Treatment Of Bifurcation Lesions Research Articles

Comparison of the Incidence of Periprocedural Myocardial Infarction in Bifurcation Lesions Between Medina (1,1,1) and (0,1,1) in Elective Percutaneous Coronary Intervention.

Periprocedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) is more frequently observed in true bifurcation lesions such as Medina (1,1,1) and (0,1,1). The aim of this study is to compare the incidence of PMI in elective PCI between Medina (1,1,1) and (0,1,1) bifurcation lesions. This was a retrospective, single-center study. We included 162 true bifurcation lesions, which were divided into the (1,1,1) group (n = 85) and the (0,1,1) group (n = 77). We compared the incidence of PMI between the two groups and performed multivariate logistic regression analysis using PMI as a dependent variable. The incidence of PMI was similar in the (1,1,1) group and the (0,1,1) group (12.9% versus 15.6%, P = 0.658). The final TIMI flow grade of the side branches and that of the main branches were also similar in the two groups. In multivariate logistic regression analysis, Medina classification (1,1,1) was not associated with PMI (odds ratio (OR), 0.996; 95% confidence interval (CI), 0.379-2.621; P = 0.994), but the angle of the side branch < 45° (OR, 3.569; 95% CI, 1.320-9.654; P = 0.012), lesion length in a main vessel (per 10-mm increase) (OR, 1.508; 95% CI, 1.104-2.060; P = 0.010), and absence of side branch protection (OR, 3.034; 95% CI, 1.095-8.409; P = 0.033) were significantly associated with PMI. In conclusion, the Medina (1,1,1) bifurcation lesions did not increase the incidence of PMI as compared to Medina (0,1,1). However, the narrow side branch angle, diffuse long lesion, and absence of side branch protection were significantly associated with PMI. We should pay attention to these high-risk features in the treatment of true bifurcation lesions.

Defining Key Features of Complex Coronary Lesions: An Evidence Based Review of Clinical Practice. Part I: Bifurcations, Left Main Disease, and Calcifications.

Clinicians have long recognized that certain features of coronary artery lesions increase the complexity of intervention. Complex lesions are associated with worse cardiovascular outcomes and a higher risk of subsequent ischemic events. These lesions are categorized by their angiographic features. These features include bifurcation lesions, left main coronary artery disease, calcified lesions, in-stent restenosis, chronic total occlusions and graft interventions. This two-part review aims to highlight the current evidence in the percutaneous management of these lesions. Part one of this review focuses on the best techniques to treat bifurcation lesions, indications for intervention of left main coronary artery disease and additional tools used to treat calcified lesions.

Clinical and angiographic assessment of the culotte technique for the treatment of complex coronary bifurcation lesions

Clinical and angiographic assessment of the culotte technique for the treatment of complex coronary bifurcation lesions

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.

Comparison of long-term clinical outcomes in diabetic and non-diabetic patients of the mini-crush two-stent technique for percutaneous treatment of complex coronary artery bifurcation lesions

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Diabetic patients present more aggressive coronary artery disease and worse outcomes after percutaneous coronary intervention (PCI), especially in complex coronary bifurcation lesions. Currently, the benefit of "double stenting" techniques in the treatment of complex bifurcations in diabetics with coronary artery disease, is controversial. Purpose The aim of this study was to compare the outcomes of PCI with "mini-crush" two-stent technique in diabetic and non-diabetic patients, in terms of MACE: cardiovascular mortality, non-fatal myocardial infarction, target lesion revascularization (TLR) and stent thrombosis after long follow-up (median 32 months). Methods Observational study in which were included 152 consecutive patients (mean age 69.5 years, 38.3% diabetics) with 152 complex bifurcated coronary severe lesions that underwent PCI from April 2014 to April 2020. Results No significant differences were observed in the baseline characteristics, clinical presentation and antiplatelet pretreatment between both groups. Clopidogrel was the P2Y12-receptor inhibitor most commonly used. There were no differences in mean complexity according to the Syntax score (29.7 ± 11.3 in diabetics vs 30.4 ± 14.4 in non-diabetics, p=0.293). Left main bifurcation was the most frequently coronary artery affected in both groups and circumflex was the most common side vessel. The characteristics of the procedure was similar in both groups: no differences observed in pre-dilation rate either in final kissing balloon post-dilation rate. Similar length and diameter of the stents implanted in both groups. Angiographic follow-up clinically guided was 15.8% in diabetics and 16.9% in non-diabetics. We found no significant differences in the incidence of MACE or in any of its components separately. TLR rate was similar in diabetics and non-diabetics patients. Conclusions Comparable to non-diabetic patients, PCI in complex coronary bifurcation lesions with "mini-crush" two-stent technique in diabetic patients shows favorable results with low event rates and need for revascularization at long-term follow-up.

Crush techniques for percutaneous coronary intervention of bifurcation lesions.

Percutaneous coronary intervention (PCI) of coronary artery bifurcation lesions entails technical challenges and carries a higher risk of adverse events on follow-up, driven by repeat revascularisation and stent thrombosis. While most bifurcations can be tackled with a provisional (single-stent) approach, more complex lesions involving both branches (true bifurcation lesions) require a two-stent approach. In the latter context, several techniques have been proposed. Among them, the crush technique has dramatically evolved in recent years, and its more recent iterations have been shown to provide excellent and durable results, both for left main and non-left main bifurcations. The aim of the present work is to discuss the technical aspects and outcomes of the variants of the crush technique from the first description in the early 2000s to the present day.

Successful endovascular treatment of left main bifurcation lesion using the DK-CRUSH technique with intracoronary imaging using optical coherence tomography: A case report

We report the successful endovascular treatment of true left main bifurcation lesion in a patient with chronic coronary syndrome using the DK-CRUSH technique. We describe technical aspects of bifurcation stenting with intracoronary imaging using optical coherence tomography. Here, we review the current state of the problem of choosing the optimal technique for endovascular treatment of patients with true left main true bifurcation lesion.

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.

Twelve-month clinical outcomes of "nano-crush technique" for the treatment of bifurcation lesions using ultra-thin (60 µm) sirolimus-eluting coronary stents.

Provisional stenting is preferred for bifurcation lesion; however, certain anatomical substrate does require two stents as a part of dedicated stent technique. Here, the present study evaluated outcomes of ultra-thin (60 µm) Supra family sirolimus-eluting stent (SES) (Sahajanand Medical Technologies Limited, Surat, India) for dedicated bifurcation lesions using nano-crush technique at 12 months angiographic follow-up. This was prospective, single-center observational study which enrolled patients with de novo bifurcation lesion and underwent angioplasty with Supra family SES using nano-crush technique at a tertiary care center in India, between March-2017 and February-2019. Primary endpoint at 12 months was target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (CD-TLR). Secondary endpoints included patient-oriented composite endpoint (POCE), all-cause death, any revascularization, clinically driven target vessel revascularization, stent thrombosis, periprocedural and spontaneous MI, and device failure. The study enrolled total 63 patients with a mean age of 62.5±4.9 years and had male dominance (89%). Left main (LM) bifurcation and non-LM bifurcation were observed in 21 (33%) and 42 (67%) patients, respectively. Total 50 (80%) patients had Medina class- 1,1,1. At 12 months, TLF occurred in 4 (6%) patients which included one cardiac death (1.5%), two (3.0%) TV-MI, and one CD-TLR (1.5%). POCE was observed in 6 (9.6%) patients. Stent failure was seen in 2 (3.1%) patient and one patient (1.5%) developed late stent thrombosis. Twelve months angiographic follow-up indicated intact stent patency in all other patients. On multivariate analysis, LM bifurcation, renal dysfunction, LM bifurcation with renal dysfunction, ejection fraction (<35%) and calcified lesion were found as predictors of TLF. Dedicated stenting with ultra-thin Supra family SES for complex bifurcation lesion using nano-crush technique reported acceptable clinical outcomes among real-world patients and can be performed safely with ease without any procedural complications.

Improved Outcomes of Combined Main Branch Stenting and Side Branch Drug-Coated Balloon versus Two-Stent Strategy in Patients with Left Main Bifurcation Lesions.

Background Drug-eluting stent (DES) plus drug-coated balloon (DCB) is a safe and effective treatment strategy for coronary artery bifurcation lesions, but there is no report about this strategy being used for left main (LM) bifurcation lesions. We aim to explore the efficacy and safety of DES plus DCB in the treatment of LM bifurcation lesions. Methods A total of 100 patients diagnosed with LM bifurcation lesions by coronary angiography were retrospectively enrolled at our center from January 2018 to December 2019. They received either a two-stent strategy or a main branch (MB) stenting plus side branch (SB) DCB strategy and were accordingly divided into the 2-DES group and the DES + DCB group. Patients treated with DES + DCB were compared with a cohort of matched patients treated with a 2-DES strategy. Clinical data was collected and quantitative coronary analysis was performed. Results For immediate postoperative angiography, though the two groups had no differences in the minimal luminal diameter (MLD) and luminal stenosis of MB, the DES + DCB group had significantly lower SB ostial MLD and a higher degree of residual lumen stenosis than the 2-DES group (P < 0.05). At the time of follow-up, the SB ostial MLD of the DES + DCB group was higher than that of the 2-DES group, but lumen stenosis, late lumen loss (LLL), and LLL at the distal end of the left MB were all smaller than those of the 2-DES group (Ps < 0.05). Furthermore, the incidence of lumen restenosis and MACE between the two groups had no significance. Conclusion The combination of DES and DCB is relatively safe and effective for the treatment of LM bifurcation lesions, and this strategy seems to have advantages in reducing LLL at the SB ostium.

A Case Summary of the Application of a Drug-Eluting Stent Combined with a Drug-Coated Balloon in Left Main Coronary Artery Disease

Objective: To evaluate the clinical efficacy of a drug-eluting stent (DES) combined with a drug-coated balloon (DCB) in the treatment of left main coronary artery bifurcation lesions. Methods: A retrospective analysis was conducted on the clinical data of eight patients with left main coronary artery bifurcation lesions treated with a DES combined with a DCB who were admitted to our hospital from July 2016 to July 2017. These eight patients all underwent DES treatment for their left main coronary artery and left anterior descending coronary artery lesions, and DCB treatment at the ostium of the left circumflex artery; six of the patients underwent surgical procedures under the guidance of intravascular ultrasonography. Immediate postoperative angiography was used to evaluate the patency of the diseased vessels, and the restenosis rate at the 6-month follow-up after the operation and the incidence of serious clinical events within 6 months were assessed as well. Results: The use of a DES combined with a DCB in the treatment of left main coronary artery bifurcation lesions had a low restenosis rate (left main coronary artery (8.4 ± 5.3)%, left anterior descending coronary artery (18.2 ± 5.0)%, left circumflex artery (30.5 ± 16.5)%). No serious clinical events occurred in any patients. Conclusion: A DES combined with a DCB is a safe and effective interventional treatment for left main artery coronary bifurcation lesions.

Treatment of coronary bifurcation lesions with dedicated stent BiOSS ® LIM C: A single-center observational study

The challenges of coronary bifurcation angioplasty are linked to the fractal geometry of their anatomy, responsible for the differences in diameter between the different segments with risk of stent malposition in the main branch and difficulty to access the side branch. Dedicated stents for bifurcation have been developed to reduce these potential risks. The BiOSS ® LIM C stent (Balton, Warsaw, Poland) is a Cobalt Chrome drug eluting stent with Sirolimus dedicated to the treatment of bifurcation lesions. Our single-center retrospective study included 173 consecutive patients treated for a bifurcation lesion with a BiOSS ® LIM C stent between December 2017 and February 2020. The mean age was 71 ± 11.6 years. The percentage of true bifurcation lesions was 27.2%. The angioplasty success rates for the main branch and the side branch were respectively 100% and 99.4%. The mean duration of follow-up was 311 days. We observed during the follow-up: 4 cardiovascular deaths (2.3%), 5 myocardial infarctions (2.9%), 2 stent thrombosis (1.2%), 10 TLR (6%), 16 TVR (9.2%), 18 TVF (10.4%). The probabilities of overall survival, survival without cardiovascular death or myocardial infarction and survival without TVF are respectively 95%, 90% and 81%. Angioplasty of coronary bifurcation lesions with a dedicated stent BiOSS ® LIM C is safe and provides very good immediate and long-term results.

Drug-eluting balloon catheters in the treatment of left main coronary artery bifurcation lesions

<h3></h3> В статье представлен обзор современных исследований по применению баллонных катетеров с лекарственным покрытием при чрескожных коронарных вмешательствах. Имеются многочисленные данные, подтверждающие эффективность и безопасность их использования у пациентов с рестенозами стентов, а также при поражениях артерий малого диаметра. Доказательная база их применения у пациентов с бифуркационными стенозами коронарных артерий остается ограниченной. Тем не менее, существующие исследования демонстрируют отсутствие преимуществ двухстентовых методик бифуркационного стентирования перед одностентовыми с применением баллонных катетеров с лекарственным покрытием. Однако остаются нерешенными вопросы отбора пациентов для подобных вмешательств при бифуркационных стенозах ствола левой коронарной артерии, технические аспекты процедуры стентирования, целесообразность применения внутрисосудистых методов исследования для оптимизации результатов лечения, недостаточно сведений об отдаленных результатах лечения таких пациентов.

Practice Patterns in the Interventional Treatment of Coronary Bifurcation Lesions: A Global Survey.

The study aim was to assess current procedural strategies and perceptions for percutaneous coronary intervention (PCI) involving bifurcations. We distributed an online survey via email (8050 invitations) and social media. Among 440 responders, median annual PCI volumes were 15 cases (interquartile range [IQR], 10-29 cases) for left main (LM) and 50 cases (IQR, 27-73 cases) for non-LM (nLM) bifurcation lesions. Radial access use was reported in 51% of LM and 82% of nLM cases. An upfront 2-stent strategy, most commonly double-kissing (DK) crush, was reported in 49% of LM and 29% of nLM lesions. Bailout stenting during provisional stenting was reported in 26% of LM-PCIs, usually using the T and protrusion technique. In provisional stenting cases, most operators (<35%) did not report predilating the side branch, but routinely postdilated after successful provisional stenting (>85%), most often using both kissing-balloon inflation and the proximal optimization technique. Intravascular imaging was used in 80% of LM and 46% of nLM cases. Among the survey responders, the DK crush technique was the most frequently used 2-stent strategy for bifurcation PCIs. For LM lesions, bailout stenting was performed after provisional strategy in approximately 25% of cases. For nLM lesions, use of intravascular imaging and coronary physiology was lower than for LM lesions.

The Drug Coated Balloon-Only Strategy for Treatment of de Novo Left Main Coronary Artery Bifurcation Lesion: Stentless Strategy.

The study aimed to evaluate the efficacy and safety of drug coated balloon-only strategy (DCB-only) in the treatment of de novo left main coronary artery (LM) bifurcation lesions. 85 patients were enrolled in this study and classified them into two groups: DCB-only group (n = 36) and DES group (n = 49). The MLD of target vessels was measured before and immediately after percutaneous coronary intervention (PCI) and late luminal loss (LLL) were also calculated. And the occurrence of major adverse cardiovascular events (MACE) was also evaluated. Compared with that before PCI, the MLD of target lesions significantly increased immediately after PCI (P < .05) and no MACE was recorded during the perioperative period both in two groups. The MLD at follow-up was significantly higher than that before both DCB and DES treatment. Compared with the DES group, the MLD of the DCB group was smaller than immediately after PCI in the LM and LAD (P < .05). The LLL of LAD in DCB group was smaller than that in DES group (P < .05). There was no significant difference in the incidence of luminal restenosis at the target lesion between the two groups, and no significant difference in the incidence of MACE (P > .05). The use of DCB-only to treat de novo LM bifurcation lesions is effective and relatively safe, which provides new ideas for the treatment of LM coronary artery bifurcation lesions in the future.

Mini-Crush Technique in Left Main Coronary Bifurcation: A Case Report

Percutaneous coronary intervention of Left Main (LM) coronary artery bifurcation disease remains technically challenging. Despite the plethora of techniques in current practice and guidelines advocating provisional strategy (one-stent or main branch-stent only), controversy still persists regarding the two-stent techniques.Moreover, there is improved mindfulness towards various factors affecting LM treatment such as patient selection, stent characteristics, risk stratification, optimum imaging, as well as vessel preparation. The latest generation stent with ultra-thin struts have been safe and efficient in the treatment of LM bifurcation lesions, as they have upgraded designs that aid in the expansion of their diameters to larger extent. Additionally, being ultra-thin leads to lower metal load at the carina, thus improving the long-term outcomes. The authors here present with the case of a 42-year-old patient with LM bifurcation disease who was successfully managed with mini-crush technique using ultra-thin Tetriflex Sirolimus-Eluting Stents (SES). The case depicts that optimum amalgamation of ultrathin strut stents implantation and mini-crush technique would provide very favourable results.

Practice Patterns in the Interventional Treatment of Coronary Bifurcation Lesions: A Global Survey.

The study aim was to assess current procedural strategies and perceptions for percutaneous coronary intervention (PCI) involving bifurcations. We distributed an online survey via email (8050 invitations) and social media. Among 440 responders, median annual PCI volumes were 15 cases (interquartile range [IQR], 10-29 cases) for left main (LM) and 50 cases (IQR, 27-73 cases) for non-LM (nLM) bifurcation lesions. Radial access use was reported in 51% of LM and 82% of nLM cases. An upfront 2-stent strategy, most commonly double-kissing (DK) crush, was reported in 49% of LM and 29% of nLM lesions. Bailout stenting during provisional stenting was reported in 26% of LM-PCIs, usually using the T and protrusion technique. In provisional stenting cases, most operators (<35%) did not report predilating the side branch, but routinely postdilated after successful provisional stenting (>85%), most often using both kissing-balloon inflation and the proximal optimization technique. Intravascular imaging was used in 80% of LM and 46% of nLM cases. Among the survey responders, the DK crush technique was the most frequently used 2-stent strategy for bifurcation PCIs. For LM lesions, bailout stenting was performed after provisional strategy in approximately 25% of cases. For nLM lesions, use of intravascular imaging and coronary physiology was lower than for LM lesions.

Bioresorbable magnesium scaffold in the treatment of simple coronary bifurcation lesions: The BIFSORB pilot II study.

ObjectivesTo evaluate the feasibility, safety, and healing response of a magnesium‐based bioresorbable scaffold (BRS) in the treatment of simple bifurcation lesions using the single stent provisional technique.BackgroundBRS may hold potential advantages in the treatment of coronary bifurcation lesions, however low radial strength and expansion capacity has been an issue with polymer‐based scaffolds. The magnesium BRS may prove suitable for bifurcation treatment as its mechanical properties are closer to those of permanent metallic drug‐eluting stents.MethodsThe study was a proof‐of‐concept study with planned inclusion of 20 patients with stable angina pectoris and a bifurcation lesion involving a large side branch (SB) > 2.5 mm with less than 50% diameter stenosis. Procedure and healing response were evaluated by optical coherence tomography (OCT). The main endpoints were a composite clinical safety endpoint and an OCT healing index at 1 month (range: 0–98).ResultsEleven patients were included in the study. The study was prematurely terminated due to scaffold fractures and embolization of scaffold fragments in three cases requiring bailout stenting with drug‐eluting stents. One patient underwent bypass surgery at 3 months due to stenosis proximal to the study segment. All SB were patent for 1 month. One‐month OCT evaluation showed strut coverage of 96.9% and no malapposition. Scaffold fractures and uncovered jailing struts resulted in a less favorable mean OCT healing index score of 10.4 ± 9.0.ConclusionsImplanting a magnesium scaffold by the provisional technique in nontrue bifurcation lesions was associated with scaffold fracture, embolization of scaffold fragments, and a high need for bailout stenting.

Clinical outcomes of the proximal optimisation technique (POT) in bifurcation stenting.

Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate. We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how post-implantation deployment techniques influence clinical outcomes. Data from the e-ULTIMASTER registry were used to perform an analysis of 4,395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at one year (follow-up rate 96.2%). The global one-year TLF rate was low (5.1%). The proximal optimisation technique (POT) was used in 33.9% of cases and was associated with a reduction in the adjusted TLF rate (4.0% [95% confidence interval: 3.0-5.1%] vs 6.0% [5.1-6.9%], p<0.01) due to a reduction of all components of this composite endpoint, except for cardiac death. Stent thrombosis was also positively impacted (0.4% [0.04-0.7%] vs 1.3% [0.8-1.7%], p<0.01). POT benefit was uniform across subgroups. Conversely, the use of the kissing balloon technique (36.5%) did not influence the adjusted TLF rate. Despite a low one-year failure rate in this large bifurcation stenting cohort, POT was associated with a further reduction in the event rate and a uniform benefit across subgroups, suggesting systematic use of this deployment technique regardless of the bifurcation anatomy and stenting technique.

The use of modern techniques in percutaneous coronary intervention for bifurcation lesions: A single centre experience

The use of modern techniques in percutaneous coronary intervention for bifurcation lesions: A single centre experience