Final Kissing Balloon Inflation Research Articles

Unprotected Left Main Stenting in the Real World

Cardiac surgery is the reference treatment for patients with left main (LM) disease, although percutaneous coronary intervention with drug-eluting stents is emerging as a possible alternative. The objective of this registry was to evaluate the 2-year outcome of elective percutaneous coronary intervention for unprotected LM disease with paclitaxel-eluting stents. A total of 291 patients were prospectively included from 4 centers. Acute myocardial infarction and cardiogenic shock were the only exclusion criteria. Patients were 69+/-11 years old, 29% were diabetic, and 25% had 3-vessel disease. For distal LM lesions (78%), the provisional side-branch T-stenting approach was used in 92% of cases and final kissing balloon inflation in 97%. Angiographic success was obtained in 99.7% of cases. At 2-year follow-up, the total cardiac death rate was 5.4% (1 EuroSCORE point was associated with a 15% [95% confidence interval 2.9% to 28.2%, P=0.013] higher risk of cardiac death), target-lesion revascularization was 8.7%, and incidence of Q-wave or non-Q-wave myocardial infarction was 0.9% and 3.1%, respectively. The combined end point occurred in 15.8% of cases and stroke in 0.7%. The incidence of definite and probable LM stent thrombosis was 0.7%, whereas the incidence of any stent thrombosis was 3.8%, with a higher risk in patients with side-branch stenting in the presence of LM bifurcation lesions (hazard ratio 9.6, 95% confidence interval 1.2 to 77.7, P=0.035). Unprotected LM stenting with paclitaxel-eluting stents, with a strategy of provisional side-branch T-stenting for distal lesions, provides excellent acute angiographic results and good mid-term clinical outcomes, with a 15.8% rate of major adverse cardiac events at 2-year follow-up.

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.

Twenty‐Four‐Month Update on Double‐Kissing Crush Stenting of Bifurcation Lesions

A group of 312 patients who underwent percutaneous coronary intervention for bifurcation lesions at 12 centers in China, Singapore, Thailand, Israel, India, and Japan were enrolled in a prospective, randomized DKCRUSH-1 trial. The goal of the study was to compare the double kissing (DK) crush technique with the classical crush stenting technique. This study was carried out to determine the differences in the rates of final kissing balloon inflations (FKBI) and the long-term clinical outcomes. The 8-month results of the DKCRUSH-1 study have been previously reported. Here, we present several subgroups analysis and a 24-month clinical update. The results confirmed a sustained, lower MACE rate at 24 months with the double kissing (DK) crush stenting technique compared with that for the classical crush stenting technique (18.1% vs. 29.9%, p = 0.044).

Percutaneous Revascularization Is the Preferred Strategy for Patients With Significant Left Main Coronary Stenosis

In the early 1970s, coronary artery bypass graft (CABG) was found to improve late survival in comparison to medical therapy in patients with significant left main stenosis.1–3 Once CABG became the standard of care for left main disease, a distinction between “protected”—by at least 1 patent bypass graft to the left coronary artery—and “unprotected left main (UPLM)”— no patent bypass graft to the left coronary artery—was made. In the 1980s, early attempts at balloon angioplasty of UPLM stenoses were associated with poor early outcomes because of coronary dissection, abrupt closure, and restenosis. Mortality rates as high as 30% at 1 year were reported.4–6 In the 1990s, bare metal stents were introduced and soon used to treat UPLM disease. Several small registries found a low rate of procedural complications, but repeat revascularization rates of 20% to 30% because of restenosis were considered unacceptable.7–12 Early bare metal stent registries for UPLM also found high mortality rates, particularly in high-risk patients, such as patients with acute coronary syndromes and poor left ventricular function. Importantly, high-risk subgroups often presented with late sudden death after stenting.11,13 In the early 2000s, the introduction of drug-eluting stents (DES), with the promise of vastly reduced rates of restenosis,14–17 raised the possibility of improved late outcomes in this challenging patient group. Response by Smith p 1033 Clinical outcomes after treatment of UPLM disease with either the sirolimus-eluting stent or the paclitaxel-eluting stent from >20 small registries have been published. Results reported in these registries vary widely.18–40 As depicted in Table 1, cardiac mortality between 6 and 12 months after the procedure ranges from 0% to 11%. Target lesion revascularization (TLR) or target vessel revascularization (TVR) rates range from 2% to 38%. This wide variation in clinical outcome appears largely because of variation …

Effect of coronary bifurcation angle on clinical outcomes in Chinese patients treated with crush stenting: a subgroup analysis from DKCRUSH-1 bifurcation study

Background Bifurcation angles may have an impact on the clinical outcomes of crush stenting. We sought to compare high (≥60°) with low (<60°) bifurcation angle in patients who underwent either classical or double kissing (DK) crush stenting for bifurcation lesions from the DKCRUSH-1 data base. Methods There were 212 patients with 220 lesions, some with low-angle (n=138) and some with high-angle (n=74). Angiography was indexed at 8-month after procedure. Primary endpoint was the occurrence of major adverse cardiac events (MACEs), defined as cardiac death, myocardial infarction and target lesion revascularization (TLR). Secondary endpoint included late lumen loss, the rate of restenosis, and final kissing balloon inflation (FKBI). Results At 8 months, clinical follow-up was 100%; angiographic follow-up was 75% in the low-angle group and 83.3% in the high-angle group. There were no significant differences in the FKBI between the high-angle group (91.43%) and the low-angle group (82.39%). In the high angle group, there was a significant difference in contrast volume used (P=0.005) but no significant difference in acute gain, minimum lumen diameter (MLD), late loss and diameter stenosis in the pre-bifurcation segment, post-bifurcation segment or side branch. When lesions were assigned into with-(n=133) and without-FKBI (n=42), significant side-branch late loss was seen in the group without-FKBI ((0.65±0.49) mm vs (0.47±0.62) mm, P=0.02), with a resultant greater restenosis rate (37.68% vs 18.32%, P=0.001). No difference was detected in the MACE free survival rate between the high and low angle groups (82.39% vs 82.36%, P=0.84). The rate of stent thrombosis tended to be higher in the lower-angle group although there was no significant difference (P=0.38). The TLR free survival rate was 87.2% in the with-FKBI group vs 73.5% in the without-FKBI group (P=0.001). Cox regression analysis showed that the independent predictors for target vessel revascularization were the side branch stent MLD post stenting (hazard ratios (HR) 1.028, 95% CI 2.357–16.233, P=0.002), lack of FKBI (HR 4.910, 95% CI 4.706–8.459, P=0.001) and unsatisfactory kissing (HR 3.120, 95% CI 2.975–5.431, P=0.001). Conclusions Bifurcation angles do not influence the clinical outcome of crush stenting. Successful final kissing balloon inflation, regardless of bifurcation angles, can predict TLR.

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.

Immediate and long-term results of treatment of complex lesions of the left anterior descending coronary artery involving a large diagonal branch with drug-eluting stents

The treatment of complex long lesions of proximal left anterior descending artery involving the origin of diagonal branch is controversial. The aim of the present study is the evaluation of safety and clinical results of percutaneous coronary angioplasty with drug-eluting stents. Since June 2002, we instituted a prospective longitudinal registry of all consecutive patients according to inclusion criteria. Default strategy was drug-eluting stent implantation on left anterior descending coronary artery and provisional stenting of side branch. We enrolled 232 patients; only 35 were sent to surgery, 12 were treated with bare metal stents and eight with medical therapy. Provisional stenting was possible in 197 patients, whereas two stents were necessary in 35 patients. Final kissing balloon inflation was performed in 90% of patients. Overall, 30-day fatality linked with subacute stent thrombosis was 0.4%. Other in-hospital complications were 2.6% non-Q and 0.4% Q wave myocardial infarction. Global incidence of stent thrombosis was 1.7% (0.8% subacute, 0.4% late and 0.4% very late) with 50% fatality rate. Two patients died during follow-up; early and late mortality was 1.7%. Target lesion revascularization or target vessel revascularization was 7.3%, all managed by additional percutaneous intervention or medically. In our population of patients with complex 'off-label', bifurcated, long lesion of left anterior descending artery involving the main diagonal branch, the treatment by drug-eluting stents on left anterior descending artery and provisional stenting of the diagonal is possible in the absolute majority of patients with excellent long-term outcome.

Interventional therapy of coronary artery disease in China: retrospective and perspective

Interventional therapy of coronary artery disease in China: retrospective and perspective

2-Year Outcome of Patients Treated for Bifurcation Coronary Disease With Provisional Side Branch T-Stenting Using Drug-Eluting Stents

Our goal was to determine whether the deployment of drug-eluting stents (DES) in bifurcation lesions, according to a uniform provisional side-branch T-stenting strategy (PTS), is a safe and effective treatment in the immediate and long term. In comparison with simple stenoses, successful percutaneous intervention for coronary bifurcation lesions is limited by a higher incidence of procedural complications and need for repeat revascularization. The ideal strategy to overcome these limitations remains to be demonstrated while recent controversy surrounds the long-term safety of DES in bifurcations. Consecutive patients treated for bifurcation lesions using DES were studied in a prospective single-center registry. Between 2003 to 2005, 477 procedures were performed. The PTS strategy was used in 92%, with a side-branch stent in 28% and final kissing balloon inflation in 95%. Angiographic success was achieved in 99% with 2.5% in-hospital major adverse cardiac events. The cumulative rate of major adverse cardiac events was 10.7% at 1 year and 13.6% at 2 years, including 6.9% and 8.9% target vessel revascularization. Deviation from the PTS strategy independently predicted 2-year mortality (odds ratio: 5.5 [95% confidence interval: 1.63 to 18.3], p < 0.01). The rate of definite or probable stent thrombosis at 2 years was 2.5% with half of all events occurring before hospital discharge. The PTS strategy for the treatment of bifurcation lesions is applicable to over 90% of patients in the real world. With DES, both safety and efficacy have been demonstrated in the long-term with <10% need for repeat revascularization in the first 2 years and a low incidence of late stent thrombosis.

Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH‐1 Bifurcation Study with drug‐eluting stents

BackgroundClassical crush has a lower rate of final kissing balloon inflation (FKBI) immediately after percutaneous coronary intervention (PCI). The double kissing (DK) crush technique has the potential to increase the FKBI rate, and no prospective studies on the comparison of classical with DK crush techniques have been reported.Materials and methodsThree hundred and eleven patients with true bifurcation lesions were randomly divided into classical (n = 156) and DK crush (n = 155) groups. Clinical and angiographic details at follow-up at 8 months were indexed. The primary end point was major adverse cardiac events (MACE) including myocardial infarction, cardiac death and target lesion revascularization (TLR) at 8 months.ResultsFKBI was 76% in the classical crush group and 100% in the DK group (P < 0·001). The incidence of stent thrombosis was 3·2% in the classical crush group (5·1% in without- and 1·7% in with-FKBI) and 1·3% in the DK crush group. Cumulative 8 month MACE was 24·4% in the classical crush group and 11·4% in the DK crush group (P = 0·02). The TLR-free survival rate was 75·4% in the classical crush group and 89·5% in the DK crush group (P = 0·002).ConclusionsDK crush technique has the potential of increasing FKBI rate and reducing stent thrombosis, with a further reduction of TLR and cumulative MACE rate at 8 months.Eur J Clin Invest 2008; 38 (6): 361–371

Impact of bifurcation lesions on clinical outcome and prognosis of primary angioplasty in acute myocardial infarction

The aim of this study was to determine the impact of bifurcation lesions on outcomes after primary percutaneous intervention (PCI) for acute myocardial infarction. We retrospectively reviewed a single-centre database of 646 patients admitted for primary angioplasty within 12 hours after AMI. We compared baseline characteristics and outcomes between bifurcation and non-bifurcation lesions. Bifurcation lesions were found in 23% of patients. They predominantly involved the left anterior descending artery. Provisional T-stenting was used in 89.3% of patients (with stenting of the main branch in 82% and of both branches in 7.3%), side-branch protection in 54.6%, and final kissing balloon inflation in 33%. The procedural success rate was 92% for the main branch of bifurcation lesions compared with 93% for non-bifurcation lesions (P=0.65). Major adverse cardiac event (MACE) rates were comparable in the two groups: in-hospital MACE was 13.3% in the bifurcation group versus 11.4% in the non-bifurcation group (P=0.72), and the 1-year total MACE rate was 22.6% in the bifurcation group versus 19.5% in the non-bifurcation group (P=0.56). Bifurcation lesions are common in patients with AMI. In a population with AMI, immediate and mid-term outcomes of primary PCI were similar in patients with and without bifurcation lesions.

Crush stenting in treating coronary bifurcate lesions: paclitaxel eluting stents versus sirolimus eluting stents

Because no data regarding the comparison of crush stenting with paclitaxel (PES) or sirolimus eluting stents (SES) for coronary bifurcate lesions have been reported, we compared the clinical outcomes of these two types of stents. Two hundred and thirty patients with 242 bifurcate lesions were enrolled in a prospective, nonrandomized trial. Primary endpoints included myocardial infarction, cardiac death and target vessel revascularization at 8 months. All patients were followed up clinically and 82% angiographically at 8 months. Final kissing balloon inflation was performed in 72% in the PES and 75% in the SES groups (P>0.05). Compared to the SES group, PES group had a higher late loss and incidence of restenosis (P=0.04) in the prebifurcation vessel segment. The postbifurcation vessel segment in the PES group had a greater late loss ((0.7+/-0.6) mm vs (0.3+/-0.4) mm, P<0.001) and higher restenosis in the side branch (25.5% vs 15.6%, P=0.04) when compared to the SES group. There was significant difference of insegment restenosis in the entire main vessel between PES and SES groups (P=0.004). Target lesion revascularization was more frequently seen in the PES group as compared to the SES group (P=0.01). There was significant difference in the accumulative MACE between these two groups (P=0.01). The survival rate free from target lesion revascularization was significantly higher in the SES group when compared to the PES group (P<0.001). SES is superior to PES in reducing restenosis and target lesion revascularization by 8-month follow-up after crush stenting for bifurcate lesions.

Final kissing balloon inflation by classic crush stenting did not improve the clinical outcomes for the treatment of unprotected left main bifurcation lesions: The importance of double‐kissing crush technique

The mechanisms contributing to final kissing balloon inflation between classic crush and double-kissing (DK) crush stenting techniques for the treatment of coronary bifurcation lesions contrast. The authors compared the clinical outcomes in patients with unprotected distal left main bifurcation lesions treated by classic crush or DK crush stenting techniques. Thirty-seven patients with unprotected left main bifurcation lesions were selected (20 in classic crush, 17 in DK crush groups) from a prospective, multicenter, randomized DKCRUSH-1 BIFURCATION STUDY. Clinical and angiographic data were analyzed. Follow-up was available for all patients. There were significant differences of the bifurcation angle between the classic and the DK crush group (83.28 +/- 20.69)(0) vs. (67.71 +/- 26.35)(0), P = 0.02). Unsatisfactory kissing rate in the classic group was significantly higher (26.32% vs. 5.88%, P = 0.01). The acute gain in the side branch was greater in the DK crush stent group (1.48 +/- 0.50 mm vs. 1.36 +/- 0.55 mm, P = 0.03). The accumulative restenosis rate in the main vessel segments, side branch, and accumulative MACE were higher in the classic group than the DK crush group (13.39% vs. 5.12%, P = 0.058, 42.10% vs. 5.88%, P = 0.01, 42.10% vs. 5.82%, P = 0.001, respectively). By logistic regression, acute gain in side branch immediately after PCI, bifurcation angle and unsatisfactory kissing were three independent factors of TLR at 8-month follow-up. Classic crush stenting with final kissing balloon inflations did not improve the clinical outcomes for the treatment of left main bifurcation lesion when compared with DK crush stenting technique.

Resultados imediatos e tardios do implante de stents farmacológicos para o tratamento de bifurcações: comparação entre as estratégias de um stent versus dois stents

FUNDAMENTOS: Os stents farmacológicos reduziram a necessidade de nova revascularização nas lesões bifurcadas. Entretanto, o seguimento tardio e a estratégia mais adequada (um stent vs. dois stents) não estão bem estabelecidos. MÉTODO: No período de junho de 2002 a dezembro de 2006, 156 pacientes consecutivos com lesões envolvendo bifurcações foram tratados com implante de stents farmacológicos. Comparou-se a taxa de eventos cardíacos adversos maiores (ECAM) combinados - óbito, infarto e revascularização do vaso-alvo (RVA) - e a incidência de trombose do stent conforme a estratégia (um stent: ramo principal vs. dois stents: ramos principal e lateral). RESULTADOS: A média das idades foi de 64 ± 12 anos, 75,6% eram do sexo masculino e 28,8%, diabéticos. O seguimento médio foi de 2,4 ± 1,3 anos. Utilizou-se a estratégia com um stent em 67,3% dos pacientes. Bifurcações verdadeiras ocorreram em 64,7% dos casos. A estratégia de dois stents foi adotada em 32,7% dos casos (crush: 14,7%; cullote: 3,2%; T-stent: 10,3%; simultaneous kissing stent: 3,8%; V-stent: 0,6%). Kissing balloon final foi utilizado em 85,9% dos casos. A sobrevida livre de ECAM estimada foi de 95% na estratégia com um stent vs. 86% com dois stents (teste do log-rank, p = 0,03). A análise multivariada identificou o uso de dois stents como único preditor independente de ECAM (OR: 2,82; IC 95%: 1,047,68; p = 0,04). A taxa de trombose no emprego de um stent em comparação com dois stents foi de 1,9% vs. 3,9% (p = 0,6). CONCLUSÕES: O emprego dos stents farmacológicos nas bifurcações apresenta baixas taxas de eventos combinados no seguimento tardio. O uso de dois stents associou-se a maior taxa de ECAM, embora constitua um subgrupo de maior complexidade.

Abstract 3346: Percutaneous Treatment Of Unprotected Left Main Coronary Stenoses With Paclitaxel-eluting Stents. Mid-term Results Of A French Prospective Multicenter Study (friend Register)

Purpose : We assessed early and mid-term results of patients (pts) treated for ULMCA disease in the FRIEND registry. Methods: After ethical committee approval and informed consent, all consecutive pts with unprotected left main stenoses treated with Taxus stents were included in a multicenter prospective study from 23 centers. Major adverse cardiacl events (MACCE) : death, myocardial infarction, stroke, target lesion (TLR), target vessel revascularisation (TVR), acute, sub-acute and late thrombosis were adjudicated at 1and 6 months by an independent committee. Immediate and 9-month angiographic results were assessed by a central core lab. For the distal lesion of ULMCA, a strategy of main branch stenting with provisional T-stenting of the side branch followed by kissing balloon inflation was strongly recommanded. Results : From December 2005 to July 2006, 155 pts were included, mean age 68 ± 11 years, 83 % male, 31 % unstable angina, 25% diabetics, 46 % 3-vessel disease. The mean Euroscore was 4.2 ± 2.8 (estimated in-hospital mortality rate after surgery 4.1%). The LM reference diameter was 3.6 ± 0.5mm. LM lesion was ostial-proximal in 28 %,mid shaft 18 % and distal 66%. In this group, 72 % were located at the bifurcation including LAD, LCX or both ostia affected. All patients were successfully treated on the LM (stent length 15.7 ± 5.2 mm) and a final kissing balloon inflation was performed in 90%. Apart from the LM stenosis, a total of 1.2 ± 0.8 lesions were treated during the hospitalisation (total stent length 47 ± 16mm). In-hospital MACCE rate was 4.5 % : death in 2.6% (3 acute stent thrombosis at day 2, 3, 5 and 1 before PCI) ; 2 Pts had asymptomatic non-Q-wave MI,1 pt Q-wave MI and 1CABG. At 9-month follow-up (122 pts) there was one extra-cardiac death, no cardiac failure and 3 pts (2.5 %) had recurrence of symptoms. The global rate of event-free survival was 93.5 % with a very low angiographic restenosis rate of 3 %. Conclusion: LM PCI using the TAXUS stent is feasible and safe. Preliminary results showed favourable 9-month follow-up. Stenting deserves to be considered a safe and effective alternative to CABG in institutions performing large numbers of PCIs. Adjudicated clinical and angiographic long-term (9-month) data are warranted and will be available for presentation.

Drug-Eluting Stent Update 2007

Randomized trials have largely demonstrated that percutaneous coronary intervention (PCI) with sirolimus-eluting (SES) and paclitaxel-eluting stents (PES) results in a significant reduction in the occurrence of angiographic restenosis and revascularization compared with bare metal stents (BMS).1–4 The benefit of drug-eluting stents (DES) also has been confirmed in “real-world” scenarios. In this setting, when the analysis was focused on high-risk patient and lesion subgroups, a benefit still existed despite the presence of restenosis.5–7 These expanded indications do not yet cover many other types of complex lesions for which only registries or randomized trials, not yet published, are available so far (Tables 1 through 7⇓⇓⇓⇓⇓⇓). This topic is discussed in detail in this review. An important clarification is that the lack of proof is most probably due to the difficulty in performing randomized trials in high-risk groups using BMS as controls. It will be no surprise to find that the field in which DES perform best compared with BMS is likely to be complex lesions and patients8 (Figure 1). View this table: TABLE 1. DES in Unprotected Left Main Stenosis View this table: TABLE 2. DES in Bifurcation Lesions View this table: TABLE 3. DES in Chronic Total Occlusions View this table: TABLE 4. DES in Small-Vessel Disease and Long Lesions View this table: TABLE 5. DES in SVGs View this table: TABLE 6. DES in Acute MI View this table: TABLE 7. DES in Multivessel Disease Figure 1. Lesion complexity and stent performance in the BMS and DES eras. Adapted from Edelman et al.8 Current American Heart Association/American College of Cardiology (AHA/ACC) and European Society of Cardiology (ESC) guidelines consider the presence of a stenosis in the unprotected left main coronary artery (LMCA) a class IIa or IIb indication, respectively, for PCI if coronary artery bypass grafting (CABG) is not a viable option.9,10 Moreover, according to the AHA/ACC 2005 guidelines, in …

Stenting des bifurcations

The optimal treatment of coronary bifurcation lesions remains a challenging theoretical and technical area for percutaneous coronary intervention. Questions remain unanswered regarding the optimal technique and devices to be used in order to achieve and maintain a safe and effective clinical result. Many studies or registries have shown that treatment of bifurcation lesions with drug eluting stents was associated with a lower risk of restenosis and reintervention. An increased risk of drug eluting stent thrombosis in bifurcation lesions has been shown but it seems that it is more related to a problem of optimal treatment than bifurcation or drug eluting stent by itself. Today there is a consensus for a “provisional side branch stenting approach with final kissing balloon inflation” and the remaining question is when and how to stent the side branch. Dedicated devices are now emerging as new tools which may solve some technical problems and improve the quality and reproducibility of treatment.

Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): Immediate procedure result and short‐term clinical outcomes

Sleeve technique is a modified version of crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter. The aim of this study was to examine the feasibility, safety, and early clinical outcomes of sleeve technique in stenting different types (de novo, in-stent restenotic or in-stent bifurcation) of coronary bifurcation lesions at different locations. From August 2005 to May 2006, 41 consecutive patients with symptomatic, nonleft-main coronary bifurcation stenoses of diameter narrowing >or=50% were treated with two-stent strategy, using sleeve technique. The mean age was 63.6 +/- 11.6 years with male predominance (70.7%). High prevalence of diabetes mellitus (31.7%), total occlusion (22.0%), and multi-vessel disease (65.9%) was observed in this cohort. Intravenous abciximab was given in 35 (85.4%) patients. Final kissing balloon inflation was successfully performed in all patients. The minimal luminal diameter in main vessel and side branch was increased from 0.97 +/- 0.53 mm and 0.81 +/- 0.45 mm to 2.76 +/- 0.34 mm and 2.22 +/- 0.35 mm, respectively. The mean procedure time was only 66.6 +/- 24.6 min. There was one (2.4%) case of subacute stent thrombosis presented as non-Q-wave myocardial infarction at day 3 postprocedure. The resultant in-hospital and 30-day major adverse cardiac event rate were both 2.4%. Sleeve technique is a feasible and efficient approach in stenting of coronary bifurcation stenoses.

Stenting of Unprotected Distal Left Main Coronary Artery Bifurcation Stenoses Using Modified Crush Technique with Double Kissing Balloon Inflation (Sleeve Technique): Immediate Procedure Result and Early Clinical Outcome

Sleeve technique is a modified version of the crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter. This study sought to look at the feasibility, safety, and early clinical outcome of sleeve technique in stenting of unprotected distal left main coronary artery (LMCA) bifurcation stenoses. From August 2005 to April 2006, 12 consecutive patients with symptomatic distal LMCA bifurcation stenoses of diameter narrowing > or =50%, who refused coronary artery bypass graft surgery, were treated with two-stent strategy using the sleeve technique. Eleven patients (91.7%) were male, with a mean age of 64.4 +/- 9.3 years. Intravenous abciximab was given to 10 patients (83.3%). The baseline reference vessel diameters of the main vessel and side branch were 3.32 +/- 0.44 and 3.00 +/- 0.58 mm, respectively. After intervention, the minimal luminal diameter was increased from 0.99 +/- 0.46 to 3.26 +/- 0.28 mm and 1.43 +/- 0.71 to 2.93 +/- 0.45 mm in the main vessel and side branch, respectively. The intervention procedure was successful in all patients with 100% final kissing balloon inflation rate. The average procedure time was 58.6 +/- 20.5 minutes. Two patients had a small non-Q myocardial infarction postprocedure. The resultant major adverse cardiac event rate was 16.7% at 30 days after the procedure. Sleeve technique is a safe and feasible approach in the stenting of distal LMCA bifurcation stenoses.

Predictors of restenosis after treatment of bifurcational lesions with paclitaxel eluting stents: A multicenter prospective registry of 150 consecutive patients

The aim of the study was the assessment of the clinical, angiographic and procedural characteristics correlated with freedom from adverse events at 1 year in a real life setting of consecutive bifurcation lesions. Even if stent implantation has shown to be superior to conventional balloon angioplasty in most coronary lesions, bifurcation treatment with stent implantation both in main and in side branch (SB) still raises controversy. We reviewed the results obtained in a prospective multicenter registry of 150 patients with 158 bifurcation lesions involving a SB of sufficient diameter to be treated, if necessary, with a polymer based paclitaxel eluting stent (PES, TAXUS). Two stents were used in 118 lesions (74.7%). Final kissing balloon inflation was performed in 87/118 lesions (73.7%) and in 30/40 lesions (75.0%) of the 2 and 1 stent group respectively. At 1-year clinical follow-up we observed 4 stent thromboses, all involving the SBs of the 2 stents group (2.7%). Unlike previous reports, revascularization involved the main vessel in the majority of patients (21/150, 14.0%). After an exploratory multivariable analysis the only parameter predictive of target lesion revascularization (TLR) (HR 0.52; CI 95% 0.11-0.86; p = 0.02) and target vessel revascularization (TVR) (HR 0.47; CI 95% 0.14-0.90; p = 0.03) was postprocedural main branch minimal lumen diameter (MB-MLD). In a real life setting of consecutive bifurcation lesions, thrombosis rate, concentrated in the SB and the 2-stents group, and need for target lesion revascularization remain higher than in less complex lesion subgroups treated with PES. No differences in immediate success and TLR were observed between 2 stents and 1 stent groups. The frequently observed suboptimal stent expansion and final MB-MLD predict 1 year revascularization.