Treatment Of Coronary Bifurcations Research Articles

Coronary artery bifurcation interventions: The disconnect between randomized clinical trials and patient centered decision‐making

The current evidence-base pertaining to PCI in coronary bifurcation lesions is not adequate to inform decision making in all patients, hence a gap still exists between the evidence-base and patient-centered decision-making. Although meta-analyses of the existing RCTs improve the statistical power of the data they do not remedy the problem of trial design. The reason for the gap between "evidence" and patient-centered decision-making is that the research methodology used in the RCTs does not simulate the questions asked in practice. The purpose of this review is to make the case for a counter perspective to the narrative that provisional stenting (PS) [stenting the main vessel (MV), with additional stenting of the side branch (SB) only in the case of an unsatisfactory result] is better than elective double stenting (EDS) of both branches in all patients. Namely, that neither approach should be the default strategy in all patients with bifurcation lesions and a decision as to which technique to use should be based on the patient's bifurcation anatomy. The majority of patients with bifurcation lesions will have anatomy that can be safely treated with PS; however, some patients have "at risk" bifurcation anatomy where PS may be associated with high risk of side branch occlusion.

Provisional side branch stenting for the treatment of bifurcation lesions

resulting in lowerangiographic success rates, higher complication rates andincreased risk of restenosis. Therefore, the treatment of coronarybifurcation lesions is part of the history of coronary angioplasty andkissing balloon inflation for example was strongly recommended asearly as the 80s.Though the use of bare metal stents (BMS) and subsequently drug-eluting stents (DES) was instrumental in improving acute results, anumber of difficulties still remained to be overcome. Manytherapeutic strategies, techniques, tips and tricks have beenproposed, some of them in contradiction with simple basic data; allthis has made the topic of coronary bifurcation treatment one of themost debated issues in the field of interventional cardiology.After the plain old balloon period and some unsuccessful attemptswith atherectomy, the advent of stenting resulted in a high creativityby interventional cardiologists in the 90s

Randomized study on provisional stenting with sirolimus-eluting stent vs. bare metal stent for the treatment of true coronary bifurcations: The PROSUMER (PROvisional with sirolimus-eluting vs. bare metal stents in truE bifuRcations) study

⁎ Corresponding author. Via Tommaso Inghirami 85, 00179 Rome, Italy. Tel.: +39 348 3392006; fax: +39 06 330 62516. E-mail address: f.pelliccia@mclink.it (F. Pelliccia). Percutaneous treatment of coronary bifurcations with stent implantation is still a matter of debate [1]. Despite the implementation of numerous techniques to stent both branches, none has shown clinical and angiographic superiority to the main branch (MB) stent technique with provisional T-stenting of the side branch (SB) in case of dissection or residual severe disease [2]. In addition, concerns have been raised about safety of drug-eluting stents (DES) because of the greater late and very late [3] stent thrombosis and mortality as compared to bare metal stents (BMS). Also, technical characteristics of stents (i.e. high radial force, favorable vessel wall covering percentage and larger patency of SBs) seem to be crucial factors in case of provisional T-stenting strategy [2,4]. To address these issues, we designed the PROSUMER (PROvisional with sirolimus-eluting vs. bare metal stents in truE bifuRcations) study in order to prospectively and randomly compare the safety and efficacy of sirolimus-eluting stent (SES) vs. a BMS in case of treatment of true coronary bifurcation lesions with provisional T-stenting. The studywasdesigned as a prospective, single-center pilot trial, and included consecutive angina patients with a de novo true coronary arterybifurcation lesion (Medina classifications1,1,1 or 1,0,1 or0,1,1)[5] who were allocated to SES (CypherTM, Johnson & Johnson, Miami Lakes, Fla) or a novel BMS (Horus S, International Biomedical Systems, Trieste, Italy). The BMS under investigation is made from 316 LVM stainless steel. The stent is a cylindrical helix with sinusoidal loops, consisting of medical-grade stainless-steel continuouswire, that has high radial force (1.5% diameter reduction at 200 mm Hg) with good scaffolding and favorable vesselwall coveragewith patency of SBs (covering percentage in the expanding state ranging between 19.1%—2.5 mm and 16.2%— 3.5 mm).All patientswere followedup to9 months. Theprimary clinical end point of the study was the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiac or noncardiac death, Q-wave or non-Q-wave myocardial infarction, or target vessel revascularization. The primary angiographic end point of the study was the insegment per cent diameter stenosis of the SB at 9 month follow-up. Coronary angiograms were analyzed off-line with the use of an automated edge-detection system (Cardiovascular Medical System, MEDIS Imaging Systems, Leiden). Sixty consecutive patients (age: 62±12 years) were randomized to a SES (N=30) or a BMS (N=30) in the MB. The two study groups did not show any significant difference in baseline clinical and angiographic characteristics. Procedural success after stenting the MB was similar in the two groups (97%), with 2 cases of periprocedural non-Q-wave myocardial infarction (1 in the SES group and in 1 in the BMS group) caused by periprocedural occlusion of the nonstented SB because of dissection. The primary clinical endpoint of the study, cumulative MACE at 9month follow-up, occurred in 6 patients of the SES group and in 4 patients of the BMS group (20 vs. 17%; P=1.00) (Table 1). During follow-up, no patient died, but one patient of the SES group had stent thrombosis. No significant differences in the rate of target lesion revascularization and target vessel revascularization occurred between the two groups (Table 1). The primary study angiographic endpoint did not differ significantly between the SES and BMS groups (20% vs. 34%, P=0.38). When restenosis rates were analyzed by restenosis site, the two groups showed similar rates of binary restenosis occurring in both MB and SB, in MB only and in SB only (Table 1). Quantitative data at follow-up angiography (Table 2) revealed that, as compared with the BMS group, the SES group had significantly larger minimal lumen diameter and percent diameter restenosis as well as lower late loss at MB. Conversely, no significant difference was found between the two study groups in any angiographic variable at SB. The PROSUMER study shows that good long-term results when treating coronary bifurcations can be achieved with a strategy of provisional stenting with BMS as compared with SES, provided that a stent with favorable technical characteristics for bifurcations coupled with an optimal delivery technique are adopted. The results of PROSUMER show that binary restenosis rate at 9-month control angiography did not differ significantly between the SES and BMS

Recent Perspective on Coronary Bifurcation Intervention: Statement of the “Bifurcation Club in KOKURA”

The treatment of coronary bifurcation lesion remains a challenging issue even in the drug-eluting stent era. Frequent restenosis and stent thrombosis have been recently shown to be related not only to geometrical gap or stent structural deformation but also to rheological disturbance. Low wall shear stress at the lateral side of the bifurcation is likely to cause atherosclerotic changes due to easy access of the macrophages that induce chemical mediators. The turbulent flow over stent metal may facilitate accumulation of platelets, which results in thrombosis. The jailed strut and excess metal overlap may increase these risks. Since dramatic changes of the coronary flow pattern at the bifurcation are closely related to the genesis of atherosclerosis, future bifurcation intervention technique should be considered to restore the original physiological state as well as the anatomical structure. This article summarizes the global consensus of the members of the Asian Bifurcation Club and European Bifurcation Club at the KOKURA meeting. It also provides a perspective of basic sciences relating to bifurcation anatomy, physiology, and pathology, in the search for a best strategy for bifurcation intervention.

Guide wire fracture during percutaneous transluminal coronary angioplasty: possible causes and management

A 46-year-old woman underwent diagnostic coronary angiography in our institution due to a myocardial ischemia following a dobutamine echo-stress test. The patient showed critical stenosis of the left anterior descending (LAD) artery involving the ostium of a large diagonal branch. The planned treatment of coronary bifurcation by percutaneous coronary intervention (PCI) was direct stenting of the main branch with 'jailed' wire technique to protect the side branch, provisional T stenting of the side branch, and final kissing balloon inflation. After successful stent implantation in the LAD, the 'jailed' wire fractured during withdrawal: the distal part of the fragment was trapped in the side branch, and the proximal one was knotted in the LAD, left main coronary and the aortic bulb. We decided not to retrieve the fragment by snare, and we planned heart surgery to safely retrieve the fragment and bypass the side branch not treated by percutaneous coronary interventions. Angiographic control nine months after surgery showed non in-stent restenosis; patient is alive and event-free at 18 months' clinical follow-up. In conclusion, percutaneous management of particularly complex bifurcational lesions may be associated with procedural risks; accordingly, it is important to consider and be ready for a rescue surgical revascularization.

Sirolimus- Versus Paclitaxel-Eluting Stents for the Treatment of Coronary Bifurcations: Results From the COBIS (Coronary Bifurcation Stenting) Registry

We aimed to compare the long-term clinical outcomes of patients treated with sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) for coronary bifurcation lesions. There are limited data regarding comparisons of SES and PES for the treatment of bifurcation lesions. Patients who received percutaneous coronary intervention for non-left main bifurcation lesions were enrolled from 16 centers in Korea between January 2004 and June 2006. We compared major adverse cardiac events (MACE [cardiac death, myocardial infarction, or target lesion revascularization]) between the SES and PES groups in patients overall and in 407 patient pairs generated by propensity-score matching. We evaluated 1,033 patients with bifurcation lesions treated with SES and 562 patients treated with PES. The median follow-up duration was 22 months. Treatment with SES was associated with a lower incidence of MACE (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.32 to 0.89, p < 0.01) and target lesion revascularization (HR: 0.55, 95% CI: 0.31 to 0.97, p = 0.02), but not of cardiac death (HR: 2.77, 95% CI: 0.40 to 18.99, p = 0.62) and cardiac death or myocardial infarction (HR: 0.97, 95% CI: 0.38 to 2.49, p = 0.94). After propensity-score matching, patients with SES still had fewer MACE and target lesion revascularization incidences than did patients with PES (HR: 0.52, 95% CI: 0.30 to 0.91, p = 0.02, and HR: 0.48, 95% CI: 0.25 to 0.91, p = 0.02, respectively). There was no significant difference in the occurrences of stent thrombosis between the groups (0.7% vs. 0.7%, p = 0.94). In patients with bifurcation lesions, the use of SES resulted in better long-term outcomes than did the use of PES, primarily by decreasing the rate of repeat revascularization. (Coronary Bifurcation Stenting Registry in South Korea [COBIS]; NCT00851526)

Long-term outcome of percutaneous catheter intervention for de novo coronary bifurcation lesions with drug-eluting stents or bare-metal stents

The purpose of this study was to assess the long-term risks and benefits of drug-eluting stents (DESs) compared with bare-metal stents (BMSs) for treatment of coronary bifurcation lesions. Our registry comprised 1,038 patients treated for coronary bifurcation lesion according to the provisional T-stenting strategy who were followed up for 3 years. Target lesion revascularization rates were 24.3% for BMSs (n = 337), 15.6% for sirolimus-eluting stents (SESs, n = 422), and 17.3% for paclitaxel-eluting stents (PESs, n = 279) (P = .003 BMSs vs DESs, P = .54 SESs vs PESs). The respective incidences were 11.4%, 9.5%, and 14.8% (P = .65, P = .13) for death and myocardial infarction and 9.9%, 6.5%, and 10.6% (P = .72, P = .19) for death. Propensity score adjusted hazard ratios (95% CI) for DESs versus BMSs were 0.49 (0.35-0.68, P < .001) for target lesion revascularization, 0.94 (0.64-1.40, P = .078) for death and myocardial infarction, and 0.85 (0.55-1.32, P = .47) for death. We did not find any significant differences between SESs and PESs, except for an increased risk of death after PESs compared with SESs (but not BMSs) in the subgroup receiving a side-branch stent (adjusted hazard ratio 2.45, 95% CI 1.05-5.73, P = .035). Compared with BMSs, both PESs and SESs substantially reduced the long-term need for repeated revascularization but did not increase the risk of death and myocardial infarction.

Modelling of the provisional side-branch stenting approach for the treatment of atherosclerotic coronary bifurcations: effects of stent positioning

The most common approach to treat atherosclerosis in coronary bifurcations is the provisional side-branch (PSB) stenting, which consists sequentially of the insertion of a stent in the main branch (MB) of the bifurcation and a dilatation of the side branch (SB) passing through the struts of the stent at the bifurcation. This approach can be followed by a redilatation of the MB only or by a Final Kissing Balloon (FKB) inflation, both strategies leading to a minor stent distortion in the MB. The positioning of the stent struts in the bifurcation and the stresses generated in the stent and vessel wall are worthy of investigation for a better understanding of the mechanobiology of the system. For this purpose, a computer model of an atherosclerotic coronary bifurcation based on the finite element method was developed; the effects of performing the final redilatation with the two strategies utilising one or two balloons and those created by a different stent strut positioning around the SB were investigated. Results correlate well with previous experimental tests regarding the deformation following balloon expansion. Furthermore, results confirm firstly that the re-establishment of an optimal spatial configuration of the stent after the PSB approach is achieved with both strategies; secondly, results show that case of stent positioning with one cell placed centrally (with regard to the SB) should be preferred, avoiding the presence of struts inside the vessel lumen, which may reduce hemodynamic disturbances. The central positioning also resulted in a better solution in terms of lower stresses in the stent struts and, more importantly, in the vascular tissues.

Percutaneous Coronary Intervention for Complex Bifurcation Lesions

Coronary bifurcations are prone to the development of atherosclerosis. They pose technical difficulties for angioplasty treatment and are a predictor of stent thrombosis and restenosis. Treatment of coronary bifurcations is still subject to debate, especially when the side branch (SB) is large, not easily accessible and narrowed by a long lesion. There is currently no indexed treatment for this type of lesion (Medina classification), as the strategy of provisional SB stenting with drug-eluting stents (DES) has proved to be equally efficient as the dualstent technique. Complex techniques are associated with poor outcome in certain lesion types, such as T-stenting when the angle between the two distal branches is small or the crush and culotte technique in the presence of an open angle. Provisional SB stenting may be used when primary dual stenting is required, with a low risk of failure provided that the following guidelines are implemented: stenting of the main branch through the protected SB with a stent diameter adapted to the distal main branch, immediate optimisation of the proximal stent segment (Finet’s law), guidewire exchange, kissing balloon inflation with non-compliant balloons selected according to the diameter of the distal branches and T-stenting of the SB before final kissing inflation.

9-Month Clinical, Angiographic, and Intravascular Ultrasound Results of a Prospective Evaluation of the Axxess Self-Expanding Biolimus A9-Eluting Stent in Coronary Bifurcation Lesions: The DIVERGE (Drug-Eluting Stent Intervention for Treating Side Branches Effectively) Study

This study sought to assess the safety and performance of the Axxess (Devax Inc., Lake Forest, California) self-expanding drug-eluting stent in coronary bifurcation lesions. Percutaneous treatment of coronary bifurcations is a predictor of adverse late outcomes, in part because of the lack of dedicated devices. Patients with de novo bifurcation lesions were prospectively enrolled in a multicenter study. The Axxess stent was deployed at the level of the carina followed by additional sirolimus-eluting stents in the distal parent vessel (PV) and/or side branch (SB). All patients underwent clinical follow-up at 9 months; 150 were to receive control angiography and 76 were to receive intravascular ultrasound. The primary end point was the rate of major adverse cardiac events (MACE): a composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). Secondary end points included in-segment restenosis, late loss, and percent neointimal volume obstruction. Overall, 302 patients were treated with 299 Axxess stents (99%). Additional stenting of 1 branch was performed in 21.7% of patients (17.7% PV, 4% SB), and of both branches in 64.7%. At 9 months, 99.3% of patients returned for clinical follow-up; from the angiographic and IVUS substudies, 93.3% and 89.4% returned. The cumulative 9-month MACE rate was 7.7% (0.7% death, 3.3% non-Q-wave MI, 1.0% Q-wave MI, 4.3% TLR). Subacute and late stent thrombosis occurred in 0.7% and 0.3% of patients. Total restenosis was 6.4% (3.6% PV, 4.3% SB), late loss was 0.20 +/- 0.41 mm in the PV and 0.17 +/- 0.34 mm in the SB. In the Axxess stent segment, percent neointimal volume obstruction was 4.3 +/- 5.2%. This prospective multicenter study confirms the safety and performance of the Axxess stent in bifurcation lesions. (Drug-Eluting Stent Intervention for Treating Side Branches Effectively; ACTRN12606000259549).

A novel paclitaxel‐eluting dedicated bifurcation stent: A case report from the first human use Taxus Petal trial

A dedicated bifurcation stent has the potential to simplify and improve the outcomes of percutaneous coronary bifurcation intervention. We report a patient from the first human use trial of a novel paclitaxel-eluting dedicated bifurcation stent. By 6 months, there were no adverse events and the stent lumen and, in particular, the side-branch ostium were widely patent on angiography and intravascular ultrasound. This device may offer superior results without the limitations of conventional stent techniques in the treatment of coronary bifurcation disease.

Randomized Study of the Crush Technique Versus Provisional Side-Branch Stenting in True Coronary Bifurcations

Sirolimus-eluting stents have been reported to be effective in the treatment of coronary bifurcations. Still, it has not been fully clarified which strategy would provide the best results with true bifurcation lesions. The CACTUS trial (Coronary bifurcations: Application of the Crushing Technique Using Sirolimus-eluting stents) is a prospective, randomized, multicenter study comparing 2 different techniques of stenting, with mandatory final kissing-balloon inflation, in true bifurcations: (1) elective "crush" stenting and (2) stenting of only the main branch, with provisional side-branch T-stenting. From August 2004 to June 2007, 350 patients were enrolled in 12 European centers. The primary angiographic end point was the in-segment restenosis rate, and the primary clinical end point was the occurrence of major adverse cardiac events (cardiac death, myocardial infarction, or target-vessel revascularization) at 6 months. At 6 months, angiographic restenosis rates were not different between the crush group (4.6% and 13.2% in the main branch and side branch, respectively) and the provisional stenting group (6.7% and 14.7% in the main branch and side branch, respectively; P=NS). Additional stenting on the side branch in the provisional stenting group was required in 31% of lesions. Rates of major adverse cardiac events were also similar in the 2 groups (15.8% in the crush group versus 15% in the provisional stenting group, P=NS). In most bifurcations with a significant stenosis in both branches, a provisional strategy of stenting the main branch only is effective, with the need to implant a second stent on the side branch occurring in approximately one third of cases. The implantation of 2 stents does not appear to be associated with a higher incidence of adverse events at 6 months.

Bifurcation lesions: a never-ending challenge

Adriaenssens et al. 1 report a series of 132 patients in whom 134 coronary bifurcation lesions were treated by implantation of two stents using the Culotte technique. This is of particular interest given that most studies on coronary bifurcation treatment report the results of multiple techniques, which renders any valid interpretation of the outcome difficult to achieve. Indeed, it is often impossible to distinguish between the respective effects of technical specificities, lesions characteristics and specific stent features. Furthermore, angiographic follow-up was obtained in 82% of the study population. The overall restenosis rate was 22%; as always, the highest restenosis rate (16%) was observed in the side branch. Twelve-month target lesion revascularization (TLR) was 21% and the rate of stent thrombosis according to the ARC definition was 1.5%. Factors which emerged as predictors of restenosis were a large bifurcation angle and small-diameter side branches. The use of final kissing inflation was associated with … *Corresponding author. Tel: +33 1 60 134602, Fax: +33 1 60 134603, Email: mc.morice{at}icps.com.fr

Coronary artery bifurcation lesions: a review and update on classification and interventional techniques

Coronary artery bifurcation lesions pose a particular challenge in the field of interventional cardiology. Coronary bifurcation interventions are associated with higher rate of short- and long-term complications. There are many coronary artery bifurcation lesion classifications published in the literature. The goal of this article is to update and review current schemes of coronary artery bifurcation lesion classifications and interventional techniques.

Sirolimus-eluting and paclitaxel-eluting stents for the treatment of coronary bifurcations

The aim of the study was to compare the outcomes of sirolimus-eluting (SES) and paclitaxel-eluting (PES) stent implantation in coronary bifurcations treated with either a 1-stent or 2-stent strategy. The study used a retrospective cohort analysis of consecutive de novo bifurcations, excluding left main, treated with SES or PES between April 2003 and June 2005. We identified 170 bifurcations in 161 patients treated with SES and 119 bifurcations in 112 patients treated with PES. During a median follow-up of 1,061 days (interquartile range 814-1,314), 43 patients (26.7%) in the SES group and 28 (25.0%) in the PES group had a major adverse cardiac event (P = .78). The angiographic restenosis rate per bifurcation was 20.9% and 25.9%, respectively (P = .41). There was no difference overall in the occurrence of target lesion revascularization (TLR) per bifurcation, 22 with SES (12.9%) and 18 with PES (15.1%), P = .61. The TLR rate was similar for SES and PES in bifurcations treated with 1 stent (6.7% vs 11.4%, P = .40) and in bifurcations treated with both branch stenting (20.0% vs 20.4%, P =1.0). In this cohort, the long-term clinical outcomes appear similar overall between SES and PES in the treatment of coronary bifurcations irrespective of whether a 1-stent or 2-stent strategy was used.

Bifurcation Disease: What Do We Know, What Should We Do?

The percutaneous treatment of coronary bifurcations has moved past an important milestone in that the 1- versus 2-stent debate appears to have been resolved. The provisional approach of implanting one stent on the main branch should be the default approach in most bifurcations lesions. Selection of the most appropriate strategy for an individual bifurcation is important. Some bifurcations require 1 stent, whereas others require the stenting of both branches. Irrespective of whether a 1- or 2-stent strategy is chosen, the results after bifurcation percutaneous coronary intervention (PCI) have dramatically improved. Dedicated bifurcation stents are an exciting new technology that may further simplify the management of bifurcation PCI and change some of these concepts.

Treatment of coronary bifurcations: might less be more?

Percutaneous coronary interventions (PCIs) on coronary arteries in which the lesion involves a clinically significant side branch, termed a bifurcation lesion, are among the most challenging lesions for intervention.1 Coronary occlusions are often cited as the most challenging type of lesion, but an unsuccessful PCI on a coronary occlusion is rarely associated with a clinically important event, and initial success is only rarely complicated by late adverse events. In contrast, PCI of bifurcation lesions is associated with an unusually high risk, perhaps the highest risk, for both early and late complications. For every bifurcation lesion on which a PCI is attempted, two major procedural questions must be answered: (i) should the side branch be treated in addition to the main branch; and, if the answer is yes, (ii) how should it be treated? Prior to beginning the percutaneous treatment of a bifurcation lesion, the decision about whether to treat a side branch lesion is usually based on whether there is a flow-limiting lesion in it before the procedure is initiated. When evaluating the functional significance of ostial side branch stenoses, it must be remembered that coronary angiography often leads to an overestimation (and less often an underestimation) of the functional significance of ostial branch lesions; more so than do lesions in other parts of the coronary circulation. This is in part due to difficulties in visualizing ostial lesions in multiple orthogonal views, and in part due to the fact that such lesions are often very short, reducing the likelihood that they limit blood flow. Measurement of the fractional flow reserve (FFR) can overcome the limitations of coronary angiography and should probably be considered the gold standard for assessing whether any lesions, let alone difficult to visualize lesions, are functionally significant.2 Guidewires that can measure the FFR, however, are … *Corresponding author. Email address: pbberger{at}geisinger.edu

Registry on a new T technique for bifurcation coronary lesions: the Utrech-“T”- experience

The goal of this study was to clinically evaluate the effectiveness of a new coronary stenting approach for bifurcation lesions designed to provide adequate main and side-branch ostial scaffolding and provide a simplified technique. The technique was used in 100 consecutive patients with suitable bifurcation lesions. Sequential placement of two stents was performed in all patients, resulting in complete coverage of the bifurcation ostium and carina with minimal crushing of a small portion of the side-branch stent. Clinical follow-up was done for a six months period. The rate of clinically driven target vessel revascularisation at six months was 4%. One patient died during follow-up. Subacute thrombosis occurred in two patients. Treatment of bifurcation lesions using this new approach is feasible, with a low rate of procedural and clinical events. Larger trials with angiographic follow-up are necessary to prove the potential advantage of this approach relatively to the currently used techniques for the treatment of coronary bifurcations.

Percutaneous Treatment of Coronary Bifurcations: Lesion Preparation Before Provisional Bare Metal Stenting and Subsequent Immunosuppression with Oral Prednisone. The IMPRESS‐Y Study

Aim of the study was to assess the clinical and angiographic efficacy of oral treatment with prednisone at immunosuppressive dosage after percutaneous coronary interventions (PCI) in patients with bifurcation lesions treated with elective bare metal stent (BMS) implantation in the main-branch (MB) and provisional stenting in the side-branch (SB). Twenty-five patients were treated on 29 bifurcation lesions (58 vessel segments). Lesion preparation before stenting was performed with atherectomy in 7 cases, and balloon PCI over double wires in all other cases; none was treated directly with stents. The mean length of stents implanted in the MB was 19.6 +/- 4.9 mm (10-30 mm). Balloon PCI was successful in 23 of 29 SB and provisional stenting was needed in 6 SB (21%). All patients received oral prednisone according to the immunosuppressive protocol previously reported (1 mg/kg/day/10 days, 0.5 mg/kg/day/20 days, 0.25 mg/kg/day/15 days). At 12 months, one patient had recurrence of angina (4%) and two patients underwent repeated target lesion revascularization (8%). No patient died or had stent thrombosis. Quantitative coronary analysis was performed in all patients at 8 months. Global restenosis rate per vessel was 8.6% (5/58), and 17.2% (5/29) per lesion. The restenosis rate and late lumen loss were 3.4% and 0.36 +/- 0.6 mm, and 13.8% and 0.47 +/- 0.46 mm in the MB and the SB, respectively. Single stent implantation in the MB and provisional stenting of the SB is feasible in most cases after adequate lesion preparation. The systemic treatment with oral prednisone after BMS implantation offers good clinical and angiographic results even in the difficult setting of bifurcation lesions.

A modified balloon crush approach improves side branch access and side branch stent apposition during crush stenting of coronary bifurcation lesions

Despite the advent of drug eluting stents and newer interventional techniques designed to treat the main vessel and side branch in bifurcation stenoses, optimal treatment of the side branch remains problematic. We aimed to assess the feasibility of a modified balloon crush technique for percutaneous treatment of coronary bifurcation stenoses. Use of the crush technique in bifurcation stenoses remains limited by access to the side branch after main vessel stent deployment, as well as limitations of side branch stent deployment. The modified balloon crush technique aims to improve side branch access and stent apposition. The modified balloon crush is similar to the previously described balloon crush technique. Following side branch stent deployment, a balloon positioned in the main vessel is deployed to crush the proximal side branch stent. A guide wire is then placed into the side branch with a subsequent high-pressure balloon inflation at the side branch ostium. This opens the stent struts at the ostium of the side branch, facilitating future passage of the guide wire following main vessel stent deployment, prior to kissing balloon inflation. We performed this modification of the crush technique safely in 10 patients. We were successful in obtaining side branch access in nine of ten patients following initial main vessel stent deployment. In the only failure, there was a 90 degrees angle between the main vessel and side branch. The modified balloon crush technique can be safely performed, while optimizing side branch access and side branch stent apposition.