Double Stenting Strategy Research Articles

The feasibility of double stent strategy in left main true bifurcation with small and large angle change between diastole and systole: The Milan and New-Tokyo (MITO) registry.

Provisional single stenting strategy (PSS) is a default strategy for percutaneous coronary intervention (PCI) of unprotected left main distal bifurcation lesions (ULMD). Previous study reported that a bifurcation angle change (BAC) between end diastole and systole was associated with outcomes after PCI with double stent strategy (DSS) for ULMD. However, there are no data comparing outcomes after PCI with PSS versus DSS according the degree of BAC. We evaluated outcomes after PCI with PSS versus DSS for true ULMD with small and large BAC. We identified 566 patients with true ULMD underwent PCI in three high-volume centers. We calculated the BAC in ULMD between end-diastole and systole before stenting with 2-dimensional quantitative coronary angiographic assessment. We defined small (BAC < 7.0°) and large BAC (≥7.0°) group. We compared clinical outcomes after PCI with PSS versus DSS in each cohort after propensity score adjustment. The primary endpoint was target-lesion failure (TLF), which was defined as a composite of cardiac death, target lesion revascularization, and myocardial infarction. In small BAC cohort, TLF rate was significantly lower in DSS group than in PSS group (12.5% vs. 20.1%, adjusted HR 0.45; 95% CI, 0.26-0.79; p = 0.006). In contrast, in large BAC cohort, TLF rate was significantly higher in DSS group than in PSS group (54.9% vs. 29.0%, adjusted HR 2.25; 95% CI, 1.50-3.38; p < 0.001). The TLF rate after PCI with DSS was significantly lower in true ULMD with small BAC compared to PSS even after propensity score adjustment. In contrast, it was significantly higher in those with large BAC.

Single-stent and double-stent strategy for complex, true and false bifurcation lesions of the left main coronary artery in patients with acute coronary syndrome: a single-center retrospective analysis

Single-stent and double-stent strategy for complex, true and false bifurcation lesions of the left main coronary artery in patients with acute coronary syndrome: a single-center retrospective analysis

P38 SINGLE VERSUS DOUBLE STENTING IN NSTEMI PATIENTS WITH COMPLEX LEFT MAIN BIFURCATION DISEASE

Abstract Background Among patients with non–ST–segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long–term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target–vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results Four hundred and forty–five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow–up of 37.1 months (IQR 22.1–39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score &amp;gt; 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long–term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2–stent strategy.

Prognostic Value of Logistic Clinical Syntax Score in Coronary Bifurcation Lesions Treated with Double Stent Technique

Introduction: In this study, we aimed to investigate the relationship between the preprocedural logistic clinical SYNTAX score (Log CSS) and major cardiovascular events (MACE) in patients with true bifurcation lesions who underwent revascularization with the double stent strategy. Patients and Methods: A total of 233 non-ST elevation myocardial infarction (NSTEMI) patients who underwent revascularization with a double stent strategy were retrospectively included in the study. Anatomical SYNTAX score (SS) and log CSS were calculated. The patients were divided into two groups according to the cut-off value determined by ROC analysis. The prediction of two-year MACE with Log CSS was evaluated. Results: MACE developed in 33.9% of patients with high Log CSS and 8.5% of patients with low Log CSS (p&lt; 0.001). In the Kaplan-Meier survival analysis, the long-term survival of the high Log CSS patients was significantly lower than the low Log CSS group (Log-rank p&lt; 0.001). In multivariate COX analyses, high Log CCS (HR= 3.781; 95% CI= 1.706-8.377; p= 0.001) was the strongest independent predictor of MACE. Conclusion: Log CSS can be a simple and useful tool to predict the development of MACE in patients with true bifurcation lesions revascularized by percutaneous coronary intervention.

Meta-Analysis of Provisional Versus Systematic Double-Stenting Strategy for Left Main Bifurcation Lesions

ObjectiveWe sought to compare the clinical outcomes with provisional versus double-stenting strategy for left main (LM) bifurcation percutaneous coronary intervention (PCI). BackgroundDespite two recent randomized controlled trials (RCTs) and several observational reports, the optimal LM bifurcation PCI technique remains controversial. MethodsPubMed, Cochrane Central Register of Controlled-Trials (CENTRAL), Clinicaltrials.gov, International Clinical Trial Registry Platform were leveraged for studies comparing PCI bifurcation techniques for LM coronary lesions using second-generation drug eluting stents (DES). The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), target vessel or lesion revascularization, and stent thrombosis. ResultsTwo RCTs and 10 observational studies with 7105 patients were included. Median follow-up duration was 42 months (IQR: 25.7). Double stenting was associated with a trend towards higher incidence of MACE (odds ratio [OR] 1.20; 95 % confidence interval [CI] 0.94 to 1.53) compared with provisional stenting. This was mainly driven by higher rates of target lesion revascularization (TLR) (OR 1.50; 95 % CI 1.07 to 2.11). There were no statistically significant differences in the incidence of all-cause mortality, cardiovascular mortality, MI, or stent thrombosis. On subgroup analysis according to the study type, provisional stenting was associated with lower MACE and TLR in observational studies, but not in RCTs. ConclusionFor LM bifurcation PCI using second-generation DES, a provisional stenting strategy was associated with a trend towards lower incidence of MACE driven by statistically significant lower rates of TLR, compared with systematic double stenting. These differences were primarily driven by observational studies. Further RCTs are warranted to confirm these findings.

Single versus Double Stenting in NSTEMI Patients with Complex Left Main Bifurcation Disease.

Background: Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long-term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods: We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results: Four hundred and forty-five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow-up of 37.1 months (IQR 22.1-39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions: Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long-term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2-stent strategy.

The Outcome of LM PCI: A Single Center Experience of First 50 Cases without In-site IVUS Facility

Introduction: Left main disease (LMD) is related to significant morbidity and mortality. This study was done to evaluate the clinical major adverse cardiovascular event (MACE), including unstable angina, myocardial infarction, heart failure, target vessel revascularization, stroke and death in patients undergoing left main stem stenting without availability of in-site intravascular imaging (IVUS). Methods &amp; Materials: It was a prospective observational study done in National Institute of Cardiovascular Diseases &amp; Hospital (NICVD) from March 2014 to June 2019. Our study included 50 patients who underwent Percutaneous Coronary Intervention for left main disease without use of IVUS. All the patients were followed up for 1 year &amp; 2 years, one patient was lost to follow-up. Outcomes included in MACE were death, myocardial infarction, unstable angina, heart failure, stroke and target vessel revascularization (TVR). Results: Fifty patients (mean age 58.4 ± 4.1 years, 44 male, 06 female) were treated with a mean SYNTAX score of 24.8 ± 2.6. Thirty two (64%) patients had stable angina, 17 (34%) had unstable angina/non ST-elevation myocardial infarction, and 1 (02%) had ST-elevation Myocardial infarction. Among the risk factors, 21(42%) had DM, 33 (66%) were hypertensive, 22 (44%) were smoker, 19 (38%) had dyslipidemia, 09 (18%) had previous h/o MI, 11 (22%) had family h/o CAD &amp; 01 (02%) had previous h/o CVD. Preprocedural LVEF was 49.92± 6.60 % and post procedural 54.84 ± 4.55% which showed significant improvement of LVEF after PCI (p=0.003). Most of the patients presented with LM with SVD (82%). Among all patients, 39 (78%) underwent complete revascularization in compare to 11 (22%) had incomplete revascularization. Thirty eight (76%) patients received a single-stent DES and 12 (24%) received two-stents DES. Among double stent strategy, majority underwent TAP (50%). All access was femoral &amp; No reflow phenomena were found in any of the patients during the procedure. No perioperative mortalities were noted and no urgent coronary bypass graft surgery was required. One patient was lost to follow-up. After 1-year follow-up period, 1 (02%) patients had non-fatal myocardial infarction, 7 (14%) had episodes of unstable angina (UA) and 3 (06%) had heart failure (HF). After 2-years there was no new MI but 09 (18%) had UA &amp; 4 (08%) patients had HF episode in total. TLR was 2 (04%) in first year and 3 (06%) in 2nd year. Total mortality was 1(02%) in first year &amp; 3(06%) in 2nd year. The multivariable analysis showed a good prognosis in patients receiving LM PCI with a total event rate of 28% &amp; mortality 6%. A multivariate regression analysis with risk factors for coronary artery disease as predictive variables showed that high SYNTAX score (p = 0.013), incomplete revascularization (p=0.002) &amp; low post procedural LVEF (p= 0.001) was an independent predictor of MACE. Conclusion: Percutaneous coronary intervention of left main coronary disease without use of IVUS showed good prognosis after 1-year &amp; 2-years follow-up. It would not only save a procedure time for physicians but also prevent a financial burden on patients if they cannot afford intravascular imaging. Bangladesh Heart Journal 2022; 37(1): 1-9

Prognostic Impact of New-Onset Atrial Fibrillation After Single or Double Stent Left Main Bifurcation PCI.

Incidence and prognostic value of new-onset atrial fibrillation after single versus double stent strategy in bifurcation left main disease has not been yet investigated. We retrospectively analyzed the procedural and medical data of patients referred to our center for complex left main bifurcation disease, treated using crossover provisional stenting, T or T-and-Protrusion, Culotte, and Nano-inverted-T techniques between January 1, 2008, and May 1, 2018. Multivariate Cox-regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of new-onset atrial fibrillation during the follow-up period. Five hundred two patients (316 males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. At a mean follow-up of 37.1 ± 10.8 months (range: 22.1- 39.3 months); Target lesion failure rate was 10.1%. Stent thrombosis and cardiovascular mor- tality were observed in 1.2% and 3.6% in of cases, respectively. New-onset atrial fibrillation occurred in 23 out of 502 patients (4.6%). Patients with new-onset atrial fibrillation resulted more frequently female, older, obese, and diabetic and more frequently experienced target lesion failure and cardiovascular death. New-onset atrial fibrillation-free survival favored single versus double stent technique and among double stent techniques nano-inverted-T tech- niques compared to the others. Single stent strategy had a lower risk of new-onset atrial fibril- lation compared to double stent technique on multivariate analysis (Hazard Ratio (HR): 1.14, 95% CI: 1.10-1.19, P < .001 vs. HR: 1.28, 95% CI: 1.23-1.32, P < .0001). New-onset atrial fibrillation in distal left main bifurcation disease treated with per- cutaneous coronary intervention had a low incidence but resulted more frequently after double than after single stenting technique and was associated with worse outcomes.

P66 GENDER–RELATED DIFFERENCES IN CLINICAL OUTCOMES AFTER EITHER SINGLE OR DOUBLE LEFT MAIN BIFURCATION STENTING

Abstract Background We sought to examine the impact of gender differences in clinical outcomes at 3 years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. Methods We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Cross–over provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT) techniques between January1st, 2008 to May1st2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Results Five hundred and sixty–seven patients (251 females, mean age 70.0±10 years, mean Syntax score 31.6±6.3) were evaluated. Cross–over, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98(17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri–procedural items among gender. At a mean follow–up of 37.1±10.8 months (range 22.1–39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Conclusions Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3–year follow–up either using a single or double stent technique.

P80 PROGNOSTIC IMPACT OF NEW ONSET ATRIAL FIBRILLATION AFTER SINGLE OR DOUBLE STENT LEFT MAIN BIFURCATION PCI

Abstract Objective Incidence and prognostic value of new onset atrial fibrillation (NOAF) after single versus double stent strategy in bifurcation Left Main (LM) disease has not been yet investigated. Methods We retrospectively analysed the procedural and medical data of patients referred to our center for complex LM bifurcation disease, treated using Cross–over provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT) techniques between January 1st, 2008 to May 1st 2018. Multivariate Cox–regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of NOAF during the follow–up period. Results Five hundred and two patients (316 males, mean age 70.3±12.8 years, mean Syntax score 31.6±6.3) were evaluated. At a mean follow–up of 37.1±10.8 months (range 22.1–39.3 moths), Target lesion failure (TLF) rate was 10.1%. Stent thrombosis and Cardiovascular mortality were observed in 1.2% and 3.6% in of cases, respectively. NOAF occurred in 23 out of 502 patients (4.6%). Patients with NOAF resulted more frequently female, older, obese, diabetic and more frequently experienced TLF and cardiovascular death. NOAF free survival favoured single versus double stent technique and among double stent techniques NIT compared to the others. Single stent strategy had a lower risk of NOAF compared to double stent technique on multivariate analysis (HR: 1.14, 95% CI: 1.10–1.19, p &amp;lt; 0.001 vs HR: 1.28, 95% CI: 1.23–1.32, p &amp;lt; 0.0001). Conclusions NOAF in distal LM bifurcation disease treated with PCI had a low incidence but resulted more frequent after double than after single stenting technique and associated with worse outcomes.

Gender-related differences in clinical outcomes after either single or double left main bifurcation stenting.

We sought to examine the impact of gender differences in clinical outcomes at 3years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Crossover provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT) techniques between January 1st, 2008 and May 1st 2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Five hundred and sixty-seven patients (251 females, mean age 70.0 ± 10years, mean Syntax score 31.6 ± 6.3) were evaluated. Crossover, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98 (17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri-procedural items among gender. At a mean follow-up of 37.1 ± 10.8months (range 22.1-39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3-year follow-up either using a single or double stent technique.

Long-term outcomes of single stenting compared with double stenting strategy for unprotected left main coronary artery disease: A protocol for systematic review and meta-analysis.

Background:The optimal interventions for unprotected left main coronary artery (ULMCA) disease have long been debated, and long-term clinical studies comparing single stenting to double stenting strategies for ULMCA are currently lacking.Methods:We plan to perform a systematic review and meta-analysis of clinical trials comparing single stenting with double stents strategy for ULMCA disease. We will search PubMed, EMBASE, Web of science and Cochrane Library using a comprehensive strategy. The related conference proceedings and reference lists of the included studies will also be checked to identify additional studies. Two reviewers will screen retrieved records, extract information and assess the risk of bias independently. STATA software will be used to conduct data synthesis. There is no requirement of ethical approval and informed consent.Results:This study will be submitted to a peer-reviewed journal for publication.Conclusion:We hope it will provide a relatively comprehensive reference for clinical practice and future relevant clinical trials.Ethics and dissemination:Ethics approval and patient consent are not required, as this study is a systematic review and meta-analysis.INPLASY registration number:INPLASY2020110030

Percutaneous Coronary Intervention for Left Main Coronary Artery Bifurcation Lesions: Two-stent versus one-stent Strategy for Comparison of 6-month MACE.

To assess the short term clinical outcomes for a single-stent (SS) strategy versus a double-stent (DS) strategy in percutaneous coronary intervention (PCI) of distal unprotected left main coronary artery (ULMCA) lesions. Descriptive comparative study. Armed Forces Institute of Cardiology, Rawalpindi, Pakistan from January 2017 to April 2018. SS treatment was defined as stenting of the main branch alone and DS treatment as stenting of both the main and side branches. Patients who underwent LMCA PCI were recruited in the study using consecutive sampling. Crossover technique, with or without kissing balloon (KB) dilatation, was employed in those getting PCI with a SS strategy; whereas, DK crush, mini-crush , culotte and T-stenting techniques were used in patients undergoing PCI with a DS strategy. The primary endpoints were a composite of major adverse cardiovascular event (MACE) i.e. myocardial infarction, stroke or death and target lesion revascularisation (TLR). A total of 103 patients were recruited in the study; out of which, 73 underwent LMCA PCI employing a SS technique; whereas, 30 of them were treated with a DS strategy. Mean age of the study participants was 63.2 ±10.6 years. The procedural success rate was 100% in both groups. There was a lower frequency of MACE with single-stent strategy (4.1%) versus the double-stent strategy (16.7%, p=0.031) during the 6-month follow-up period. In comparison to the two-stent strategy of ULMCA bifurcation intervention, a single-stent approach seems to show favourable clinical outcomes and 6-month MACE-free survival. The choice of optimal revascularisation technique proves to be important for the prognosis; therefore, it requires pragmatic decision-making. Key Words: PCI (percutaneous coronary intervention), ULMCA (unprotected left main coronary artery), SS (single-stent), DS (double-stent), MACE (major adverse cardiovascular events), CABG (cardiopulmonary bypass grafting), TLR (target lesion revascularisation).

Clinical outcomes of double stent strategy for unprotected left main distal bifurcation lesions using current generation drug eluting stent comparing to early generation drug eluting stent; The Milan and New Tokyo (MITO) registry.

There are only little data available on the comparison of clinical outcomes between a early generation drug eluting stent (eDES) and a current generation drug eluting stent (cDES) for percutaneous coronary intervention (PCI) with double stent strategy (DSS) for unprotected distal left main disease (ULMD). Between April 2005 and December 2015, we recruited 452 consecutive ULMD patients treated with DSS (eDES, 236 patients; cDES, 216 patients). In this study, eDES included Cipher, Taxus, and Endeavor and cDES included Ultimaster, Resolute family, Xience family, Promus family, Synergy, and Nobori. The primary endpoint was target lesion failure (TLF) defined as a composite of cardiac death, target lesion revascularization (TLR) and myocardial infarction (MI) during the median follow-up period of 1,809(IQR: 1,190-2,510) days. In entire population, the rate of overall TLR was significantly lower in cDES group than that in eDES group (adjusted HR 0.62, 95% CI 0.40-0.96, p = .032). The rate of TLR for the ostium of LCX was significantly lower in cDES group than that in eDES group (adjusted HR 0.63, 95% CI 0.39-0.99, p = .047). Cardiac mortality, the rate of TLR for LM-LAD, MI and definite/probable ST did not significantly differ between both groups. The results were preserved in the propensity adjusted population. cDES significantly improved the clinical outcomes in population treated with DSS mainly driven by the reduction of TLR for the ostium of LCX.

Modified double-stent strategy may be an optimal choice for coronary bifurcation lesions: A systematic review and meta-analysis.

The modified double-stent and provisional stenting strategies have been widely used in patients with coronary bifurcation lesions, but what is the optimization has not been clearly defined. This meta-analysis is to elucidate the benefits from modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions. Electronic databases were searched to identify studies comparing the modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions. The clinical outcomes were divided into early (≤6 months) and late (>6 months) events according to the follow-up duration. The early endpoints included cardiac death, myocardial infarction, target lesion revascularization or target vessel revascularization, and major adverse cardiac events (MACE), and the late endpoints also include stent thrombosis in addition to the early endpoints index. The angiographic endpoint was in-stent restenosis. Data were analyzed by the statistical software RevMan (version 5.3). A total of 6 studies involving 1683 patients with coronary bifurcation lesions were included in this meta-analysis, which found that the modified double-stent strategy was associated with a lower risk of cardiac death (odds ratio [OR] = 0.29, 95% confidence intervals [CI] 0.11-0.78, P = .01), myocardial infarction (OR = 0.41, 95% CI 0.21-0.82, P = .01), target lesion revascularization or target vessel revascularization (OR = 0.31, 95% CI 0.15-0.63, P = .001), and MACE (OR = 0.41, 95% CI 0.22-0.74, P = .003) compared with provisional stenting in the early follow-up endpoint events, while the risk of cardiac death and stent thrombosis were similar between both strategies (OR = 0.59, 95% CI 0.31-1.10, P = .09; and OR = 0.62, 95% CI 0.34-1.15, P = .13; respectively) in the late follow-up endpoint events. There were significant differences between both strategies in myocardial infarction (OR = 0.42, 95% CI 0.24-0.75, P = .003), MACE (OR = 0.44, 95% CI 0.31-0.62, P < .00001), and target lesion revascularization or target vessel revascularization (OR 0.35, 95% CI 0.25-0.49, P < .00001) between both strategies in the late follow-up endpoint events. The risk of in-stent restenosis favored the modified double-stent strategy (OR 0.29, 95% CI 0.20-0.43, P < .00001). The modified double-stent strategy is associated with excellent clinical and angiographic outcomes except for the occurrence of cardiac death and stent thrombosis late-term outcome compared with provisional stenting strategy in patients with coronary bifurcation lesions. These findings suggest that the modified double-stent strategy can be recommended as an optimization in patients with coronary bifurcation lesions.

Long-term results after PCI of unprotected distal left main coronary artery stenosis: the Bifurcations Bad Krozingen (BBK)-Left Main Registry.

Percutaneous coronary intervention (PCI) of unprotected distal left main stenosis (UDLM) is increasingly performed as an alternative to surgical treatment. The optimal strategy for stenting in this setting is still a matter of debate. Therefore, this analysis investigated the long-term clinical outcome of a single- versus a double-stenting strategy for treatment of UDLM. From a large registry, 867 consecutive patients with UDLM undergoing either single or double stenting with drug-eluting stents (DES) were identified. Follow-up was up to 10 (median 3.1, interquartile range 1.1-5.3) years. Primary endpoint was MACE consisting of all-cause death, myocardial infarction, or target lesion re-intervention (TLR). Secondary clinical endpoints included these single endpoints and stent thrombosis. MACE occurred in 41.5% after single and in 49.0% after double stenting (P = 0.03). TLR was lower after single (17.4%) as compared to double stenting (27.2%; P < 0.01). Between single and double stenting, there were no significant differences for death (26.4 versus 23.3%; P = 0.31), death or myocardial infarction (29.1 versus 27.2%; P = 0.55), or definite/probable stent thrombosis (1.3 versus 2.1%; P = 0.42). Compared with single stenting, double stenting was associated with a significantly higher long-term risk of MACE. This was driven by a higher incidence of TLR, whereas the risk of death, MI, or stent thrombosis was similar between the two strategies.

TCTAP A-136 6-month Outcome of Provisional Versus Double Stent Strategy for True Bifurcation Lesion Using Transradial Approach: Single Centre, Single Operator Study in Bangladesh

Coronary bifurcation lesions are frequent in everyday practice and account for up to 20% of all PCIs. The question relating to a one or two stent strategy for bifurcation lesions has been a subject of many debates over recent years. Double stent technique is associated with a lower procedural

Non-malignant respiratory tract fistula from the oesophagus. A lethal condition for which novel therapeutic options are emerging

Fistulas between the oesophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after oesophageal resection, without any signs of local residual tumour growth. Other causes that are, by definition, benign may rarely prevail. The traditional therapeutic approach is to divert the proximal portion of the oesophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. We have evaluated our stent-based strategy for managing these life-threatening situations. At Karolinska University Hospital, all patients admitted with an oesophago-respiratory fistula during the period 2003-2011 followed a stent-based strategy. On clinical suspicion, a prompt computed tomography scan was performed with contrast ingestion, to visualize the status of the anastomosis and the potential communications. Often an endoscopy was done to assess the oesophagus and the conduit. The respiratory tree was inspected through a concomitant bronchoscopy. The double-stent strategy presently applied meant that covered self-expandable metal stents (SEMS) were applied on the alimentary and airway sides to adequately cover the fistula orifice on both sides. The subsequent clinical course determined the ensuing therapeutic strategy. During the study period, 17 cases with oesophago-respiratory fistulas were treated at our unit, of which 13 exhibited fistulation following an oesophageal resection due to cancer and 4 cases had a benign underlying disease. The cancer patients did not show any obvious demographic profile when it came to the cancer sub-location, histological type of cancer, or treatment with neoadjuvant chemo- and radiochemotherapy. There was an equal distribution between hand-sutured and stapled anastomoses. In 10 of the cases, the anastomoses were located in the upper right chest; the remainder in the neck, and all reconstructions were carried out by a tubulized stomach. The diagnosis of the fistula tract between the anastomotic area and the respiratory tract was attained on the 15th postoperative day (median), with a range from 5 to 24 days. When an oesophago-respiratory fistula is diagnosed, even in a situation where no neoplastic tissue is prevailing, attempts should be made to close the fistula tract by SEMS from both directions, i.e. from the oesophageal as well as the respiratory side. By this means, a majority of these patients can be initially managed conservatively with prospects of a successful outcome, although virtually all will eventually require a single-stage resection and reconstruction.

Stent malapposition caused by improper rewiring during left main intervention: The role of intravascular ultrasound in avoidance and management—A case report

The optimal technique for bifurcation stenting of distal Left main (LM) lesions remains unestablished and controversial. Some techniques with superior stent apposition, such as culotte technique were supposed to be associated with lower rate of stent thrombosis. However, with culotte technique, the double-stent layer at the carina and in the proximal part of the bifurcation, may lead to difficult or improper rewiring of the side branch before final kissing balloon postdilatation (KBP). We describe a case of distal LM disease associated with distal left circumflex (LCX) and posterior descending artery stenosis. During LM stenting using culotte technique, improper rewiring of LCX before final KBP caused malapposition of the inner sent layer at the mid part of LM. Despite the optimal angiographic result, intravascular ultrasound (IVUS) was able to detect stent malapposition and guided further management to achieve complete stent apposition. The present case indicates that IVUS is an essential tool for LM stenting particularly when applying double stent strategy requiring final rewiring before KBP. Moreover, we suggest that some tools, such as Crusade and Venture catheters, can be used to ensure proper rewiring and hence, prevent subsequent stent malapposition, which may lead to catastrophic complications such as early and late LM stent thrombosis.

Importance of Kissing Balloon Inflation in Bifurcation Stenting

Percutaneous bifurcation intervention is usually sufficient with a single-stent strategy. When the double-stent strategy is employed, higher restenosis and target lesion revascularization (TLR) rates are observed, especially at the side-branch ostium. The results may be improved, however, with refinement in techniques, for example, final kissing balloon inflation and double kissing balloon inflation.