Coronary Bifurcation Lesions Research Articles

B-16 | The RESOLUTE ONYX Bifurcation Study: 3-Year Outcomes in Patients With Coronary Bifurcation Lesions

Coronary bifurcation lesions are challenging to treat, with higher risk of procedural complications and adverse events than non-bifurcation lesions. In this study, we evaluated the 3-year clinical outcomes in patients with bifurcation lesions treated with the Resolute Onyx zotarolimus-eluting stent (ZES). Patients with a single bifurcation target lesion undergoing planned treatment using the provisional stenting technique were enrolled at 25 centers in the United States and Europe. Inclusion criteria included main branch reference vessel diameter (RVD) 2.25-5.0 mm, lesion length ≤35 mm, stenosis ≥50%, side branch ≥2.0 mm, and TIMI flow ≥2. The primary endpoint was target vessel failure (TVF) at 1-year. Follow-up was for 3 years. Between Apr 2017 to Dec 2019, 205 patients with 209 bifurcation lesions (of 267 total) were enrolled. Patients were 66.6 ± 10.7yrs, 21.5% female, 26.3% type II diabetic, 35.1% had previous PCI. Core lab analysis showed that 32.5% of lesions were true bifurcation lesions per Medina classification (1.1.1, 1.0.1, 0.1.1). Target vessel RVD was 2.65 ± 0.47 mm and lesion length was 17.03 ± 9.64 mm. 12.1% of patients had TVF through 3 years. There were no instances of stent thrombosis (Figure). Patients with coronary bifurcation lesions treated with the Resolute Onyx ZES had favorable long-term clinical outcomes at 3 years, with only 6% of target lesion revascularization and no cases of stent thrombosis. These results support the use of Resolute Onyx ZES to treat complex coronary bifurcation lesions using a planned provisional stenting technique, safely and effectively.

The 17th expert consensus document of the European Bifurcation Club - techniquesto preserve access to the side branch during stepwise provisional stenting.

Provisional stenting has become the default technique for the treatment of most coronary bifurcation lesions. However, the side branch (SB) can become compromised after main vessel (MV) stenting and restoring SB patency can be difficult in challenging anatomies. Angiographic and intracoronary imaging criteria can predict the risk of side branch closure and may encourage use of side branch protection strategies. These protective approaches provide strategies to avoid SB closure or overcome compromise following MV stenting, minimising periprocedural injury. In this article, we analyse the strategies of SB preservation discussed and developed during the most recent European Bifurcation Club (EBC) meetings.

Drug-coated balloon combined with drug-eluting stent for the treatment of coronary bifurcation lesions: insights from the HYPER study.

True coronary bifurcation lesions (CBL) represent a challenging scenario for percutaneous coronary interventions (PCI), and are associated with a higher risk of target lesion failure (TLF), particularly when two stents are implanted. A hybrid strategy combining a drug-eluting stent (DES) in the main branch, and a drug-coated balloon in the side branch may improve outcomes by reducing the total stent length while maintaining an effective anti-prolipherative action. In this sub-study of the HYPER trial, 50 patients with true CBL were treated with a hybrid strategy: procedural success was 96%, one case of peri-procedural myocardial infarction and one case of TLF (in a DES-treated segment) at 1 year were reported. This study suggests that such a hybrid strategy may be a safe and effective option for true CBL PCI, and warrants additional investigations to compare outcomes with standard of care strategies.

Safety and Efficacy of a Hybrid Approach Combining a Paclitaxel-Coated Balloon With a New Generation Drug-Eluting Stent in Patients With De Novo True Coronary Bifurcation Lesions

BackgroundThe use of drug-coated balloon in the management of true bifurcation lesions appears to be an attractive option to reduce the rate of stent thrombosis and restenosis particularly at the level of the side branch ostium. We aim to assess the safety and the efficacy of a hybrid approach combining a drug-eluting stent in the main branch and a drug-coated balloon to treat the side branch ostium in patients with de novo true bifurcation. MethodsFrom September 2020 to March 2022, 45 patients with a de novo true bifurcation lesion Medina (1.1.1) or Medina (0.1.1) were enrolled. All patients underwent a percutaneous coronary intervention with the hybrid approach. Clinical assessment with functional stress imaging test was scheduled at 6 months. In case of documented ischemia, coronary angiography was performed. The primary endpoint was the composite of target lesion failure at 6 months including cardiac death, target vessel MI or ischemia-driven target lesion revascularization. The secondary endpoints were technical success, defined by performing the percutaneous coronary intervention without an additional drug-eluting stent at the level of the side branch ostium, and clinical success, defined by a technical success associated with the absence of severe complications during in-hospital phase. ResultsThe immediate results show a technical success of the procedure in the majority of cases (88.9 %) with a low rate of bailout side branch stenting (11.1 %). The clinical success was obtained in 86.7 % and only one patient experienced a severe in-hospital complication. A side branch ostial lesion length > 10 mm was the only independent predictor of clinical failure of the procedure (OR 12.49, 95 % CI 1.17–133.6; p = 0.037). At 6 months, the TLF was low and occurred in 1 patient (2.2 %). No cardiac death was observed. No TVMI was observed. Importantly, at 6 months, no side branch thrombosis was observed. ConclusionThe use of a hybrid approach combining a drug-eluting stent in the main branch and a drug-coated balloon in the side branch to treat true bifurcation lesions appears to be safe and efficient with few immediate complications and with satisfactory results at mid-term follow up.

TCTAP A-032 Factors Associated With Major Adverse Cardiovascular Events in Patients Treated by Provisional Stenting for Coronary Artery Bifurcation Lesions

TCTAP A-032 Factors Associated With Major Adverse Cardiovascular Events in Patients Treated by Provisional Stenting for Coronary Artery Bifurcation Lesions

MANAGEMENT OF MEDINA (0,0,1): CASE REPORT

Percutaneous coronary intervention of bifurcation coronary lesions is associated with a high risk of major adverse cardiac events. Identifying the side branch will come first, then deciding whether or not it is a significant one. The aim of this article is to discuss how to manage the Medina 0,0,1 lesion: either optimal medical therapy or PCI. The inverted T stenting has long been preferred in that matter, and was considered safe. And for that we will be reporting a case of a severe lesion of the first diagonal branch at its ostium.

Randomized Pilot Study to Compare DCB-Based versus DST-Based Strategies for the Treatment of True or Complex Coronary Bifurcation Lesions.

Dual stenting technique (DST) is still mandatory for some true bifurcation lesions (BLs), but drug-coated balloon (DCB) alone may offer a new optional treatment with the potential benefits of fewer implants. However, procedural safety presents a concern when using DCB-only to treat true BLs. This study sought to explore the safety and efficacy of the DCB-only strategy for the treatment of true BLs. Sixty patients with TBLs were randomly assigned to be treated by a DCB-based strategy or DST-based strategy. All patients received angiographic follow-up scheduled after one-year and staged clinical follow-up. The primary endpoint was the one-year late lumen loss (LLL) and cumulative major cardiac adverse events (MACEs) composed of cardiac death (CD), target vessel myocardial infarction (TVMI), target lesion thrombosis (TVT), or target vessel/lesion revascularization (TLR/TVR). The secondary endpoint was the one-year minimal lumen diameter (MLD), diameter stenosis percentage (DSP) or binary restenosis (BRS), and each MACE component. The baseline clinical and lesioncharacteristics were comparable with similar proportions (20.0% vs. 23.3%, p = 1.000) of the complex BLs between the two groups. At the one-year follow-up, LLL was significantly lower in the DCB-based group (main-vessel: 0.05 0.24 mm vs. 0.25 0.35 mm, p = 0.013; side-branch: -0.02 0.19 mm vs. 0.11 0.15 mm, p = 0.005). MLD, DSP and TLR/TVR were comparable between the groups. The one-year cumulative MACE, all driven by TLR/TVR (6.7% vs. 13.3%, p = 0.667), was low and similar without CD, TVMI or TVT in both groups. Compared to the DST strategy, the DCB- based strategy may be safe and effective in treatment of the selected true BLs. Clinical registration number is ChiCTR1900024914.

Keep it simple.

Key Points Studies of coronary bifurcation lesions have shown no advantage of systematic two‐stent strategies over one‐stent strategies. The provisional stenting provides a dynamic approach to the treatment of the majority of bifurcation lesion. Use of noncompliant balloons for kissing balloon inflation was associated with reduced side vessel stenting and lower overall periprocedural myocardial infarction.

OCT Guidance in Bifurcation Percutaneous Coronary Intervention.

Coronary bifurcation is defined by the European Bifurcation Consensus as a coronary artery stenosis adjacent to the origin of a significant side branch. Its anatomy is composed of 3 different segments: proximal main vessel, distal main vessel and side branch. Coronary artery bifurcation lesions are encountered in approximately 15-20% of all percutaneous coronary interventions and constitute a complex subgroup of lesions characterized by lower procedural success rates and higher rates of adverse outcomes. In recent years, a growing focus in the European and Japanese bifurcation club meetings has been the emerging role of intravascular imaging, in guiding successful bifurcation percutaneous coronary interventions (PCI). In this review we will present the main ways optical coherence tomography (OCT) can be used to improve outcomes during bifurcation PCI.

Coronary stent failure: role of a blended approach with drug-coated balloons for complex lesions.

The management of coronary artery disease by means of percutaneous approach have been focused initially to overcome the recoil and acute occlusion after vessel ballooning; therefore, to develop and improve metallic stent platforms, and later drug-eluting technologies. Contemporarily, the necessity emerged to optimize interventional procedures using functional physiologic tests and intravascular imaging guidance, but still stent failures, especially in the complex lesion setting, continue to be not negligible. This comprehensive review is focused on the technology of drug-coated balloons as a tool to treat coronary artery disease without the need for metal implantation but still eluting antirestenotic drugs such as paclitaxel or sirolimus. We delve into these technologies, the drugs, the technical aspects of the deployment and the most updated evidence also proposing a dedicated interventional algorithm. There is solid data to support the use of drug-coated balloons in patients with in-stent restenosis and de-novo small coronary artery disease but also new evidence with promising results from recent studies indicate the feasibility of this approach in complex coronary interventions, bifurcation lesions and larger coronary vessels. In this state-of-the-art review, we also propose a blended approach based on the combination of drug-eluting stents and drug-coated balloons, keeping in mind the necessity to reduce the total stent length in order to reduce the long-term risk of complications.

DEFINITION criteria for left main bifurcation stenting − from clinical need to a formula

Percutaneous coronary intervention using drug-eluting stents for coronary bifurcation lesions is associated with higher rates of in-stent restenosis, myocardial infarction, and revascularisation as compared with non-coronary bifurcation lesions. The increased percentage of suboptimal results after stenting bifurcation lesions is largely, if not always, due to the extreme complexity of the anatomy. Obviously, one weapon (stenting technique) does not suit all enemies (bifurcation lesions with different anatomies), and it underscores the importance of establishing a stratification system.

Anatomical classification of chronic total occlusions in coronary bifurcations.

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) in coronary bifurcation lesions (CBL) is undergoing substantial technical progress and standardization, paralleling the evolution of dedicated devices, tools, and techniques. A standard consensus to classify CTO-CBL might be instrumental to homogenize data collection and description of procedures for scientific and educational purposes. The Medina-CTO classification replicates the classical three digits in Medina classification for bifurcations, representing the proximal main vessel, distal main vessel, and side branch, respectively. Each digit can take a value of 1 if it concerns atherosclerosis and is anatomically stenosed, or 0 if it is not. In addition, the occluded segment(s) of the bifurcation are noted by a subscript, which describes key interventional features of the cap: t (tapered), b (blunt), or a (ambiguous). This approach results in 56 basic categories that can be grouped by means of different elements, depending on the specific needs of each study. Medina-CTO classification, consisting of adding a subscript describing the basic cap characteristics to the totally occluded segment(s) of the standard Medina triplet, might be a useful methodological tool to standardize percutaneous intervention of bifurcational CTO lesions, with interesting scientific and educational applications.

Protection of side-branch ostium by the jailed balloon technique validated by three-dimensional optical coherence tomography

Objective: To evaluate the protective effect of jailed balloon technique on side branch (SB) ostium using three-dimensional optical coherence tomography(OCT). Methods: This is a retrospective study. Consecutive coronary disease patients with coronary artery bifurcation lesions who underwent percutaneous coronary intervention (PCI) and completed pre-and post-procedural OCT examinations at the Chinese People's Liberation Army General Hospital from September 2019 to March 2022 were enrolled. Patients were divided into the jailed balloon technique group and the unprotected group according to the options applied for the SB. The SB ostium area difference was calculated from OCT images (SB ostium area difference=post-PCI SB ostium area-pre-PCI SB ostium area). The SB ostium area differences were compared between the two groups and compared further in the subgroup of true bifurcation lesions and non-true bifurcation lesions. In the jailed balloon group, the SB ostium area difference was compared between the active jailed balloon technique and the conventional jailed balloon technique, between the jailed balloon>2.0 mm diameter and the jailed balloon≤2.0 mm diameter, and between the higher balloon pressure (>4 atm, 1 atm=101.325 kPa) and the lower balloon pressure (≤4 atm). Multivariate linear regression analysis was used to explore the correlation between the technical parameters of the jailed balloon technique and the SB protection effect. Results: A total of 176 patients with 236 bifurcation lesions were enrolled, aged (60.7±9.3) years, and there were 128 male patients (72.7%). There were 67 patients in the jailed balloon technique group with 71 bifurcation lesions and 123 patients in the unprotected group with 165 bifurcation lesions. Fourteen patients had 2 to 3 lesions, which were treated in different ways, so they appeared in the unprotected group and the jailed balloon technique group at the same time. The area difference in SB ostium was greater in the jailed balloon group than in the unprotected group (0.07 (-0.43, 1.05)mm2 vs.-0.33 (-0.83, 0.26)mm2, P<0.001), and the results were consistent in the true bifurcation lesion subgroup (0.29 (-0.35, 0.96)mm2 vs.-0.26 (-0.64, 0.29)mm2, P=0.004), while the difference between the two groups in the non-true bifurcation lesion subgroup was not statistically significant (P=0.136). In the jailed balloon technique group, the SB ostium area difference was greater in patients treated with the active jailed balloon technique than in those treated with the conventional jailed balloon technique ((0.43±1.36)mm2 vs. (-0.22±0.52)mm2, P=0.013). The difference in SB ostium area was greater in those using>2.0 mm diameter jailed balloons than in those using≤2.0 mm diameter jailed balloons (0.25 (-0.51, 1.31) mm2 vs.-0.01 (-0.45, 0.63) mm2, P=0.020), while SB ostium area difference was similar between those endowed with higher balloon pressure (>4 atm) compared to those with lower balloon pressure (≤4 atm) (P=0.731). Multivariate linear regression analysis showed that there was a positive correlation between jailed balloon diameter and SB ostium area difference (r=0.344, P=0.019). Conclusions: The jailed balloon technique significantly protects SB ostium, especially in patients with true bifurcation lesions. The active jailed balloon technique and larger diameter balloons may provide more protection to the SB.

Current state of knowledge on the use of drug-coated balloon in coronary bifurcation lesions

Current state of knowledge on the use of drug-coated balloon in coronary bifurcation lesions

Szabo versus provisional stenting of bifurcation coronary lesions

Highlights. This article presents a comparative analysis of the results of PCI of bifurcation coronary lesions using the Szabo technique and provisional stenting in patients with chronic coronary artery disease.Background. Coronary bifurcation and ostial stenosis are difficult to treat and require precise stent positioning in order to prevent restenosis and thrombosis.Aim. To perform a comparative analysis of the outocmes of percutaneous coronary interventions (PCI) of coronary bifurcation lesions using the Szabo technique and provisional stenting in patients with chronic coronary artery disease.Methods. The retrospective single-center observational study included 791 patients. In accordance with the performed bifurcation PCI technique, the patients were divided into two groups: 42 patients in the Szabo group and 749 in the provisional stenting group. Propensity score matching was performed for endpoint analysis, as a result of which 42 patients were selected out of 749 patients in the provisional stenting group, comparable in baseline characteristics with 42 patients in the Szabo group. Study endpoints were cardiac death, myocardial infarction, and repeat revascularization. A composite endpoint (MACE) including all of the above was also evaluated.Results. The median follow-up in the provisional stenting and Szabo groups was 1.3 and 1.4 years, respectively. There were no significant differences between the groups in terms of mortality, myocardial infarction, repeated revascularization and composite endpoint (MACE 23.80% provisional stenting and 19.04% Szabo, p = 0.594).Conclusion. Thus, Szabo is technically simple and safe technique for stenting coronary bifurcation lesions in patients with chronic coronary artery disease, which is not inferior in terms of efficiency to provisional stenting.

CRT-100.16 Provisional With Side Branch Rescue Stenting Is Associated With Increased 3-Year Target Lesion Failure in Patients With Acute Coronary Syndrome and Coronary Bifurcation Lesions

CRT-100.16 Provisional With Side Branch Rescue Stenting Is Associated With Increased 3-Year Target Lesion Failure in Patients With Acute Coronary Syndrome and Coronary Bifurcation Lesions

Clinical Outcomes of Various Two Stent Bifurcation Techniques in Treating Coronary Bifurcation Lesions at Pakistan Institute of Medical Sciences (PIMS), Islamabad

Objective: To determine the clinical outcomes of different two stent bifurcation techniques in the treatment of coronary bifurcation lesions, taking this as a challenge presented at the Pakistan Institute of Medical Sciences (PIMS), Islamabad. Methods: This descriptive cross-sectional was done at the Cardiology Department, PIMS, Islamabad, from September 2017 to February 2018. Individuals aged 20–60 years with true bifurcation lesions (&gt; 50% stenosis diameter) in both parent/main vessel side branch ostia from lesions and with a diameter of &gt;2.5 mm via visual approximation, silent ischemia, un-stable or stable angina, and denovo coronary bifurcation lesions of either gender were included. For PCI of these lesions, a variety of methods have been developed, frequently involving the use of numerous balloons and the implantation of two or more stents, including the crush stent technique, the Cullotte stent technique, and the kissing stent technique to allow maximum apposition to the vascular wall with efficient drug delivery in situation of drug-eluting stents. Patients were observed for clinical outcomes like cardiac death, stent thrombosis, nonprocedural MI, and during operation complications like edge dissection and side branch closure, recurrent myocardial infarction (MI), unstable angina, and MACE. All the information was collected via a study proforma, and the analysis was done using SPSS version 20. Results: The study included 100 cases, with an average age of 40 years and a range of 20 to 60 years. Out of all 58 (58%) males and 42 (42%) females. The T-Stent Technique was used in 30% of the study population, the Crush Stenting approach was used in 18% of the cases, the Culotte stenting approach was done in 22% of the cases, and kissing stenting approach was done in 30% of the study subjects. Amongst all the procedures, the Kissing Stent Technique was most successful in treating coronary bifurcating lesions 93.3%. As per procedures, complications were found to be statistically significant (p = 0.011). Conclusions: As per the study conclusion, kissing stent technique has been observed to be the most successful and least complicated technique in treating coronary bifurcating lesions.

One-stent Versus Two-stent Techniques for Unprotected Distal Left Main Bifurcational Lesions: Early and Late Outcomes

Background and aim: Left main disease account for 3% to 5% of the coronary lesions. PCI on coronary bifurcation lesions is considered a challenge for any cardiologist. These lesions include a wide spectrum of anatomic complexity varying from simple lesions, which can be managed with a single stent, to complex lesions necessitating more complex procedures. The goal of the present study was to compare the clinical outcomes of PCI with single-stent vs. double-stent implantation for the management of ULMCA distal bifurcation lesions. Patients and methods: a total of 60 cases with ULMCA distal bifurcation lesions eligible for PCI were included in the current study. Cases were divided into 2 main groups: one-stent group (20 cases) and two-stents group (40 cases). All patients underwent follow up during hospitalization and post-discharge at 1 and 6 months. Results: Comparison between the study groups as regards the lesional and angiographic characteristics demonstrated that cases in the one-stent group had significantly lower SYNTAX score (21.70 ± 5.58 versus 24.88 ± 4.93, p=0.028) and lower frequency of true bifurcation lesion (65.0 % versus 100.0 %, p0.001) and higher frequency of 1,1.0 Median class (55.0 % versus 7.5 %, p0.001). Besides, both groups had similar early post-interventional outcomes including hematoma and used target vessel revascularization techniques. Also, no significant differences were reported between both groups as regards the 6-month outcome parameters including cardiac death, TV MI, TVR and TL failure. Conclusions: Both single-stent and two-stents techniques are technically feasible and safe techniques for management of ULMCA with comparable outcomes.

Intracoronary Electrocardiography-guided Strategy for the Treatment of Coronary Bifurcation Lesions

Introduction: Revascularization of bifurcation lesions remains an interventional challenge. Intracoronary electrocardiograms can predict the functional significance of side branch stenosis after bifurcation stenting. Aim: This study was aimed at evaluating the effects of an intracoronary ECG electrocardiography (icECG)-guided revascularization strategy, compared with the currently accepted standard of care, on the clinical outcomes of patients after coronary bifurcation stenting. Methods: Patients with coronary bifurcation lesions who underwent percutaneous revascularization were enrolled in a prospective all-comers’ registry. Clinical outcomes were compared between patients who underwent icECG-guided revascularization versus the current standard of care (SOC), provisional stenting. Results: A total of 768 patients were included in the analysis: 349 were treated with an icECG-guided strategy, and 419 received SOC. The overall all-cause death rate was 23.2%, and the cardiovascular death rate was 15.9%. Patients with icECG guidance had significantly lower all-cause mortality (20.3% vs. 25.5% for icECG vs. SOC, log-rank P = 0.006) and cardiovascular mortality (12.6% vs. 18.6% for icECG vs. SOC, log-rank P = 0.004). The decrease in mortality was most pronounced in patients with no increase or a moderate increase in troponin post-PCI, or with higher-than-normal baseline troponin concentrations. Conclusion: An icECG-guided strategy for coronary bifurcation PCI led to lower patient mortality than the provisional stenting strategy.

A Novel Descriptive Coding System for Coronary Bifurcation Lesions.

A Novel Descriptive Coding System for Coronary Bifurcation Lesions.