Left Main Bifurcation Research Articles

Comparison of transradial coronary intervention for left main bifurcation disease using the new Braidin® slender 7 Fr sheath and a standard 6 Fr sheath.

ObjectivesTo compare the effectiveness and safety of the Braidin® slender 7 Fr sheath with a standard 6 Fr sheath for treating left main bifurcation disease.MethodsFrom January 2017 to March 2019, 277 patients with left main bifurcation disease who underwent the transradial approach for percutaneous coronary intervention were divided into the slender 7 Fr sheath group (Braidin® slender 7 Fr sheath, n = 154) and standard 6 Fr sheath group (n = 123). Pathological features, surgical effect, and complications were evaluated.ResultsThe rate of using the classic crush technique was significantly higher in the slender 7 Fr sheath group than in the standard 6 Fr sheath group. The slender 7 Fr sheath group had a significantly shorter operation time than the standard 6 Fr sheath group. There were no significant differences in the radial artery occlusion rate after surgery and at 1 month of follow-up between the groups. Multivariate logistic regression analysis showed that 6 Fr and Braidin slender 7 Fr sheaths did not predict radial artery occlusion.ConclusionThe Braidin slender 7 Fr sheath has a superior operative process and similar safety for the radial artery as that of the standard 6 Fr sheath for treating left main bifurcation disease.

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

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

Successful bailout T-stenting for iatrogenic coronary dissection involving left main stem bifurcation: "first, do no harm".

Successful bailout T-stenting for iatrogenic coronary dissection involving left main stem bifurcation: "first, do no harm".

Efficacy of drug-coated balloon angioplasty after directional coronary atherectomy for coronary bifurcation lesions (DCA/DCB registry).

To evaluate the efficacy and safety of additional drug-coated balloon (DCB) angioplasty after directional coronary atherectomy (DCA) for coronary bifurcation lesions. The optimal therapy for bifurcation lesions has not been established, even in the drug-eluting stent era. DCA possibly prevents plaque and carina shift in bifurcation lesions by plaque debulking; however, the efficacy of combined DCA and DCB (DCA/DCB) for bifurcation lesions remains unclear. This multicenter registry retrospectively recruited patients with bifurcation lesions who underwent DCA/DCB and follow-up angiogram at 6-15 months. The primary endpoint was the 12-month target vessel failure (TVF) rate. The secondary endpoints were procedure-related major complications, major cardiovascular events at 12 months, restenosis at 12 months, target lesion revascularization (TLR) at 12 months, and target vessel revascularization (TVR) at 12 months. We enrolled 129 patients from 16 Japanese centers. One hundred and four lesions (80.6%) were located around the left main trunk bifurcations. No side branch compromise was found intraoperatively. Restenosis was observed in three patients (2.3%) at 12 months. TLR occurred in four patients (3.1%): 3 (2.3%) in the main vessel and 1 (0.8%) in the ostium of the side branch at 12 months. TVF incidence at 12 months was slightly higher in 14 patients (10.9%), and only two patients (1.6%) had symptomatic TVR. One patient (0.8%) had non-target vessel-related myocardial infarction. Our data suggested that DCA/DCB provided good clinical outcomes and minimal side branch damage and could be an optimal non-stent percutaneous coronary intervention strategy for bifurcation lesions.

Optimal strategy for side branch treatment in patients with left main coronary bifurcation lesions

Introduction and objectivesThere are no guidelines regarding the most appropriate approach for provisional side branch (SB) intervention in left main (LM) bifurcation lesions. MethodsThe present prospective, randomized, open-label, multicenter trial compared conservative vs aggressive strategies for provisional SB intervention during LM bifurcation treatment. Although the trial was designed to enroll 700 patients, it was prematurely terminated due to slow enrollment. For 160 non-true bifurcation lesions, a 1-stent technique without kissing balloon inflation was applied in the conservative strategy, whereas a 1-stent technique with mandatory kissing balloon inflation was applied in the aggressive strategy. For 46 true bifurcation lesions, a stepwise approach was applied in the conservative strategy (after main vessel stenting, SB ballooning when residual stenosis> 75%; then, SB stenting if residual stenosis> 50% or there was a dissection). An elective 2-stent technique was applied in the aggressive strategy. The primary outcome was a 1-year target lesion failure (TLF) composite of cardiac death, myocardial infarction, or target lesion revascularization. ResultsAmong non-true bifurcation lesions, the conservative strategy group used a smaller amount of contrast dye than the aggressive strategy group. There were no significant differences in 1-year TLF between the 2 strategies among non-true bifurcation lesions (6.5% vs 4.9%; HR, 1.31; 95%CI, 0.35-4.88; P=.687) and true bifurcation lesions (17.6% vs 21.7%; HR, 0.76; 95%CI, 0.20-2.83; P=.683). ConclusionsIn patients with a LM bifurcation lesion, conservative and aggressive strategies for a provisional SB approach have similar 1-year TLF rates.

Clinical Implications of Bifurcation Angles in Left Main Bifurcation Intervention Using a Two-Stent Technique.

Objectives The aim of this study was to assess the clinical impact of 3 bifurcation angles in left main (LM) bifurcation treated with the 2-stent technique. Background Data are limited regarding the impact of bifurcation angles after LM percutaneous coronary intervention (PCI). Methods Using patient-level 4 multicenter registries in Korea, 462 patients undergoing LM bifurcation PCI with the 2-stent technique were identified (181 crush, 167 T-stenting; 63% 1st generation drug-eluting stent (DES), 37% 2nd generation DES). Three bifurcation angles, between the LM and left anterior descending (LAD), the LM and left circumflex (LCX), and the LAD and LCX, were measured. The primary outcome was target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization (TLR). Results In patients treated with the crush technique, the best cutoff value (BCV) to predict TLF was 152° of the LM-LAD angle. In the crush group, a significantly higher TLF rate, mostly driven by TLR, was observed in the LM-LAD angle ≥152° group compared with the <152° group (35.7% vs. 14.6%; adjusted hazard ratio 3.476; 95% confidence interval 1.612–7.492). An LM-LAD angle ≥152° was an independent predictor of TLF. In the T-stenting, no bifurcation angle affected the clinical outcomes. Conclusions In LM bifurcation PCI using the 2-stent technique, wide LM-LAD angle (≥152°) was associated with a greater risk of TLF in the crush, whereas none of the bifurcation angles affected T-stenting outcomes.

Percutaneous management of coronary bifurcation lesions: current perspective.

Coronary artery disease affecting bifurcations poses a challenge for percutaneous intervention. Several techniques and strategies for percutaneous management of bifurcation lesions have been described in the literature with variable data available for outcomes. In this review, we provide an overview of the strategies and techniques used for percutaneous intervention of bifurcation lesions with an update of recent technical developments and clinical evidence. The coronary bifurcation lesions of both left main and other coronary segments are best treated with a provisional stenting strategy where main branch is treated with a stent placement and side branch intervention reserved for angiographically or physiologically determined hemodynamically significant residual stenosis despite application of a proximal stent optimization technique. When a provisional stent strategy is not likely to be successful due to anatomic or morphologic lesion characteristics and a large side branch or distal left main bifurcation is involved, an upfront bifurcation stenting strategy with double kissing crush technique may provide the optimum results. Coronary imaging and fractional flow determination may guide lesion specific management, facilitate device selection and improve clinical outcomes for percutaneous therapy for bifurcation lesions. Despite advances in technology and procedural techniques, percutaneous intervention of coronary bifurcation lesions remains challenging and associated with higher adverse outcomes compared to non bifurcation lesions. Among the several bifurcation strategies, a provisional stenting approach is preferred for technical simplicity and better long term outcomes. Double kissing crush technique provides superior clinical results and should be preferred when a two stent strategy is indicated. Use of coronary imaging and physiology assessment should be incorporated in the algorithm of bifurcation interventions for greater technical and clinical success.

Impact of the metal-to-artery ratio on clinical outcomes in left main and nonleft main bifurcation: insights the RAIN-CARDIOGROUP VII study (veRy thin stents for patients with left mAIn or bifurcatioN in real life).

The impact on clinical outcomes of the metal coverage on the coronary surface (namely the metal-to-artery ratio) of currently used drug-eluting stents (DESs) has not been defined. All patients with a left main or bifurcation stenosis treated with percutaneous coronary intervention (PCI) using ultrathin stents (struts thinner than 81 μm) were enrolled with a prospective multicentre fashion. The rate of device-oriented endpoint [DOE, defined as a composite of target lesion revascularization (TLR) and stent thrombosis] was the primary endpoint, while its single components were the secondary ones, evaluated according to the metal-to-artery ratio. After 14 ± 10.4 months 62 (7.5%) of 830 patients undergoing PCI on left main experienced a DOE without differences in the metal-to-artery ratio (14.5 ± 2.1 vs. 14.4 ± 1.9, P = 0.51). Fifty out (2.4%) of 2082 patients treated with PCI on a coronary bifurcation other than left main experienced a DOE, with a higher mean metal-to-artery ratio (15.3 ± 2.1 vs. 14.6 ± 2, P = 0.01). At multivariate analysis, together with hypertension and diabetes, the metal-to-artery ratio was an independent predictor of DOE (hazard ratio 1.7 : 1.02-1.34, P = 0.02) in nonleft main PCI. When analysed for diameter, we found a significant correlation with DOE when the stent diameter was inferior to 3.0 mm (hazard ratio 1.21: 1.06-1.38, P < 0.01, all 95% confidence interval); this result was mainly consistent for patients treated with provisional stenting. The metal-to-artery ratio does not impact on outcomes in left main PCI, both in the provisional or two-stent technique, and generally when a drug-eluting stent more than 3.5 mm in diameter is implanted. Regarding nonleft main PCI, it is independently related to DOE and TLR, especially for DES with a diameter of 3.25 mm or less. The metal-to-artery ratio does not impact on outcomes in left main PCI, both in the provisional or two-stent technique, and generally when a drug-eluting stent more than 3.5 mm in diameter is implanted. Regarding nonleft main PCI, it is independently related to DOE and TLR, especially for DES with a diameter of 3.25 mm or less.

Successful Percutaneous Coronary Intervention Using Intravascular Ultrasound-Guided Rewiring Technique in a Case of Spontaneous Coronary Artery Dissection Involving Left Main Bifurcation

We herein describe a 49-year-old woman without significant cardiovascular risk factors who was transferred to our hospital with sudden onset of chest pain. The patient was diagnosed with non-ST-elevation acute myocardial infarction, and coronary angiography revealed a dissection at the proximal site of the left anterior descending artery (LAD) extending from the left main trunk (LMT) suggestive of spontaneous coronary artery dissection (SCAD). Because coronary flow was impaired after contrast injection and the patient had chest pain with ST elevation, urgent percutaneous coronary intervention was performed. The first guide wire was initially introduced from the LMT to the distal LAD, but intravascular ultrasound (IVUS) imaging revealed that the guide wire had passed through the true lumen of the left coronary artery ostium, false lumen at the ostium of the left circumflex artery, and true lumen of the distal LAD. We then reinserted another guide wire using an IVUS-guided rewiring technique from the true lumen of the LMT to the distal LAD. Finally, a drug-eluting stent was deployed to cover the dissected segment, and final coronary angiography revealed acceptable results with a patent left circumflex artery. This case report highlights that physicians should consider SCAD among the differential diagnoses in patients presenting with acute coronary syndrome, particularly in young women. In the present case, IVUS played a pivotal role in not only detecting the arterial dissection but also correctly introducing the guide wire into the true lumen.

Crush is superior to Culotte in two-stent strategy for treatment of left main coronary artery bifurcations: A systematic review and meta-analysis.

Crush and Culotte techniques have been used increasingly to treat patients with complex unprotected left main coronary artery bifurcation lesions. This article compares published data on these two techniques. Databases, including PubMed, Embase, Cochrane Library, Wanfang Data and China National Knowledge Infrastructure, were searched for articles published before Aug 21, 2019 to identify all relevant studies on left main coronary artery bifurcation lesions treated by Crush versus Culotte techniques. The pooled data were analyzed using either fixed- or random-effects model depending on heterogeneity (assessed via the I2 index). The endpoints were major adverse cardiac events, target lesion revascularization, cardiac death, stent thrombosis, myocardial infarction and target vessel revascularization. Eight articles with a total of 1,283 patients were included, and 710 patients were treated with Crush, and 573 ones with Culotte. Crush group was trend to decreased major adverse cardiac event compared with Culotte group [Relative ratio (RR) 0.63,95% confidence interval(CI) 0.39-1.04, I2 =72.7%], mainly driven by decreased cardiac death [RR 0.49, 95% CI(0.25-0.99), I2 =0%], decreased myocardial infarction [RR 0.40, 95% CI(0.21-0.76), I2 =21.6%],and lower stent thrombosis [RR 0.39, 95% CI(0.16-0.98), I2 =39.4%]. There was no significant difference in target lesion revascularization and target vessel revascularization between Crush and Culotte [RR 0.77, 95% CI 0.46-1.28, I2=61.1%; RR 0.78, 95% CI (0.30-2.02), I2 =73.1%, respectively]. Crush was superior to Culotte for treatment of left main coronary artery bifurcation lesions with a trend of lower incidence of long-term major adverse cardiac events, mainly derived from decreased myocardial infarction, stent thrombosis and cardiac death.

Validation of bifurcation DEFINITION criteria and comparison of stenting strategies in true left main bifurcation lesions

There are controversies on optimal stenting strategy regarding true left main (LM) bifurcation lesions. The present study compared 1- and 2-stenting strategy for patients with true LM bifurcation lesions as differentiated by DEFINITION criteria. 928 patients with true LM bifurcation lesions (Medina 1,1,1 or 0,1,1) treated with DES were enrolled consecutively. 297 (32.0%) patients were identified as complex LM bifurcation, and 631 (68.0%) patients into simple LM bifurcation group according to DEFINTION criteria. Patients in complex vs. simple LM bifurcation group had significantly higher major adverse cardiac event (MACE, including cardiac death, myocardial infarction [MI] and ischemia-driven target vessel revascularization) rate at 30 days (7.8% vs. 4.0%, p = 0.01), 1 year (10.3% vs. 6.4%, p = 0.04), and numerically at 3 years (14.2% vs. 10.1%, p = 0.07), which was mainly driven by increased MI. Moreover, patients in the 2-stent strategy group had strong trend towards lower incidence of cardiac death in both complex LM bifurcation group (2.0% vs. 5.9%, p = 0.08) and simple LM bifurcation group (1.9% vs. 4.5%, p = 0.07). In conclusion, the complex bifurcation lesion criteria established in DEFINITION study was able to risk-stratify LM bifurcation patients. Two-stent technique yielded numerically lower 3-year cardiac mortality regardless of LM bifurcation complexity.

P2Y12 inhibitors monotherapy after short course of dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a meta-analysis of randomized clinical trials including 29 089 patients

Dual antiplatelet therapy (DAPT) reduces the incidence of thrombotic complications at the cost of an increase in bleedings. New antiplatelet therapies focused on minimizing bleeding and maximizing antithrombotic effects are emerging. The aim of this study is to collect the current evidence coming from randomized controlled trials (RCTs) on early aspirin interruption after percutaneous coronary intervention (PCI) and current drug-eluting stent (DES) implantation and to perform a meta-analysis in order to evaluate the safety and efficacy of this strategy. MEDLINE/PubMed was systematically screened for RCTs comparing P2Y12 inhibitors (P2Y12i) monotherapy after a maximum of 3 months of DAPT (S-DAPT) vs. DAPT for 12 months (DAPT) in patients undergoing PCI with DES. Baseline features were appraised. Major adverse cardiac and cerebrovascular events (MACCE: all causes of death, myocardial infarction, and stroke) and its single composites, stent thrombosis (ST) and Bleeding Academic Research Consortium (BARC) type 3 or 5 were considered and pooled with fixed and random-effects with inverse-variance weighting. A total of four RCTs including a total of 29 089 patients were identified. Overall, the majority of included patients suffered a stable coronary artery disease, while ST-elevation myocardial infarction was the least represented clinical presentation. Complex anatomical settings like left main intervention, bifurcations, and multi-lesions treatment were included although representing a minor part of the cases. At 1-year follow-up, MACCE rate was similar [odds ratio (OR) 0.90; 95% confidence intervals (CIs) 0.79-1.03] and any of its composites (all causes of death rate: OR 0.87; 95% CIs 0.71-1.06; myocardial infarction: OR 1.06; 95% CIs 0.90-1.26; stroke: OR 1.12; 95% CIs 0.82-1.53). Similarly, also ST rate was comparable in the two groups (OR 1.17; 95% CIs 0.83-1.64), while BARC 3 or 5 bleeding resulted significantly lower, adopting an S-DAPT strategy (OR 0.70; 95% CIs 0.58-0.86). After a PCI with current DES, an S-DAPT strategy followed by a P2Y12i monotherapy was associated with a lower incidence of clinically relevant bleeding compared to 12 months DAPT, with no significant differences in terms of 1-year cardiovascular events.

Coronary artery double stenting techniques and their results in complex left main bifurcation disease.

Aim: Complex left main (LM) bifurcation disease seems to be better approached by a planned double stent technique. Materials & methods: Medline search for articles including randomized trials, prospective series, large registries and retrospective studies >50 patients has been performed. Results: Double kissing crush demonstrated its superiority over culotte stenting and cross over, while other techniques such as the T-stenting and T-stent and Protrusion have not been extensively reported in LM setting. The nano inverted-T-stenting has provided evidences that the use of ultrathin strut stents and very minimal crush is beneficial for both the physiological and rheological properties. Conclusion: The double stenting techniques used in LM should be evaluated in terms of procedural differences and technical simplicity.

Left main bifurcation coronary intervention with provisional stenting: the role of invasive functional evaluation and intracoronary imaging to guide stenting technique

We describe a remarkable case of a patient presenting with left main bifurcation stenosis involving the origins of both the left circumflex and the first acute marginal arteries which was successfully treated using single-stent provisional technique. Intracoronary imaging and invasive functional evaluation were used to assess the anatomical and functional complexity of this case, to guide the stenting technique, and to evaluate the final result.

Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients

ObjectivesThe aim of this study was to compare clinical outcomes of different bifurcation percutaneous coronary intervention (PCI) techniques. BackgroundDespite several randomized trials, the optimal PCI technique for bifurcation lesions remains a matter of debate. Provisional stenting has been recommended as the default technique for most bifurcation lesions. Emerging data support double-kissing crush (DK-crush) as a 2-stent technique. MethodsPubMed and Scopus were searched for randomized controlled trials comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE). Secondary outcomes of interest were cardiac death, myocardial infarction, target vessel or lesion revascularization, and stent thrombosis. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. ResultsTwenty-one randomized controlled trials including 5,711 patients treated using 5 bifurcation PCI techniques were included. Investigated techniques were provisional stenting, T stenting/T and protrusion, crush, culotte, and DK-crush. Median follow-up duration was 12 months (interquartile range: 9 to 36 months). When all techniques were considered, patients treated using the DK-crush technique had less occurrence of MACE (OR: 0.39; 95% credible interval: 0.26 to 0.55) compared with those treated using provisional stenting, driven by a reduction in target lesion revascularization (OR: 0.36; 95% credible interval: 0.22 to 0.57). No differences were found in cardiac death, myocardial infarction, or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed among provisional stenting, culotte, T stenting/T and protrusion, and crush. In non–left main bifurcations, DK-crush reduced MACE (OR: 0.42; 95% credible interval: 0.24 to 0.66). ConclusionsIn this network meta-analysis, DK-crush was associated with fewer MACE, driven by lower rates of repeat revascularization, whereas no significant differences among techniques were observed for cardiac death, myocardial infarction, and stent thrombosis. A clinical benefit of 2-stent techniques was observed over provisional stenting in bifurcation with side branch lesion length ≥10 mm.

One- and 3-year outcomes of percutaneous bifurcation left main revascularization with modern drug-eluting stents: a systematic review and meta-analysis.

Optimal percutaneous coronary intervention (PCI) strategy for coronary left main (LM) bifurcation lesions remains controversial. We performed systematic review and meta-analysis comparing one and 3-year clinical outcomes of 1- and 2- stent strategies using modern drug eluting stents (DESs) for revascularization of LM bifurcation disease. We systematically identified all investigations published between January 2015 and February 2020 comparing the use of single versus double-stent strategies for the revascularization of LM bifurcation lesions. The primary endpoint was 1- and 3-years all-cause mortality. Secondary outcomes included target lesion revascularization (TLR), target lesion failure (TLF), major adverse cardiovascular vents (MACEs) and cardiovascular (CV) mortality while the tertiary outcome was overall occurrence of stent thrombosis (ST) at 1- and 3-years. No significant differences were observed between the two groups in terms of all-cause mortality rate both at 1 and 3-year follow-up. Single stent strategy was associated with a significantly lower risk of TLR (OR 0.78, 95% CI 0.62- 0.97, p = 0.03, I2 = 61%) as well as of MACEs (OR 0.78, 95% CI 0.63-0.97, I2 = 24%) compared to 2-stent strategy. Conversely no significant differences between the two groups were observed in terms of TLF, CV mortality and ST during the same follow-up period. In patients with LM bifurcation disease, single stent strategy demonstrated lower rate of MACEs and TLR but was not superior to 2-stent strategy in terms of CV mortality, TLF and ST at 1 and 3-year follow-up.

Biomechanical Evaluation of Different Balloon Positions for Proximal Optimization Technique in Left Main Bifurcation Stenting

BackgroundProximal optimization technique (POT) is a key step during left main (LM) bifurcation stenting. However, after crossover stenting, the ideal position of POT balloon is unclear. We sought to evaluate the biomechanical impact of different POT balloon positions during LM cross-over stenting procedure. MethodsWe reconstructed the patient-specific LM bifurcation anatomy, using coronary computed tomography angiography data of 5 consecutive patients (3 males, mean age 66.3 ± 21.6 years) with complex LM bifurcation disease, defined as Medina 1,1,1, evaluated between 1st January 2018 to 1st June 2018 at our center. Finite element analyses were carried out to virtually perform the stenting procedure. POT was virtually performed in a mid (marker just at the carina cut plane), proximal (distal marker 1 mm before the carina) and distal (distal marker 1 mm after the carina) position in each investigated case. Final left circumflex obstruction (SBO%), strut malapposition, elliptical ratio and stent malapposition were evaluated. ResultsThe use of both proximal and distal POT resulted in a smaller LM diameter compared to the mid POT. SBO was significantly higher in both proximal and distal configurations compared to mid POT: 38.3 ± 5.1 and 29.3 ± 3.1 versus 18.3 ± 3.6%, respectively. Similarly stent malapposition was higher in both proximal and distal configurations compared to mid POT: 1.3 ± 0.4 and 0.82 ± 1.8 versus 0.78 ± 1.2, respectively. ConclusionsMid POT offers the best results in terms of LCx opening maintaining slightly smaller but still acceptable LM and LAD diameters compared to alternative POT configuration.

Accuracy of the PARIS score and PCI complexity to predict ischemic events in patients treated with very thin stents in unprotected left main or coronary bifurcations.

The PARIS risk score (PARIS-rs) and percutaneous coronary intervention complexity (PCI-c) predict clinical and procedural residual ischemic risk following PCI. Their accuracy in patients undergoing unprotected left main (ULM) or bifurcation PCI has not been assessed. The predictive performances of the PARIS-rs (categorized as low, intermediate, and high) and PCI-c (according to guideline-endorsed criteria) were evaluated in 3,002 patients undergoing ULM/bifurcation PCI with very thin strut stents. After 16 (12-22) months, increasing PARIS-rs (8.8% vs. 14.1% vs. 27.4%, p < .001) and PCI-c (15.2% vs. 11%, p = .025) were associated with higher rates of major adverse cardiac events ([MACE], a composite of death, myocardial infarction [MI], and target vessel revascularization), driven by MI/death for PARIS-rs and target lesion revascularization/stent thrombosis for PCI-c (area under the curves for MACE: PARIS-rs 0.60 vs. PCI-c 0.52, p-for-difference < .001). PCI-c accuracy for MACE was higher in low-clinical-risk patients; while PARIS-rs was more accurate in low-procedural-risk patients. ≥12-month dual antiplatelet therapy (DAPT) was associated with a lower MACE rate in high PARIS-rs patients, (adjusted-hazard ratio 0.42 [95% CI: 0.22-0.83], p = .012), with no benefit in low to intermediate PARIS-rs patients. No incremental benefit with longer DAPT was observed in complex PCI. In the setting of ULM/bifurcation PCI, the residual ischemic risk is better predicted by a clinical risk estimator than by PCI complexity, which rather appears to reflect stent/procedure-related events. Careful procedural risk estimation is warranted in patients at low clinical risk, where PCI complexity may substantially contribute to the overall residual ischemic risk.

Migrated remnant bioresorbable scaffolds in a left main bifurcation lesion: Insights from optical coherence tomography

Migrated remnant bioresorbable scaffolds in a left main bifurcation lesion: Insights from optical coherence tomography

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

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