Left Main Bifurcation Lesions Research Articles

TCTAP C-058 Operation Shock and Awe: The Use of Intravascular Lithotripsy in a Critical Left Main Bifurcation Lesion

TCTAP C-058 Operation Shock and Awe: The Use of Intravascular Lithotripsy in a Critical Left Main Bifurcation Lesion

Dynamic assessment of the left main-left circumflex bending angle: Implications for ostial left circumflex artery in-stent restenosis after successful two-stent PCI

BackgroundTwo-stent techniques for percutaneous coronary intervention (PCI) on left main (LM) bifurcation (LMB) lesions are associated with an increased risk of in-stent restenosis (ISR) at left circumflex artery (LCx) ostium but the underlying mechanisms are incompletely understood. This study sought to investigate the association between cyclic change of LM-LCx bending angle (BALM-LCx) and the risk of ostial LCx ISR following two-stent techniques. MethodsIn a retrospective cohort of patients undergoing two-stent PCI for LMB lesions, BALM-LCx and distal bifurcation angle (DBA) were computed with 3-dimensional angiographic reconstruction. The analysis was performed both at end-diastole and end-systole, and the angulation change throughout the cardiac cycle was defined as the cardiac motion-induced angulation change (∆CAngle). ResultsA total of 101 patients were included. The mean pre-procedural BALM-LCx was 66.8 ± 16.1° at end-diastole and 54.1 ± 13.3° at end-systole with a range of 13.0 ± 7.7°. Pre-procedural ∆CBALM-LCx > 16.4° was the most relevant predictor of ostial LCx ISR (adjusted OR 11.58, 95% CI 4.04–33.19; p < 0.001). Post-procedural ∆CBALM-LCx > 9.8° and stent-induced diastolic BALM-LCx change > 11.6° were also related with ostial LCx ISR. DBA was positively correlated with BALM-LCx and showed a weaker association of pre-procedural ∆CDBA > 14.5° with ostial LCx ISR (adjusted OR 6.87, 95% CI 2.57–18.37; p < 0.001). ConclusionsThree-dimensional angiographic bending angle is a feasible and reproducible novel method for LMB angulation measurement. A large pre-procedural cyclic change of BALM-LCx was associated with an increased risk of ostial LCx ISR following two-stent techniques.

Potential Risk of Jailed Balloon Technique in Left Main Bifurcation Lesions: Sandwiched Jailed Balloon Shaft

Potential Risk of Jailed Balloon Technique in Left Main Bifurcation Lesions: Sandwiched Jailed Balloon Shaft

The impact of chronic kidney disease severity on clinical outcomes after current generation drug-eluting stent implantation for left main distal bifurcation lesions: the Milan and New-Tokyo registry

Objectives. The impact of chronic kidney disease (CKD) on clinical outcomes after percutaneous coronary intervention (PCI) for unprotected left main distal bifurcation lesions (ULMD) is not fully understood in current generation drug eluting stent (cDES) era. We assessed clinical outcomes after PCI using cDES for ULMD according to CKD severity based on estimated glomerular filtration rate (eGFR). Design. We identified 720 consecutive patients who underwent PCI using cDES for ULMD at three high volume centers between January 2005 and December 2015. We divided those patients to the following five groups according to eGFR. Each group was defined as follows: no CKD (60 mL/min/1.73 m2 ≤ eGFR), mild CKD (45 ≤ eGFR < 60 mL/min/1.73 m2), moderate CKD (30 ≤ eGFR < 45 mL/min/1.73 m2), severe CKD (15 ≤ eGFR < 30 mL/min/1.73 m2) and hemodialysis (HD). The primary endpoint was target lesion failure (TLF) at 3 years. TLF was defined as a composite of cardiac death, target lesion revascularization (TLR) and myocardial infarction (MI). Results. TLF occurred more frequently in severe CKD and HD group compared with other three groups. Conclusions. The patients who have severe CKD or are on HD, were extremely associated with worse clinical outcomes after PCI for ULMD even with cDES.

Current Evidence and Future Perspective for Coronary Bifurcation Stenting.

Coronary bifurcation lesions account for 15%-20% of all percutaneous coronary interven tions and are associated with greater procedural complexity and consequently at higher risk for cardiac adverse events. Early clinical trials in the interventional approach to bifurcation lesions supported provisional stenting. However, the most recent randomized studies have indicated potentially superior results using a double-kissing crush technique, particularly for unprotected distal left main bifurcation lesions. Moreover, many operators recently favor double-kissing mini-culotte, nanocrush, and double-kissing nanocrush stenting techniques for bifurcation lesions. In this review, we describe the traditional and novel bifurcation stenting techniques and the current evidence for each and review general principles for bifurcation percutaneous coronary intervention.

Provisional Vs Dual Stenting of Left Main Coronary Artery Bifurcation Lesions

Background: The primary LMCA stenting methods used nowadays consist of single stent (provisional), and two stent (T and protrusion, and double kissing crush {DK crush}, culotte, or classic crush). The optimal technique for bifurcation lesion treatment for the patients present with distal ULMCA disease is still unclear and not much is known about the best course of action and the clinical outcomes following various PCI techniques for ULMCA bifurcations in Pakistan. Objective: To investigate the midterm (3-year) outcomes related to the provisional stenting compared to two-stenting technique for the bifurcations of ULMCA undergoing the percutaneous coronary intervention. Methodology: A single-center retrospective, non-randomized cohort study was conducted during the period from March 2021 to August 2022 including all the consecutive LM bifurcation lesions. The patients attending Punjab Institute of Cardiology, Lahore were divided into two groups, depending upon the treatment received. One group underwent PCI with provisional stenting technique while the other underwent 2-stent PCI. The groups were compared for procedural success and 3-year clinical outcomes. Data was analyzed using SPSS. Results: The success rate of left main bifurcation angiography was comparable between both the techniques (2-stent 93.6 % vs. Provisional 92.1 %, P = 0.62). MACE rates were comparable between groups at 1, 2, and 3 years (PS 3.0 % vs. Dual stent 2.4 %, p = 0.75 at 1-year, PS 4.8 % vs. Dual stent 8 %, p = 0.26 at 2-years, and PS 10.2 % vs. Dual stent 12 % at 3-years, p = 0.62). Conclusion: Two stenting strategy was linked to same rates of MACEs at the 3-year duration in comparison to the single stenting technique (PS 10.2 % vs. 2-Stent 12 %, p=0.62) and both the dual and single provisional stent techniques have comparable angiographic success rate for LM bifurcation lesions.

Left Main Coronary Artery Bifurcation Lesions: Two Stents vs One Stent Strategy-Comparison of Major Adverse Cardiac Events (MACE) at 2 years

Objective: To evaluate the long-term clinical results for a one-stent (1S) strategy compared to a two-stent (2S) strategy in distal unprotected left main coronary artery (ULMCA) bifurcation disease.&#x0D; Study Design: Comparative Cross-sectional study.&#x0D; Place and Duration of Study: Armed Forces Institute of Cardiology, Rawalpindi Pakistan, from Jan 2019 to Apr 2020.&#x0D; Methodology: 1-S approach was defined as stenting of the main vessel only and 2-S approach as stenting side branch and main vessel. Individual undergoing LMCA intervention were included via consecutive sampling in the study. Stent Crossover approach was used in 1-S technique; whereas, DK crush, culotte, and T-stenting approaches were employed in individuals who were treated with a 2-S approach. A composite of major adverse cardiovascular event (MACE) i.e., myocardial infarction, stroke or death and target lesion revascularization (TLR) were considered as primary end-point.&#x0D; Results: A sum of 110 individuals were inducted, 74 of them had stenting of left main bifurcation using a 1-S approach; and 36 patients underwent a 2-S PCI. Average age of the patients included in the study was 63.9±10.8 years. In 1 stent subset, the success rate of procedure was 99% whereas 100% success rate was seen in 2-S group. During the 2-year duration of follow up,frequency of MACE in single stent subset was (5.4%) whereas it was (13.8%, p=0.253) in the 2-S subset.&#x0D; Conclusion: When compared to 2-S approach of distal left main stenting, a 1-S strategy appears to demonstrate optimal clinical results and 2-year survival free of MACE. Choosing appropriate interventional strategy has proven prognostically significant; so, it demands mindful approach selection.

Prognostic Impact of Target Lesion Revascularization on Long-Term Cardiac Mortality After Current-Generation Drug-Eluting Stent Implantation for Left Main Distal Bifurcation: the Milan and New-Tokyo (MITO) Registry

BackgroundThere are scarce data about the incidence and impact on clinical outcomes of target lesion revascularization (TLR) after percutaneous coronary intervention (PCI) for unprotected left main distal bifurcation lesions (ULMD) in current generation drug eluting stent (cDES) era. ObjectivesWe evaluated the incidence and impact on clinical outcomes of TLR after PCI using cDES for ULMD. MethodsWe identified 720 patients treated with cDES for ULMD at New Tokyo Hospital (Matsudo, Japan), San Raffaele Scientific Institute and EMO-GVM Centro Cuore Columbus (Milan, Italy) between January 2005 and December 2015. We divided those patients in 2 groups; TLR group (n = 107), no TLR group (n = 613). The TLR group was comprised patients undergoing a repeat revascularization by PCI or coronary artery bypass grafting of the target lesion. Analysis using propensity score adjustment was also performed. The primary endpoint was cardiac mortality. Additionally, we analyzed the impact of TLR for each main branch (MB) or side branch on cardiac mortality using multivariate Cox regression analysis. ResultsCardiac mortality was significantly higher in TLR group than in no TLR group (adjusted HR 1.96; 95 % CI, 1.50–3.62; p = 0.032). Cardiac mortality was also significantly higher in TLR group after propensity score adjustment. TLR for MB was identified as an independent predictor of cardiac death on multivariate Cox regression analysis. ConclusionsThe TLR, especially the TLR for MB, after PCI even with cDES for ULMD, was strongly associated with worse cardiac mortality.

Drug-coated balloon in the treatment of coronary left main true bifurcation lesion: A patient-level propensity-matched analysis.

An increasing body of evidence suggests that drug-coated balloon (DCB) angioplasty represents a valuable option for revascularization in selected patients with coronary bifurcation disease. However, there remains a paucity of real-world observational evidence on the efficacy of DCB in left main (LM) true bifurcation lesion. We compared clinical and angiographic outcomes of hybrid [DCB + drug-eluting stent (DES)] versus DES-only strategy (provisional stenting or two-stent strategies) in de novo LM true bifurcated lesions. The primary endpoint was the 2-year composite rate of target lesion failure (TLF): cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (CD-TLR). A routine 1-year angiographic follow-up was scheduled. Propensity-score matching was utilized to assemble a cohort of patients with similar baseline characteristics. Among 1077 eligible patients, 199 who received DCB treatment and 398 who were assigned to DES therapy had similar propensity scores and were included in the analysis. TLF within 2 years occurred in 13 patients (7.56%) assigned to DCB group, and 52 patients (14.36%) assigned to DES group (odds ratio: 0.487; 95% confidence interval: 0.258-0.922; P = 0.025; Log-rank P = 0.024). Compared with the DES group, the DCB group resulted in a lower rate of CD-TLR (2.91% vs. 9.42%; P = 0.007). Cardiac death, TVMI, all-cause mortality, and stent thrombosis were comparable between both groups. Patients treated with DES-only were associated with a higher late lumen loss (0.42 ± 0.62 mm vs. 0.13 ± 0.42 mm, P < 0.001) compared with the DCB group at 1 year. In sensitivity analysis, the DCB group also presented a lower incidence of TLF, CD-TLR and stent thrombosis both compared to the two-stent strategy and compared to provisional stenting (Ps < 0.05). The 2-year results of PCI utilizing DCB for LM true bifurcation lesions are superior to employing DES alone in terms of safety and effectiveness.

Four-Year Outcomes of Left Main Percutaneous Coronary Intervention with a Bioresorbable Scaffold in the Circumflex Ostium.

The study aimed to investigate the long-term outcomes of a double stent scaffold strategy in patients with left main (LM) bifurcation lesions involving the ostium of the left circumflex artery (LCX), utilizing a drug-eluting stent (DES) in the LM extending into the left anterior descending artery (LAD) and a bioresorbable vascular scaffold (BVS) in the LCX ostium. The high occurrence of in-stent restenosis of the LCX ostium is the major limitation of percutaneous coronary intervention (PCI) for LM lesions with a two-stent strategy. This was a single-center, prospective, single-arm study of 46 consecutively enrolled patients with a stable coronary artery disease and significant unprotected LM distal bifurcation disease. Patients underwent imaging-guided PCI using DES in the LM-LAD and BVS in the LCX using a T-stent or mini-crush technique. The primary outcome at four years was the composite of death, myocardial infarction, stroke, and target lesion revascularization (TLR). At four years, the primary outcome was identified in 9 patients (19.6%). All events were TLRs except one myocardial infarction due to BVS thrombosis. Seven of the eight TLRs were a result of side branch BVS restenosis. Univariate predictors of the 4-year outcome were higher LDL cholesterol and BVS size ≤2.5 mm. On multivariate analysis, LCX lesion preparation with a cutting balloon and post-procedure use of intravascular ultrasound for optimization were found to be independent protective factors of MACE. In selected patients with LM distal bifurcation disease, an imaging-guided double stent scaffold strategy with DES in the LM and BVS in the LCX ostium was technically successful in all patients and was reasonably safe and effective for four years.

Provisional Versus Dual Stenting of Left Main Coronary Artery Bifurcation Lesions (from a Comprehensive Meta-Analysis)

The optimal technique for bifurcation of left main coronary artery (LMCA) stenting has been a subject of controversy since the inception of drug-eluting stents. We searched PubMed, Clinical Trials Registry, and the Cochrane Central Register of Controlled Trials from January 2002 through October 2021. A total of 13 studies comparing the use of provisional versus dual stenting in patients with LMCA bifurcation lesions were included. Any major adverse cardiac event (MACE) was considered the primary composite end point. The secondary end points included individual components of MACE, including death, myocardial infarction, and target lesion revascularization. The treatment effect was defined as the log odds ratio (OR) of provisional over dual stenting for cumulative event rate at 3 years. In 12 studies with 8,377 patients included for MACE, the use of a provisional-stenting strategy was associated with a significant reduction of 3-year MACE (OR 0.64, 95% confidence interval [CI] 0.46 to 0.88) compared with a dual-stenting strategy, primarily driven by target lesion revascularization (OR 0.51, 95% CI 0.36 to 0.73). No significant difference was found regarding death (OR 0.88; 95% CI 0.65 to 1.21) or myocardial infarction (OR 0.97, 95% Cl 0.61 to 1.54). In conclusion, our meta-analysis suggests that provisional stenting should be the preferred technique over dual stenting when treating LMCA bifurcation lesions with drug-eluting stents. Further randomized controlled studies compounded with intracoronary imaging comparing the 2 strategies are warranted.

Immediate stent fracture after everolimus-eluting stent implantation: a case report

A 60-year-old man presented with exertional chest pain and was hospitalized on a diagnosis of unstable angina. Coronary angiography revealed left main true bifurcation lesions and percutaneous coronary intervention (PCI) was conducted using the culotte-stenting technique. Post-dilatational angiography revealed an irregular protrusion of the stent strut in mid left anterior descending (LAD) coronary artery. Intravascular ultrasound (IVUS) showed a discontinuation of the middle stent strut with calcified nodules. An additional everolimus-eluting stent (EES) was placed across the discontinued lesions. Post-procedural IVUS revealed good expansion of the stents and final angiography showed optimal angiographic results with thromboly sis in myocardial infarction (TIMI) 3 flow. The patient was discharged the next day after the operation and maintained asymptomatic for chest pain at the 6-month follow-up point.

Chinese Guideline for Percutaneous Coronary Intervention in Patients with Left Main Bifurcation Disease

The coronary left main (LM) artery is characterized by large caliber, length varying from &lt;8 to &gt;15 mm, and 2 large daughter vessels branching from it; it supplies blood to a large area (&gt;75%) of the myocardium. LM bifurcation lesion is defined as the presence of atherosclerosis involving either or both of the 2 daughter vessels. Thus, the optimal strategy of revascularization for diseased LM has been an interesting research topic for a long time. With developments in percutaneous techniques, design, and materials of drug-eluting stents; intravascular imaging; new generation of antiplatelet medications; and particularly recent pooled evidence from randomized clinical trials comparing percutaneous coronary intervention with coronary artery bypass grafting, implantation of a drug-eluting stenting with or without other approved techniques is considered an important therapeutic approach for LM bifurcation lesions. Mirroring the anatomical complexity of the LM, stenting LM bifurcations is technically demanding, and intraprocedural complications can be catastrophic given the large amount of jeopardized myocardium. Therefore, the Chinese Society of Cardiology designed a writing committee with members from 3 working groups (ie, clinical research, intravascular imaging and physiology, and interventional cardiology) for the first time, to write a guideline on percutaneous treatment for LM bifurcation lesions, with view to improve the procedural quality and clinical outcomes. This guideline consists of introduction, anatomical description of the LM tree, risk stratification, strategies of revascularization, antiplatelet strategy, follow-up, and long-term management for patients with LM bifurcation lesions.

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

A Review of Double Kissing Crush Stenting in Coronary Bifurcation Lesions

Double kissing (DK) crush stenting for coronary bifurcation lesions has gain popularity worldwide because of its superior randomized studies data and excellent clinical outcomes. This review evaluates all DK crush clinical trials and studies. It also reveals the contemporary technique steps by steps as well as the trouble shooting with illustrated clinical scenarios. Among all the available evidence, the DK crush technique is superior when compared to the provisional stenting technique for complex bifurcation lesion. DK crush stenting provides the best evidence-based approach to complex bifurcation lesions especially the left main coronary artery bifurcation lesions. Future direction of how to make this DK crush technique better is also proposed.

Provisional Versus Dual Stenting of Left Main Bifurcation Lesions: A Comprehensive Meta-Analysis

Provisional Versus Dual Stenting of Left Main Bifurcation Lesions: A Comprehensive Meta-Analysis

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.

TCTAP C-071 Crush Stenting at Nodular Calcified Left Main Bifurcation Lesion

TCTAP C-071 Crush Stenting at Nodular Calcified Left Main Bifurcation Lesion

DCB combined with provisional DES implantation in the treatment of De Novo Medina 0,1,0 or 0,0,1 left main coronary bifurcation lesions: A proof-of-concept study.

ObjectiveTo investigate the safety and efficacy of a percutaneous revascularization strategy that is based on the use of drug-coated balloon for the treatment of patients with acute coronary syndrome and de novo Medina type 0,1,0 or 0,0,1 left main stem bifurcation lesions.Methods: In this multicenter, prospective, proof-of-concept study, patients fulfilling the above criteria were enrolled and received treatment with drug-coated balloon combined with provisional drug-eluting stent implantation in the proximal major branches of the left main stem. Patients who declined this revascularization approach were treated with drug-eluting stent implantation 1-2 mm distally to the left anterior descending or left circumflex artery ostium followed by drug-coated balloon therapy for the ostial disease. The primary endpoint of the study was the calculation of percent diameter stenosis on quantitative coronary angiography post-procedure as well as event rate at 8 months follow-up.ResultsA total of 30 patients were enrolled in the study; their mean age was 60.3 ± 7.8 years, while 22 (73.3%) were male. Twenty-two patients were treated only with drug-coated balloon and provisional drug-eluting stent implantation and 8 had drug-eluting stent implantation followed by drug-coated balloon therapy of the ostium of the left main stem major branch. All the procedures were successful with no immediate complications. The percent diameter stenosis of lesion decreased significantly post-procedure from 87.5% (80.0-90.0) to 20% (17.5-30.0), P < .001. During the follow-up period, no major adverse cardiac events were reported.ConclusionsThis proof-of-concept study indicates that ostial drug-coated balloon therapy of the left main stem major branches is safe and effective. Larger clinical data and longer follow-up are needed before advocating its regular use in clinical practice.

Impact of Left Main Calcium With Chronic Kidney Disease on Outcomes After Percutaneous Coronary Intervention for Left Main Narrowings (from the Milan and New-Tokyo Registry)

Limited data are available about the association between coronary artery calcification and chronic kidney disease severity on clinical outcomes after percutaneous coronary intervention (PCI). This study aimed to assess the association between coronary artery calcification and chronic kidney disease severity on clinical outcomes after PCI. We identified 1,391 patients treated with drug-eluting stent for unprotected left main distal bifurcation lesions (ULMD), including 604 without calcified lesions (noncalcified left main group) and 787 with calcified ULMD (calcified left main group) in Japan and Italy. We divided the calcified group into the following 2 groups: estimated glomerular filtration rate (eGFR) ≥30 (n=687) and <30 (n=100) and compared the clinical outcomes. The primary end point was target lesion failure (TLF) at 3 years. TLF was defined as a composite of cardiac death, target lesion revascularization, and myocardial infarction. TLF occurred more frequently in the calcified group (adjusted hazard ratio 1.36, 95% confidence interval 1.08 to 1.71, p=0.01), especially in calcified ULMD with eGFR <30 (adjusted hazard ratio relative to the other 2 groups 2.59, 95% confidence interval 1.60 to 4.18, p <0.001). In conclusion, the calcified ULMD treated with PCI was associated with poorer clinical outcomes than noncalcified ULMD, especially in those with eGFR <30.