of neointimal coverage between the outer wall and inner wall at coronary bifurcations lesions (BL) treated with metallic drug-eluting stents (DES) due to endothelial shear stress. Everolimus-eluting bioresorbable scaffolds (BRS) have thicker struts and could therefore have a stronger influence on endothelial shear stress compared to DES. However, the neointimal coverage of BL treated with BRS has not been adequately studied. We sought to evaluate the vascular response to BRS struts deployed at BL using optical coherence tomography (OCT). Methods: 50 patients (64 lesions) underwent follow-up OCT 11.0 ± 2.1 months after BRS implantation. Cross-sectional area of BL with a side branch more than 1mm using OCT was analyzed every 200μm. All images were divided into 3 regions according to shear stress: the 1/2 circumference of the vessel opposite to the ostium (OO), side branch ostium (SO), and the vessel wall adjacent to the ostium (AO). %uncovered strut of all struts and the averaged neointimal thickness (NIT) in 3 regions were evaluated. Additionally, to assess the impact of the side branch size on neointimal proliferation in BL, we calculated the ratio of the diameter of side branch ostium (Ds) to the diameter of main branch (Dm) (Ds/Dm) and divided patients into two groups based on median value of Ds/Dm of 0.318 as follow: large ratio side branch group (LRSB, n=32) and small ratio side branch group (SRSB, n=32). Results: Mean BRS diameter and length were 3.01±0.37 and 20.7±5.5mm. Mean diameter of all side branches was 1.69±0.51mm. In all patients, there was a significant difference in NIT among 3 regions (OO, 121±66 vs. AO, 96±32 vs. SO, 82±43μm, p=0.03). A significant difference was shown in %uncovered strut among 3 regions (OO, 0.45 vs. AO, 1.5 vs. SO, 4.7%, p=0.03). Further, in LRSB group, there was a significant difference in NIT among 3 regions (OO, 130±63 vs. AO, 92±38 vs. SO, 75±39 μm, p=0.01), and a significant difference was shown in %uncovered strut among 3 regions (OO, 0.37 vs. AO, 2.0 vs. SO, 8.8%, p=0.01). Conclusion: Different patterns of neointimal coverage are observed between the outer wall and inner wall of BL treated with BRS. Neointimal coverage is least at and adjacent to large side branches.

Clinical outcomes following target lesion revascularization for bioresorbable scaffold failure.

To investigate clinical outcomes following target lesion revascularization (TLR) for bioresorbable scaffold (BRS) failure in a real world population. BRS has become a new option in percutaneous coronary intervention, and may be potentially advantages because of the absence of a permanent metallic cage and the possibility for restoration of vasomotion and endothelial function. However, the requirement for TLR following BRS has been reported, but data on outcomes following reintervention are currently lacking. Eighteen patients (20 lesions) who underwent TLR for BRS failure were identified at two high-volume centers in Milan, Italy. Clinical outcomes including all cause death, myocardial infarction, and repeat TLR after TLR for BRS failure were examined. The type of scaffold failure at TLR was classified into focal pattern in 15 lesions, diffuse pattern in two lesions, restenosis at side branch ostium in one lesion and scaffold thrombosis in two lesions. TLR was treated with plain old balloon angioplasty (POBA) in two lesions, with drug-coating balloon in three lesions, drug eluting stent implantation in 11 lesions, further BRS implantation in four lesions. During the followup (median: 345 days after TLR), one sudden death and three repeat TLRs were observed. In our series, we observed an adverse event rate of 20% of during the followup period following TLR for BRS failure. The optimal treatment option for these patients remains to be determined.

Balloon crushing of a protruding everolimus-eluting stent for isolated coronary stenosis at the side branch ostium

Balloon crushing of a protruding everolimus-eluting stent for isolated coronary stenosis at the side branch ostium

Technical aspects of the T And small Protrusion (TAP) technique.

The T and small protrusion (TAP) technique is a modification of provisional T-stenting aimed at optimising "bail-out" SB stent implantation in bifurcated coronary lesions treated using the "provisional" approach. The main strengths of the TAP stenting technique are: compatibility with 6 Fr guiding catheters, full coverage of the side branch ostium, and facilitation of final kissing balloon inflation. The main drawback of TAP is related to the creation of a single layer stent strut neocarina of variable length. In this paper, we review the technical aspects which should be considered in order to achieve TAP stenting successfully in the case of "bail-out" need for side branch stenting. Furthermore, we report the technical details which may help in the practice of TAP stenting in complex bifurcated lesions with the anticipated high probability of requiring double stenting. Although no large trial has investigated this technique, the clinical results reported so far look promising.

Technical aspects of the culotte technique.

The culotte technique provides near perfect coverage of the carina and side branch ostium at the expense of an excess of metal covering the proximal end. It can be used in almost all true bifurcation lesions, but should be avoided in bifurcations when there is a large mismatch between the proximal main branch and the side branch diameters. The main disadvantage of this technique is that rewiring of both branches through the stent struts is required, which can be difficult, technically demanding, and time-consuming.