Jailed Side Branch Research Articles

Initial Experience with the New DERIVO® Mini Embolisation Device for the Treatment of Intracranial Aneurysms.

The aim of this study is to present the outcomes of cerebral aneurysm treatment with the DERIVO® mini Embolisation Device (DMD), which is compatible with microcatheters with 0.021-inch inner diameters. Consecutive patients treated with DMD were identified retrospectively. Patient and aneurysm characteristics, procedural findings, clinical outcomes and follow-up imaging results were evaluated. A total of 44 target aneurysms in 30 patients were treated with DMD. The mean age of the patients was 49.9 (range, 4-77 years). Four patients with five aneurysms presented with acute subarachnoid hemorrhage. The mean aneurysm size was 6.8 mm (range, 1.5-22 mm). In 29 (65.9%) aneurysms, adjunctive devices were used for endovascular treatment. The overall mortality rate was 3.3% and procedure-related mortality was 0%. Overall neurologic morbidity was 6.6% and none of the patients had a permanent sequela secondary to the procedure. The mean clinical follow-up period was 20.9 months (range, 3 days-46 months) and the mean DSA follow-up period was 10.9 months. A total of 37 (84.1%) aneurysms demonstrated total occlusion (Raymond-Roy [RR 1]); 3 (6.8%) aneurysms had a neck remnant or infundibular filling at the origin of the jailed side branch (RR 2), 4 (9.1%) aneurysms had residual aneurysm filling (RR 3). For those aneurysms treated with bare DMD, the total occlusion rate was 73.3% at a mean follow-up of 16.1 months. In this initial clinical single-center experience, DMD had a good safety profile and efficacy comparable with the currently used flow diverters.

Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms.

The invention of flow diverting stents (FDS) is a novel milestone in the field of endovascular aneurysm therapy, promoting physiological healing of the vessel segment contrary to prior deconstructive treatment strategies, such as coiling. The effects of FDS are based on changes in flow patterns, segmental wall stabilization, and the growth of a neointima. Although flow diversion is already well established for cerebral aneurysms in proximal segments, peripheral locations remain challenging. Especially the middle cerebral artery (MCA) with its predominance of non-collateralized perforators and functional end arteries that supply the eloquent areas of the brain is of major concern.The literature was reviewed for flow diversion of the MCA and antiplatelet therapy.Resulting from the special anatomical characteristics of the MCA, FDS implantation in this territory is completely different from the proximal vessel segments. Still, flow diversion represents an effective endovascular strategy, especially in otherwise non-accessible or sufficiently treatable lesions. However, the risk of ischemic adverse events might be increased. Special attention to the individual decision regarding device selection, antiplatelet regimen, and exact definition of the proximal and distal landing zone considering the jailed side branches is essential for a good angiographic and clinical outcome. · MCA aneurysms can be sufficiently treated by FDS.. · The anatomic and hemodynamic characteristics of the MCA result in an increased risk of thromboembolism.. · Individual device selection and antiplatelet regimen are essential for treatment success.. · Schüngel M, Wohlgemuth WA, Elolf E et al. Review: Flow Diversion for the Treatment of Middle Cerebral Artery Aneurysms. Fortschr Röntgenstr 2024; DOI 10.1055/a-2343-0046.

Angiographic Safety and Efficacy of the ReSolv Flow-Diverting Stent in a Rabbit Model.

Bioresorbable polymer-based flow-diverting stents have potential benefits over existing metal devices. This study aimed to evaluate the safety and efficacy of the novel ReSolv device, which is a primarily polymer-based flow-diverting stent, using the in vivo rabbit sidewall saccular aneurysm model. ReSolv stents were deployed in 14 New Zealand White rabbits that had undergone aneurysm creation procedures. Animals were allocated to follow-up time points of 1, 3, 6, 9, 12, 16, or 18 months. Angiographic images were evaluated by an independent neurointerventionalist blinded to follow-up time points for (1) in-stent stenosis, (2) parent vessel and jailed side branch patency, (3) wall apposition, and (4) aneurysm occlusion using the Raymond-Roy Occlusion Classification (RROC), O'Kelly Marotta grading scale, and the 4F flow diversion predictive score. Primary efficacy outcome was defined as RROC Class I or II. At a median follow-up time of 7.5 months, parent vessel (14/14) and jailed side (33/33) branches were patent in all cases. There was no development of thrombus on the stent or cases of significant in-stent stenosis, and all stents had good wall apposition. Adequate occlusion was found in 85.7% (n = 12) of animals, including an RROC Class I in 64.3% (n = 9) and RROC Class II in 21.4% (n = 3). The ReSolv stent shows encouraging angiographic safety and efficacy outcomes after placement in a rabbit sidewall saccular aneurysm model. Longer term studies are ongoing to determine eventual fate of the aneurysm, parent vessel, and jailed side branches after absorption of the polymer component of the stent.

Coronary Stent Avulsion by Jailed Side-Branch Pressure Wire

Coronary Stent Avulsion by Jailed Side-Branch Pressure Wire

Association between post-procedural and long-term functional outcomes of jailed side branches in stented coronary bifurcation lesions assessed with side-branch murray law-based quantitative flow ratio

Abstract Background In coronary bifurcation lesions treated with percutaneous coronary intervention (PCI) using a 1-stent strategy, the occurrence of side branch (SB) compromise may lead to long-term myocardial ischemia in the SB territory. Murray law-based quantitative flow ratio (μQFR) is a novel angiography-based approach estimating fractional flow reserve from a single angiographic view, and thus more feasible to assess SB compromise in routine practice. However, its association with long-term SB coronary blood flow remained unknown. Aim To explore the association between post-procedural SB μQFR and long term SB coronary blood flow in non-left main (LM) coronary bifurcation lesions receiving 1-stent strategy. Methods A total of 146 patients with 313 non-LM bifurcation lesions receiving 1-stent strategy with drug-eluting stents was included in this retrospective study. These lesions had post-procedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in SBs, and documented angiographic images of index procedure and 6- to 24-month angiographic follow-up. The post-procedural SB μQFR was calculated. Long-term SB coronary blood flow was quantified with the TIMI grading system using angiograms acquired at angiographic follow-up. Results At follow-up, 8 (2.6%), 16 (5.1%), 61 (19.5%), and 228 (72.8%) SBs had a TIMI flow grade of 0, 1, 2, and 3, respectively. The incidences of SB TIMI flow grade <2 and <3 at follow-up both tended to decrease across the tertiles of post-procedural SB μQFR (TIMI flow grade <2: P=0.086; TIMI flow grade <3: P=0.052). In the multivariable logistic regression models, post-procedural SB μQFR was independently associated with SB TIMI flow grade <2 and <3 at follow-up, respectively (all P<0.05). The receiver operating characteristic curve analyses indicated that the area under the curve of post-procedural SB μQFR to identify SB TIMI flow grade <2 at follow-up was 0.6673 (95% CI, 0.5610-0.7737; P=0.0064), and the QFR limits to yield specificity and sensitivity >80% were 0.79 and 0.90, respectively. Conclusions Post-procedural SB μQFR in non-LM bifurcation stenoses was independently associated with impaired long-term SB coronary blood flow. Further investigations should focus on whether PCI optimization based on μQFR may contribute to improve SB flow in the long term.

Importance of optimal rewiring guided by 3-dimensional optical frequency domain imaging during double-kissing culotte stenting demonstrated through a novel bench model

The usefulness of optical frequency domain imaging (OFDI) guidance on two-stenting at left main bifurcation has not been evaluated. Here, we used a novel bench model to investigate whether pre-defined optimal rewiring with OFDI-guidance decreases acute incomplete stent apposition (ISA) at the left main bifurcation segment. A novel bench simulation system was developed to simulate the foreshortening and overlapping of daughter vessels as well as left main bifurcation motion under fluoroscopy. Double-kissing (DK) culotte stenting was performed using the novel bench model under fluoroscopy with or without OFDI-guidance. In the OFDI-guidance group, if the guidewire did not pass through the pre-defined optimal cell according to the 3-dimensional OFDI, additional attempts of rewiring into the jailed side branch were performed. The success rate of optimal jailed side branch rewiring after implantation of the first and second stent under OFDI-guidance was significantly higher than that under only angio-guidance. After completion of the DK-culotte stenting, the incidence and volume of ISA at the bifurcation segment in the OFDI-guidance group was significantly lower than that in the angio-guidance group. Online 3-dimensional OFDI-guided DK-culotte stenting according to a pre-defined optimal rewiring point might be superior to only angio-guided rewiring for reducing ISA at the bifurcation.

Post-procedural and long-term functional outcomes of jailed side branches in stented coronary bifurcation lesions assessed with side branch Murray law-based quantitative flow ratio.

In coronary bifurcation lesions treated with percutaneous coronary intervention (PCI) using a 1-stent strategy, the occurrence of side branch (SB) compromise may lead to long-term myocardial ischemia in the SB territory. Murray law-based quantitative flow ratio (μQFR) is a novel angiography-based approach estimating fractional flow reserve from a single angiographic view, and thus is more feasible to assess SB compromise in routine practice. However, its association with long-term SB coronary blood flow remains unknown. A total of 146 patients with 313 non-left main bifurcation lesions receiving 1-stent strategy with drug-eluting stents was included in this retrospective study. These lesions had post-procedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in SBs, and documented angiographic images of index procedure and 6- to 24-month angiographic follow-up. Post-procedural SB μQFR was calculated. Long-term SB coronary blood flow was quantified with the TIMI grading system using angiograms acquired at angiographic follow-up. At follow-up, 8 (2.6%), 16 (5.1%), 61 (19.5%), and 228 (72.8%) SBs had a TIMI flow grade of 0, 1, 2, and 3, respectively. The incidences of long-term SB TIMI flow grade ≤1 and ≤2 both tended to decrease across the tertiles of post-procedural SB μQFR. The receiver operating characteristic curve analyses indicated the post-procedural SB μQFR ≤0.77 was the optimal cut-off value to identify long-term SB TIMI flow grade ≤1 (specificity, 37.50%; sensitivity, 87.20%; area under the curve, 0.6673; P = 0.0064), and it was independently associated with 2.57-fold increased risk (adjusted OR, 2.57; 95% CI, 1.02-7.25; P = 0.045) in long-term SB TIMI flow grade ≤1 after adjustment. Post-procedural SB μQFR was independently associated with increased risk in impaired SB TIMI flow at long-term follow-up. Further investigations should focus on whether PCI optimization based on μQFR may contribute to improve SB flow in the long term.

Long-term prognostic value of Murray law-based quantitative flow ratio in jailed left circumflex coronary artery after left main crossover stenting

We aimed to evaluate the impact of new Murray law-based QFR of jailed left circumflex coronary artery (LCx) on long-term clinical outcomes after left main coronary artery (LM) simple crossover stenting. 164 patients who underwent LM-to-left anterior descending coronary artery simple crossover stenting and had appropriate angiographic view of LCx for QFR computation were enrolled. The primary clinical outcome was the 5-year target lesion failure (TLF), defined as a composite of cardiac death, a target vessel myocardial infarction or target lesion repeat revascularization. The mean QFR of the LCx after LM stent implantation was 0.88 ± 0.09, and 29 patients (17.7%) had a low QFR (< 0.80), which was significantly associated with a higher 5-year rate of TLF when compared with the high QFR group (27.6% vs. 6.7%; HR: 4.235; 95% CI 1.21–14.95; p = 0.0015). The 5-year LCx ostium-related TLR rate in the low QFR group was also higher (17.2% vs. 3.0% in the high QFR group; HR: 6.07, 95% CI 1.63–22.59, p = 0.002). In a multivariate Cox regression analysis, a low QFR in the LCx after LM stenting was an independent predictor of the 5-year TLF rate (HR: 3.21, 95% CI 1.21–8.53; p = 0.019). ROC analysis showed that QFR a negative predictive value (NPV) of 89.6% ([AUC] 0.73, 95% CI 0.58–0.88, p < 0.05), the cutoff point is 0.85. The patients with a low QFR (< 0.80) in jailed LCX after LM simple crossover stenting had worse 5-year outcomes than those with a high QFR. Conversely, a QFR ≥ 0.85 of jailed LCx could serve as a good predictor of low risk of adverse outcome in LCx ostium. The QFR computation of the jailed LCx may be helpful to determine whether an additional procedure is required for the jailed side branch.

Effect of Clinical and Lesional Characteristics On Side Branch Compromise During Provisional Bifurcation Stenting

Background :One of the most serious side effects of percutaneous coronary intervention (PCI) for bifurcationlesions is major side branch (SB) blockage. PCI is used to treat coronary bifurcations lesions inabout 15-20% of cases. Because of the risk of SB compromise, PCI of coronary bifurcationlesions is frequently thought to be a difficult procedure.OBJECTIVE: The goal of this study was to investigate the clinical and lesional predictability ofsevere SB blockage during coronary bifurcation intervention.MATERIAL &amp; METHODS: It was a retrospective study performed at Cardiac CatheterizationLab, Punjab Institute of Cardiology, Lahore. It was a six months study from 15th April 2022 to14th Oct, 2022. 93 patients enrolled using non-probability sampling technique. Patients betweenthe ages of 30 and 70 of either gender, with coronary bifurcation lesions undergoing PCI and atleast one significant SB were included. Data was entered in the predesigned proforma. SPSSversion 24 was used to analyze our data.RESULTS: In our study a total of 93 patients were enrolled, the mean age of the cases was53.30 ± 1.12. There were 68 (73%) male and 25 (27%) females in our study. There were 52(56%) diabetic, 50 (54%) hypertensive, 63 (68%) smokers and 42 (45%) hypercholestrolemicpatients were present in our study. In our study 36 (39%) patients were found with family historyof CAD and 6 (7%) patients found with recent MI. LAD was most frequently utilized bifurcationlesion in our study. The mean of lesion length was 28.82 ± 10.91 in this study. SB angle was 41º-50º in most of the cases 20 (22%), side branch diameter stenosis post MV stenting was 70-75%in 40 (43%) cases. Medina classification 1,1,1 was found in 43 (46%) cases. In 62 (67%) casesno side branch jailing was observed. Side branch predilatation before MV stenting was found in72 (77%) cases. Need of stenting in SB was found in 60 (65%) cases. Most frequently usedtechnique for SB provisional stenting was DK crush and mini crush in this study.Keywords: Bifurcation Lesions, SB, PCI

Three dimensional reconstruction of coronary artery stents from optical coherence tomography: experimental validation and clinical feasibility

The structural morphology of coronary stents (e.g. stent expansion, lumen scaffolding, strut apposition, tissue protrusion, side branch jailing, strut fracture), and the local hemodynamic environment after stent deployment are key determinants of procedural success and subsequent clinical outcomes. High-resolution intracoronary imaging has the potential to enable the geometrically accurate three-dimensional (3D) reconstruction of coronary stents. The aim of this work was to present a novel algorithm for 3D stent reconstruction of coronary artery stents based on optical coherence tomography (OCT) and angiography, and test experimentally its accuracy, reproducibility, clinical feasibility, and ability to perform computational fluid dynamics (CFD) studies. Our method has the following steps: 3D lumen reconstruction based on OCT and angiography, stent strut segmentation in OCT images, packaging, rotation and straightening of the segmented struts, planar unrolling of the segmented struts, planar stent wireframe reconstruction, rolling back of the planar stent wireframe to the 3D reconstructed lumen, and final stent volume reconstruction. We tested the accuracy and reproducibility of our method in stented patient-specific silicone models using micro-computed tomography (μCT) and stereoscopy as references. The clinical feasibility and CFD studies were performed in clinically stented coronary bifurcations. The experimental and clinical studies showed that our algorithm (1) can reproduce the complex spatial stent configuration with high precision and reproducibility, (2) is feasible in 3D reconstructing stents deployed in bifurcations, and (3) enables CFD studies to assess the local hemodynamic environment within the stent. Notably, the high accuracy of our algorithm was consistent across different stent designs and diameters. Our method coupled with patient-specific CFD studies can lay the ground for optimization of stenting procedures, patient-specific computational stenting simulations, and research and development of new stent scaffolds and stenting techniques.

A Randomized Trial Evaluating Online 3-Dimensional Optical Frequency Domain Imaging-Guided Percutaneous Coronary Intervention in Bifurcation Lesions.

Clinical implications of online 3-dimensional optical frequency domain imaging (3D-OFDI)-guided stenting for bifurcation lesions have not been investigated in the randomized controlled trials. The purpose of this study was to determine whether online 3D-OFDI-guided stenting is superior to angiography-guided percutaneous coronary intervention (PCI) in terms of incomplete stent apposition at the bifurcation segment. The OPTIMUM trial (Online 3-Dimensional Optical Frequency Domain Imaging to Optimize Bifurcation Stenting Using UltiMaster Stent) was a randomized, multicenter clinical trial. Eligible patients had an angiographically significant stenosis in the bifurcation lesion treated with a provisional single stent strategy using the Ultimaster sirolimus eluting stent. Patients were randomly allocated to either online 3D-OFDI-guided or angiography-guided PCI. Patients randomized to 3D-OFDI guidance underwent online 3D-OFDI assessment after rewiring into the jailed side branch after stenting and proximal optimization technique, while in the angiography guidance arm, rewiring was performed using conventional fluoroscopic/angiographic guidance. The primary end point of this trial was the postprocedural average percentage of malapposed struts per lesion assessed by OFDI in the confluence zone of the main and side branches. Between June 8, 2017 and September 26, 2018, 110 patients with 111 bifurcation lesions were randomized at 4 Japanese centers. Of these, 56 patients with 57 lesions were treated with 3D-OFDI-guided PCI, whereas 54 patients with 54 lesions were treated with angiography-guided PCI. In the 3D-OFDI guidance arm, the feasibility of online 3D-OFDI was 98.2%. The average percentage of incomplete stent apposition per lesion at bifurcation was lower in the 3D-OFDI guidance arm than that in the angiography guidance arm (19.5±15.8% versus 27.5±14.2%, P=0.008). The superiority of the 3D-OFDI guidance arm was also confirmed in the strut level analysis (odds ratio: 0.54 [95% CI, 0.36-0.81]; P=0.003). Online 3D-OFDI-guided bifurcation PCI was superior to angiography-guided bifurcation PCI in terms of acute incomplete stent apposition at bifurcation. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02972489.

Comparison of fractional flow reserve and instantaneous wave-free ratio for the hemodynamic assessment of jailed side branches in bifurcation stenting

Abstract Background Provisional side-branch stenting strategy is one of the preferred strategies for treatment of bifurcation lesions. Whereas using fraction flow reserve (FFR) for the physiologic assessment of jailed side branches is well studied, the reliability of resting indices such as instantaneous wave free ratio (iFR) is unknown. Methods Consecutive patients with provisional stenting of a bifurcation and a jailed side branch were enrolled in this study. FFR and iFR were measured and, after assuring absence of baseline shift and drift, both measurements were repeated after 3 minutes. Hyperemia was induced by intra-coronary adenosine with a dose of 48μg for the right coronary artery and 96μg for the left coronary artery. Cut-off for the assumed functional significance of a stenosis was 0.80 for FFR and 0.89 for iFR. The decision to treat the side branch was left to the interventionalist's discretion. Results 37 jailed side branches in 36 patients (age 68.4±8.2; male 81% (n=29)) were consecutively enrolled in the study. The main vessel was the left main in 3% (n=1), the left anterior descending (LAD) in 65% (n=24), the diagonal branch (D1) in 3% (n=1), the left circumflex artery (LCX) in 24% (n=9) and the right coronary artery (RCA) in 5% (n=2). The Medina classification revealed true bifurcation stenosis defined as Medina 1–1-1 prior to treatment in 35% (n=13). FFR showed 35% (n=13) of the stenosis to be functionally significant with a high reproducibility of the results (r=0.986). FFR showed a low correlation with angiographic assessment (r=−0.477). iFR indicated hemodynamic relevance in 38% of lesions (n=14) with a high reproducibility (r=0.967) and also correlated poorly with angiographic assessment (r=−0.271). iFR was found to closely correlate with FFR in jailed side branches (r=0.720, Figure 1A). Bland-Altman analysis showed iFR and FFR agreed with a mean difference between FFR and iFR of −0.054±0.146. In 81% (n=30) FFR and iFR showed the same results regarding functional significance. In 8% (n=3) FFR was ≤0.80 and iFR &amp;gt;0.89, in 11% (n=4) FFR was &amp;gt;0.80 and iFR was ≤0.89 (Figure 1B). Side branch treatment was performed in 32% (n=12). All of these lesions showed functional significance in FFR or iFR. Stent implantation was performed in 8% (n=3), balloon angioplasty in 19% (n=7) and balloon angioplasty with a drug-eluting balloon in 5% (n=2). Conclusions The results of this study confirm the poor correlation of angiographic and functional assessment of coronary artery stenoses. Our data show close agreement of iFR and FFR in stent-jailed side branches. Therefore, iFR can be considered as a reliable technique for guidance of provisional side branch stenting. Figure 1 Funding Acknowledgement Type of funding source: None

Side branch FFR after provisional stenting: simplified approach based on OCT frame count

Abstract Background/Introduction Treatment of bifurcation coronary artery lesions remains a major challenge in interventional cardiology. Side branch (SB) stenoses are frequently observed after stent implantation in bifurcation lesions, although angiographically narrowed SBs may not be functionally significant. Fractional flow reserve (FFR), a pressure-derived index of the hemodynamic significance of a coronary artery stenosis, may be useful in determining whether additional intervention is required in jailed SBs. Angiography and intravascular ultrasound (IVUS) derived parameters have showed poor diagnostic accuracy in predicting the functional significance of jailed SBs. Purpose The aim of the present study was to use high resolution optical coherence tomography (OCT) imaging to predict functionally significant SB stenoses after provisional stenting defined as SB FFR ≤0.80. Methods Seventy-one patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses undergoing provisional stenting were enrolled in the prospective study. OCT pullbacks were performed before and after stent placement, and SB FFR was measured after main vessel stenting. SB ostium area (SBOA) was assessed using three-dimensional OCT cut-plane analysis off-line. In addition, we developed a simplified approach to SB ostium assessment based on SB ostium frame count using two-dimensional OCT pullback not requiring off-line 3D reconstruction. For the analysis, consecutive frames were counted between the most distal and most proximal take-off of the SB frames. Results Similar to previous studies, quantitative coronary angiography findings were not associated with the functional significance of SBs after main vessel stenting. In contrast, SBOA assessed by 3D-OCT after provisional stenting strongly correlated with post-procedure SB FFR. The optimal cut-off value for the SBOA area to predict a SB FFR ≤0.80 was 0.76 mm2 (sensitivity 82%, specificity 89% and area under the curve of 0.92 (95% CI: 0.84–0.99). A simplified approach to SB ostium assessment using OCT frame count yielded a sensitivity of 82%, specificity 89% and area under the curve 0.92 (95% CI: 0.84 to 0.99) with a cut-off of 4.5 frames allowing detection of functionally significant SB stenoses during the procedure in real time. Figure 1 shows a receiver-operating characteristic curve for SB FFR ≤0.8 and a representative case with SB FFR = 0.66 after provisional stenting and SB ostium frame count equal 3 (Frame 1 to 3) Conclusion(s) Assessment of SB using either 3D OCT off-line reconstruction or a simplified approach based on OCT frame count can detect SB branches with FFR ≤0.80 with high sensitivity and specificity. The developed approaches may represent a useful tool to assess provisional stent outcomes. Figure 1 Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific; St. Jude Medical

Developing a fully 3d animated educational application to teach bifurcation lesion treatment

Abstract Background Coronary bifurcation lesions make up around 15 to 20 percent of interventions. Especially for younger interventionalists, they pose a steep difficulty curve due to the daunting set of ways treatment can diverge from the initial plan based on plaque shift or other complications. Purpose BifurcAID 3D was designed to intuitively show some of the key phenomena during bifurcation lesion treatment. Plaque shift, the importance of proximal optimization, the opening of a jailed side branch, and the overlapping layers of stent in the Culotte technique are among some of the aspects of bifurcation lesion treatment that can benefit from a clear visual format. Methods Iterating on the bifurcation algorithm developed at a high volume metropolitan PCI center, this fully animated application has many branching points where plaque shift is assessed and the treatment plan and animation varies accordingly to show reactive balloon angioplasty, stenting, or entirely switching to dedicated two stent techniques. Results The resulting application is an easy-to-navigate algorithm for left and non left main bifurcation lesion treatment with fully animated clear depictions of bifurcation lesion treatments including provisional, bail-out strategies, and dedicated two stent techniques alongside descriptive text. Conclusions Creating free educational content for aspiring and current physicians serves to elevate the field and lower the barriers to entry. BifurcAID 3D will make available intuitive education on complex bifurcation lesion treatment worldwide. Representative Images of BifurcAID 3D Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Vascular Education Grant

Acute Thrombus Burden on Coated Flow Diverters Assessed by High Frequency Optical Coherence Tomography.

The implantation of flow diverters requires administration of dual anti-platelet therapy, posing the potential for complications. The p48MW HPC (phenox, Bochüm,Germany) hydrophilic-coated flow diverting stent is designed to be anti-thrombotic, thus opening the potential for single anti-platelet therapy. We deploy a novel intravascular high-resolution imaging technique, high-frequency optical coherence tomography (HF-OCT), to study in an animal model the acute thrombus formation on coated p48MW devices versus uncoated control devices. Three pigs were implanted with 4 flow diverters each, two test hydrophilic-coated devices, and two control uncoated devices (p48MW). Each pig was treated with a different anti-platelet regime: no anti-platelet therapy, aspirin only, aspirin and clopidogrel. Twenty minutes after the flow diverter was implanted, an HF-OCT data set was acquired. Acute clot formed on the flow diverter at each covered side branch was measured from the HF-OCT slices. Factors considered to be important were the device type (pHPC versus bare metal), aspirin, clopidogrel, and vessel location. A linear model was constructed from the significant factors. Both coating (p < 0.001) and aspirin (p = 0.003) were significantly related to reduction in clot burden, leading to an approximate 100-fold and 50-fold reduction in clot, respectively. This study shows the power of HF-OCT not onlyin the detection of clot but also the quantification of clot burden. In an animal model, the pHPC-coated p48MW significantly reduced acute thrombus formation over jailed side branches as compared to the bare metal p48MW that was nearly eliminated when combinedwith aspirin administration.

Orbital Atherectomy Through Left Main Stent Struts Complicated by Catheter Entrapment and Stent Avulsion

We performed orbital atherectomy in the left circumflex artery through a stent that jailed the circumflex artery ostium. The orbital atherectomy catheter was entrapped within the stent and the stent was avulsed during catheter withdrawal. We should consider this potential complication when performing orbital atherectomy in a jailed side branch. (Level of Difficulty: Advanced.)

Utility of fractional flow reserve in moderate in-stent re-stenosis and jailed side branches and comparison of fractional flow reserve with single-photon emission computed tomography-myocardial perfusion imaging in native coronary artery stenosis

Background: Functional flow reserve (FFR) is used to determine functional significance of coronary artery stenosis. FFR demonstrated discrepancy between angiographic and functional significance of jailed side branches (JSBs) as well as moderate in-stent restenosis (ISR), with only minority of such lesions having functional significance. An attempt was made to study the utility of FFR and comparison of FFR with single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) in native coronary artery stenoses. Methods: A total of 101 lesions in 79 patients with stable ischemic coronary artery disease were subjected to FFR and SPECT-MPI including native as well as ISR and JSB. Relation between FFR and perfusion imaging was analyzed quantitatively. Sensitivity, specificity, positive predictive value, and negative predictive value were used for diagnostic accuracy. Results: FFR was ≤≤ 0.75 in majority of the lesions having >70% stenosis. Most of the lesions having reversible perfusion defect had FFR ≤≤ 0.80. There was a significant negative correlation between summed difference score (SPECT-MPI) with FFR value. As FFR value decreased, summed difference score increased. Sensitivity and specificity did not differ much when FFR cutoff was taken as 0.75 or 0.80. Conclusion: There was a significant negative correlation between FFR and sum difference score (SPECT-MPI). Sensitivity and specificity of SPECT-MPI did not differ much when FFR value cutoff was taken as 0.75 or 0.80.

Hapsedilmiş Yan Dal Telinin Geri Çekilmesi Sırasında İmplante Edilmiş Stentin Yerinden Ayrılması: Sıradışı Bir Komplikasyon

Coronary stent dislodgement is a very rare complication during the percutaneous coronary intervention. It is associated with significant morbidity, systemic or coronary embolization, acute myocardial infarction, emergency coronary artery bypass surgery, vascular access complications, cerebrovascular complications and death. A deployed stent dislodgement is even more rare. We report an unusual complication of a deployed stent dislodgement during retrieval of stent jailed side branch guidewire and retrieval from popliteal artery via snare method. Stent dislodgements usually occur with undeployed stents while retraction of the stent into the guiding catheter .Risk factors for stent loss and dislodgement are severe calcification, tortuosity, failed stent retraction into the guiding catheter and failure to cross the lesion. Stent dislodgement can be treated either surgically or percutaneously

Comparison of diagnostic performance in assessing the rewiring position into a jailed side branch between online 3D reconstruction systems version 1.1 and 1.2 derived from optical frequency domain imaging

The three-dimensional reconstruction of optical coherence tomography and optical frequency domain imaging (3D-OCT/OFDI) helps optimize bifurcation percutaneous coronary interventions (PCIs) with side branch (SB) dilatation by identifying the optimal rewiring position. 3D-OCT/OFDI’s diagnostic performance for assessing the rewiring position into a jailed SB is unknown. We retrospectively evaluated the diagnostic performances of a conventional (ver. 1.1) and a new (ver. 1.2) online 3D-OFDI reconstruction system based on an offline 3D reconstruction system’s performance. We analyzed 45 patients’ 52 OFDI pullbacks with main vessel stenting followed by rewiring into a jailed SB for coronary bifurcation lesions. We counted the undetected stent struts in the polygon of confluence as the stent detection performance. We assessed the diagnostic agreement regarding the rewiring position into a jailed SB by the three 3D reconstruction systems. The percentage of undetected struts and the diagnostic agreement of ver.1.2 were significantly better than those of ver.1.1 [5.1 ± 5.1% vs. 30.2 ± 14.2%; p < 0.0001, and 94.2% (49/52) vs. 76.9% (40/52); p = 0.0120]. The new online 3D-OFDI reconstruction system provides better diagnostic performance than the conventional online system for assessing the rewiring position into a jailed SB.

Online three-dimensional OFDI-guided versus angiography-guided PCI in bifurcation lesions: design and rationale of the randomised OPTIMUM trial.

The feasibility of offline optical coherence tomography (OCT) guidance in bifurcation (with either two-dimensional or three-dimensional images) and its potential benefits have been demonstrated in retrospective studies; however, these have not yet been investigated prospectively. The aim of this trial is to determine the superiority of online three-dimensional optical frequency domain imaging (3D-OFDI)-guided stenting to angiography-guided percutaneous coronary intervention (PCI) in terms of incomplete stent apposition (ISA) at the bifurcation segment. The OPTIMUM trial is a randomised, superiority, multicentre clinical trial. The primary endpoint of this trial is the post-procedural percentage of malapposed struts assessed by OFDI in the main branch bifurcation region after final kissing balloon dilatation (FKBD). A total of 106 patients will be randomly allocated to either 3D-OFDI guidance or angiography guidance PCI. Bifurcation lesions will be treated with a provisional single-stent strategy using the Ultimaster sirolimus-eluting stent. Patients randomised to the 3D-OFDI guidance arm will undergo OFDI assessment in the main branch (MV) after rewiring into the jailed side branch following stent implantation, while in the angiography guidance arm re-crossing of a wire into the side branch will be performed using conventional fluoroscopic/angiographic guidance. In patients in the 3D-OFDI guidance arm, if the position of the wire is not located in the optimal cell, further attempts to redirect the wire to the optimal cell will be performed, with subsequent OFDI acquisitions to confirm the re-crossing position. The proximal optimisation technique and FKBD are mandatory in this trial. The study will provide a 90% power to show superiority of 3D-OFDI guidance PCI compared with angiography-guided PCI. The OPTIMUM trial will be the first prospective, randomised trial to evaluate the efficacy and safety of online 3D-OFDI-guided PCI in bifurcation lesions. ClinicalTrials.gov Identifier: NCT02972489.