Left Main Bifurcation Research Articles

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

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

Provisional stenting for left main bifurcation disease under IVUS guidance: Case series my Cath lab philosophy

Instead of various developments in percutaneous coronary intervention (PCI), management of the bifurcation especially left main bifurcation (LM) is diffi cult and quite challenging. In maximum number of patients who present with the LM bifurcation lesion, the one-stent strategy is the most preferred therapeutic option. However, with the objective to reduce the risk of various peri-procedural complications such as side branch occlusion, physiological and anatomical assessment of the LM lesion should be done by using the intravascular imaging techniques during the procedure. Here, we present the three cases of LM bifurcation which were successfully treated by using the provisional stenting method. All three cases were treated with the guidance of the fractional fl ow reserve (FFR) and Intravascular Ultrasound (IVUS) and heart team considerations. Measurement of the fractional fl ow reserve was done to avoid the risk of unnecessary complex interventions. At the three months follow-up, all patients were identifi ed as ischemia free.

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

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

Summary of Bifurcation Stenting Strategies and Outcomes in Women

AbstractSeveral studies have examined the efficacy of drug-eluting stents in acute and chronic coronary syndromes and demonstrated benefit in both men and women. However, the effect of gender on percutaneous coronary intervention (PCI) outcomes in more complex disease including bifurcation disease is less well-known. In particular, a two-stent or provisional strategy, for both left Main and non-Left Main bifurcation lesions, has been variable across the different studies. In addition, there is a notable geographic preference whereby a stepwise provisional strategy with culotte as a bailout technique is preferred in Europe while in Asia there is a predilection to DK Crush for a 2-stent strategy. Many of these trials, however, are underpowered to conduct subgroup analysis for outcomes in women. To date, the evidence suggests women have better outcomes with coronary artery bypass grafting in complex disease. The higher events in women undergoing PCI are largely driven by bleeding. Studies dedicated to evaluating outcomes after complex revascularization in women are desperately needed with long-term follow-up. This review examines the current landmark trials as they pertain to outcomes in women.

Left main coronary artery bifurcation coronary intervention in a patient with achondroplasia with multivessel coronary artery disease

We report a rare case of critical coronary artery disease in a 62-year-old male with achondroplasia. There is a paucity of case reports of association of achondroplasia with coronary artery disease. Left main coronary artery (LMCA) bifurcation lesion carries the highest risk of mortality out of all types of coronary artery lesions and patients with achondroplasia have two-fold more mortality as compared to the general population. That is why achondroplasia patients may be having more sudden cardiac death with the most catastrophic LMCA bifurcation lesion before they undergo revascularization. It may be the plausible explanation behind no literature description of LMCA bifurcation lesion in patients with achondroplasia. Our case is the first literature description of LMCA bifurcation lesion with successful intervention in achondroplasia. The present case will also provide a detailed insight into the association of achondroplasia with coronary artery disease without the presence of conventional cardiac risk factors.

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

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

A Warm Welcome to The First Issue of JSCAI

A Warm Welcome to The First Issue of JSCAI

Unraveling the mystique of left main stenting: A bugaboo of coronary intervention

For many years, CABG has been the gold standard treatment for unprotected Left Main (LM) coronary artery lesions. Because of its high artery size and anatomical accessibility, the LM lesion makes a good PCI candidate. Subset PCI has been broadened by the development of Drug-Eluting Stent (DES) as well as fast advances in procedures, devices, and adjunct pharmacotherapies. PCI and CABG had equivalent results in patients with low or moderate coronary complexity for up to fi ve years, according to current research. Most LM bifurcation lesions may be treated successfully with a single provisional stent rather than the more complex two-stent treatment. The unusual instance of a bifurcation lesion, which requires the use of not one, but two stents from the start, is an exception to the norm. Controlling this unusual species and improving treatment outcomes need an integrated strategy involving specialized procedures, additional physiological and morphologic assessment, and hemodynamic devices.

Vascular Response after Directional Coronary Atherectomy for Left Main Bifurcation Lesion.

Aims To evaluate the vascular response after directional coronary atherectomy (DCA) for left main (LM) bifurcation lesion. Methods This study was a retrospective, single-center study enrolling 31 patients who underwent stentless therapy using DCA followed by drug-coated balloon (DCB) angioplasty for LM bifurcation lesion. We compared intravascular ultrasound (IVUS) findings before and after DCA. Results After DCA, the lumen and vessel areas significantly increased, whereas the plaque area (PA) and %PA were significantly reduced. When the lesions were divided into small vessel and large vessel groups using the median value of the vessel area, the maximum balloon pressure of the DCA catheter was greater in the large vessel group. Changes in the lumen and vessel areas were also significantly greater in the large vessel group. On the other hand, the changes in PA and %PA were similar between groups. Conclusions The main vascular responses associated with lumen enlargement after DCA were plaque reduction and vessel expansion. Contribution of vessel expansion to lumen enlargement was larger than the effect of plaque reduction in large vessel lesions.

Presence of ramus intermedius increases the risk of atherosclerotic plaque formation at the left main bifurcation's region: A retrospective study from CT coronary angiography in UMMC

<h2>Background</h2> Ramus intermedius (RI) is a variant vessel arising from the left main bifurcation angle (LMBA). Haemodynamically, its presence increases coronary turbulence flow and reduces the endothelial shear stress. In theory, this haemodynamic effect promotes atherosclerotic plaque formation, especially around the bifurcation region. <h3>Objectives</h3> This study aims to identify RI as a risk factor for atherosclerosis at the left main coronary artery (LMCA), proximal left anterior descending (LAD) and proximal left circumflex (LCx) using coronary computed tomography angiography (CCTA). <h3>Methodology</h3> A retrospective review was carried out on 374 CCTA cases in University Malaya Medical Centre (UMMC) between January 2017 and December 2018. The atherosclerotic plaque at the LMCA, proximal LAD and proximal LCx arteries were analysed in the presence or absence of RI. Statistical analysis was done using the chi-square test and binary logistic regression. <h3>Results</h3> RI was identified in 32.4% (<i>n</i> = 121) of patients. Age > 65 years old, male gender, diabetes, hypertension and RI were identified as significant risk factors for atherosclerosis. The presence of RI increases plaque formation by 8.5-fold for proximal and distal LMCA compared to those without RI (aOR: 8.5, 95% CI: 1.7, 43.0, <i>p</i> > 0.001). Meanwhile, at the proximal LAD, RI increases the risk for plaque formation by 3.7 folds (aOR: 3.7, 95% CI: 1.5, 9.4 <i>p</i> = 0.006) at the lateral wall and by 4.9 folds (aOR: 4.9, 95% CI: 1.7, 14.2, <i>p</i> = 0.003) for both lateral and medial wall. RI also independently increases the risk for atherosclerosis by 3 folds at the lateral and medial wall of proximal LCx (aOR: 3.7, 95% CI: 1.2, 11.4, <i>p</i> = 0.020). Lastly, RI increases the risk of obstructive stenosis in the LMCA, LAD and LCx by 3.9 folds (aOR: 3.9, 95% CI: 1.4, 10.5, <i>p</i> < 0.001). <h3>Conclusion</h3> Our findings suggest that the presence of RI independently increases the risk for atherosclerotic plaque formation in the left main stem and its proximity. RI in situ is believed to exert altered haemodynamic effect promoting atherosclerotic plaque formation.

Randomized non-inferiority TrIal comParing reverse T And Protrusion versus double-kissing and crush Stenting for the treatment of complex left main bifurcation lesions

BackgroundThe treatment of left main bifurcation stenoses remains challenging.AimsWe compare the “Reverse T and Protrusion” (reverse-TAP) technique to Double-Kissing and crush (DK-crush).MethodsThe study was designed as non-inferiority trial, the primary endpoint was percentage stent expansion in the ostial side branch at optical coherence tomography.Results52 consecutive patients (13 females, 17 diabetics, Syntax score 25 [22–29]) with complex coronary bifurcation lesions of the left main were randomized in a 1:1 ratio to Reverse-TAP or DK-crush stenting. The intervention was performed according to protocol in all patients in both randomization groups. Side branch stent expansion was 75 [67–90]% in the DK-crush group and 86 [75–95]% in the reverse-TAP group (one-sided 97.5% lower parametric confidence interval: − 0.28%; P < 0.01 for non-inferiority; P = 0.037 for superiority). Side branch balloon pressure during final kissing was higher in the DK-crush group (14 [12–16] vs. reverse-TAP: 13 [12–14]; P = 0.043). Procedural time was shorter with reverse-TAP (DK-crush: 32 [24–44] min vs reverse–TAP: 25 [22–33] min; P = 0.044). Other procedural parameters were not different between groups. There was no difference in any of the safety endpoints up to 1 month.ConclusionsA reverse-TAP strategy for the interventional treatment of complex coronary lesions was non-inferior and superior to DK-crush for the primary endpoint side branch expansion while requiring less time. A larger study testing long-term clinical outcomes is warranted.Trail RegistrationNCT: NCT03714750.Graphical abstract

Abstract 11770: Clinical Outcomes of Optical Coherence Tomography-Guided Compared With Intravascular Ultrasound-Guided in Low-Risk Percutaneous Coronary Intervention: A Meta-Analysis

Background: Axial resolution provided by optical coherence tomography (OCT) is 10 times higher compared with intravascular ultrasound (IVUS), hence OCT could detect fine details such as edge dissections and tissue coverage of stent struts which may be missed by IVUS imaging. Given the lack of robust comparative data, utilization of IVUS or OCT in PCI guidance is mainly based on the operator experience. Recently, multiple studies have compared clinical outcomes between OCT-guided versus IVUS-guided in PCI, thus we performed this meta-analysis. Methods: We conducted a meta-analysis of all studies evaluating the clinical outcomes of OCT-guided versus IVUS-guided in low-risk PCI. Studies that included patients with left main disease, bifurcation lesions, long lesions, in-stent stenosis, and patients with history of coronary artery bypass grafting were all excluded. Our primary outcome was major cardiac adverse events (MACE). Secondary outcomes consisted of all-cause death, myocardial infarction (MI), stent thrombosis (ST), and target lesion revascularization (TLR). Results: Four RCTs and one propensity-matched observational study were included, with a total of 1,544 patients and a median weighted follow-up period of 1.26 years. Out of the total population, 51% were in the OCT arm and 49% in the IVUS arm. Our pooled analysis showed a similar risk of MACE (OCT 5.0% vs IVUS 4.7%, p=0.90), risk of all-cause death (OCT 2.7% vs IVUS 1.7%, p=0.44), MI (OCT 1.5% vs IVUS 1.3%, p=0.76), ST (OCT 0.3% vs IVUS 0.4%, p=0.66) and TLR (OCT 2.2% vs IVUS 2.6%, p=0.58) between the two groups (Figures 1). Heterogeneity was low in all outcomes (I 2 =0). Conclusion: OCT-guided PCI has similar long term clinical outcomes when compared to IVUS-guided PCI in low-risk patients. RCTs with a larger population and longer follow-up periods are needed to confirm these results.

TCT-398 Drug-Eluting Balloon Catheters in the Treatment of Left Main Coronary Artery Bifurcation Lesions: 4-Year Follow-Up

TCT-398 Drug-Eluting Balloon Catheters in the Treatment of Left Main Coronary Artery Bifurcation Lesions: 4-Year Follow-Up

Evolution of the Crush Technique for Bifurcation Stenting.

Bifurcation lesions are frequently encountered, associated with greater procedural complexity and consequently are at higher risk for restenosis and stent thrombosis. Early trials in bifurcation percutaneous coronary intervention favored a provisional stenting approach, but contemporary randomized trials have highlighted potentially superior outcomes using a double-kiss crush technique in unprotected distal left main stem bifurcation lesions. Although the evidence is greatest for double-kiss crush, many operators favor a mini-crush or nano-crush single-kiss approach. In this review, the authors describe the iterations of the crush technique and the evidence for each and review general principles for bifurcation percutaneous coronary intervention.

Drug-eluting balloon catheters in the treatment of left main coronary artery bifurcation lesions: 4-years follow-up

Abstract Aim To evaluate the long-term results of the use of drug-eluting balloon catheters in patients with Left Main (LM) bifurcation stenosis. Methods The analysis involved 142 patients with true bifurcations of the Left Main. Randomization in 2 main groups: Group I (n=52) included patients, who received kissing- dilatation with traditional NC balloon catheters and Group II (n=52), who had a kissing-dilatation of the main bifurcation artery with a traditional NC balloon catheters, and a side branch - with drug-eluting balloon catheters. In retrospectively, the third (III) control group (n=38) was formed, where the two-stent technique was performed. All patients from main groups had previously performed “Provisional T” stenting and final “kissing balloons” dilation technique. Coronary angiography and OCT were performed to evaluate the results of all patients. Inclusion criteria: true LM bifurcation stenoses according to QCA and OCT; SYNTAX score &amp;lt;32. Primary endpoints: incidence of MACE - death, MI, re-interventions. Secondary endpoints: the incidence of restenosis and late stent thrombosis. Results The long-term results after 4-years were observe in 46 patients from Group I and 48 patients from Group II. Restenosis of the side branch of more than 50% according to QCA was detected in 12 patients (26.0%) from Group I and in 5 patients (10.4%) from Group II (p&amp;lt;0.05). In-stent restenosis of the main vessel of more than 50% according to QCA was detected in 4 patients (8.6%) from Group I and in 1 patients (2.1%) from Group II (p&amp;lt;0.05). In patients from group I, the average MLA in the side branch after 4-years compared with data after PCI was 5.58±1.34 and 4.12±1.21 mm2, respectively (p&amp;lt;0.05), in the main branch – 6.34±1.56 and 5.88±1.14 mm2, respectively (p&amp;gt;0.05). In patients from Group II, the average MLA were, respectively, 5.38±1.24 and 5.01±1.14 mm2 in side branch (p&amp;gt;0.05) and 6.68±1.75 and 6.36±1.22 mm2 in main branch (p&amp;gt;0.05). When comparing the data of MLA in the side branch in groups I and II, there was a significant difference (4.12±1.21 vs. 5.01±1.14 mm2; p&amp;lt;0.05).The repeat revascularization, in connection with the detected ischemia was performed in 7 patients (15.2%) from Group I and in 1 patients (2.1%) from Group II (p&amp;lt;0.05). In the Group I was observed non-fatal myocardial infarction in 2 patients (4.3%). The total incidence of MACE were 19.5 vs. 2.1% in groups I and II respectively (χ2=7.321; p&amp;lt;0.001). The survival without MACE was 97.9 and 80.5%, respectively (p=0.0219). Conclusions The use of dug-eluting balloon catheters for the “Provisional T” stenting in patients with true LM bifurcation stenosis, associated with good prognosis and demonstrated significantly lower frequency of MACE and side branch restenosis, according to OCT data, compared with patients who used traditional NC balloon catheters for “kissing-dilatation” and two-stent technique strategy. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Russian academic excellence project 5-100

Stent strategies in left main bifurcation lesions: the simpler, the better?

Abstract Introduction Although percutaneous coronary intervention (PCI) for ostial or midshaft lesions in left main (LM) disease has shown similar results as compared with coronary artery bypass grafting (CABG), distal LM bifurcations are associated with an increase in procedural complexity and higher rates of target lesion revascularization. Several studies have investigated the optimal stenting strategy in patients with coronary bifurcation lesions and showed no benefit for systematic two-stent approach in comparison with provisional stenting. This is reflected in the current guidelines that recommend provisional stenting of the side branch as the preferred approach for most bifurcation lesions. However, there is still debate about the optimal strategy according to lesion location. Objectives This analysis aimed to compare the clinical outcomes of LM bifurcation PCI using a provisional strategy versus a two-stent strategy. Methods Retrospective, observational study including patients submitted to LM bifurcation (Medina 1,1,1) PCI between January 2010 and December 2019. Data was collected from the emergency department and hospitalization registries. Patients were divided according to the stenting approach. We made a global analysis including baseline clinical and angiographic data. The primary endpoint was target lesion failure (TLF), defined as the composite of myocardial infarction, cardiac death, and target lesion revascularization (TLR). Secondary endpoints included the individual components. Results A total of 106 patients were included (median age 74 [66–82], 79 (74.5%) males), 57 (53.8%) submitted to provisional stenting and 49 (46.2%) to a two-stent technique. Baseline characteristics were well matched (table 1). The mean SYNTAX score was 29.6±10.0 and LM stenosis grade was ≥70% in all lesions. Median follow-up was 26.6 [12.0–48.6] months. No differences were found regarding the primary endpoint (TLF in provisional stenting was 21.7% vs 21.4%, HR 2.432; 95% confidence interval, 0.472–12.450; p=0.233.). Although target lesion revascularization within the LM complex was numerically higher in the two-stent group (10.2% vs. 3.5%, p=0.245), the opposite was found in cardiac death (provisional group 10.5% vs. 4.3%, p=0.289). Conclusions Besides being a “simpler” technique, provisional stenting had no significant differences in outcomes compared to two-stent techniques. Without further evidence, revascularization strategies should primarily rely on operator expertise. Funding Acknowledgement Type of funding sources: None.

Mid-term mortality after stenting of distal left main stenosis with regular, third generation drug eluting stent or dedicated bifurcation stent or surgery-registry based,all-comers data

Abstract Background Distal left main (LM) bifurcation lesions remain a challenge for interventional cardiologists and they are associated with significant morbidity and mortality. The aim of the current study was to identify predictors of cardiac mortality at mid-term follow up after PCI (DES vs. dedicated bifurcation stent) or CABG. Methods All patients with distal LM stenosis ≥50% were included in prospective registry starting from 01.2015. The exclusion criteria for registry are cardiogenic shock, a priory life expectancy duration &amp;lt;1 year, lack of inform consent. All patients were prospectively followed about the alive status through the national security number data base. All deaths were deemed cardiac if proof otherwise (the data patient families or family's physicians were contacted through phone call about the reason of death) Results For three year follow up period (median 35 months, IQR 18–50) 303 patients were included. 220 patients were stented with 3rd generation DES, 43 with dedicated bifurcation stent BiOSS (Balton, Poland), and rest were sent for CABG. The mean age was 67±10 years, 72% were males, 37% diabetics, all with hypertension, 97% dyslipidemia, 15% PAD, 9% COPD, 16% carotid artery disease, previous MI 28%, previous PCI 50% - without significant difference between three groups. The frequency of acute coronary syndrome during admission was 11% - without difference in frequency between groups. The patient referred to CABG had significantly lower left ventricular EDV and ESV, more severe mitral regurgitation and kinetic disturbances, higher SYNTAX score and longer lesion length. On univariate COX regression analysis, the following factors were associated with mortality: age, NYHA class, GFR, baseline troponin, hemoglobin, LV EF, mitral regurgitation, kinetics disturbances, treatment with beta blockers, ACE inhibitors, statin, atrial fibrillation, SYNTAX score, lesion length. The type of treatment was not associated with differences in mortality (figure). On COX multiple regression survival analysis independent predictors of survival were: age (HR=1.036, CI 1.005–1.068, p=0.023); COPD (HR=2.313, CI 1.170–4.572, p=0.016); GFR (HR=0.988, CI 0.978–1.000, p=0.048); hemoglobin (HR=0.970, CI 0.955–0.986, p=0.000); left ventricular EF (HR=0.958, CI 0.832–0.985, p=0.003). Conclusions The type of treatment was not associated with mid-term mortality. Our data demonstrate that dedicated bifurcation stent could be used safely for distal LM stenosis treatment with similar safety as 3rd generation DES. Funding Acknowledgement Type of funding sources: None.

Prasugrel or clopidogrel in patients with acute coronary syndromes at high thrombotic risk: results from the PROMETHEUS study

Abstract Background Potent P2Y12 inhibitors are recommended on top of aspirin in patients presenting with acute coronary syndrome (ACS). However, guideline recommendations suggest that the optimal antithrombotic strategy should be tailored based on patients thrombotic and hemorrhagic risk profile. Purpose It is poorly investigated if the benefits derived from potent P2Y12 inhibition in patients with ACS depend on the individual thrombotic risk profile. Our aim was to evaluate if the benefits associated with prasugrel vs. clopidogrel in patients with ACS undergoing percutaneous coronary intervention (PCI) are similar in case of different thrombotic risk profiles. Methods PROMETHEUS was a multicenter observational study comparing prasugrel vs. clopidogrel in ACS patients undergoing PCI. According to the 2020 ESC guidelines for non-ST elevation-ACS, patients are defined at high thrombotic risk if presenting with a clinical (diabetes mellitus requiring medication, history of recurrent myocardial infarction [MI], multivessel coronary artery disease [CAD], polyvascular [coronary and peripheral] disease, premature (&amp;lt;45 years) CAD, and chronic kidney disease [estimated glomerular filtration rate &amp;lt;60 ml/min/1.73m2]) and procedural (≥3 stents implanted, ≥3 lesions treated, total stent length &amp;gt;60 mm, complex revascularization [left main PCI, bifurcation or chronic total occlusion]) risk features. The primary endpoint was major adverse cardiac events (MACE), a composite of death, MI, stroke or unplanned revascularization. Hazard ratio (HR) and 95% confidence intervals (CI) were calculated using propensity-stratified analysis to assess the effect of prasugrel vs. clopidogrel and with multivariable Cox regression to evaluate the impact of thrombotic risk. Results Among 16065 patients, 4293 were defined at high thrombotic risk and 11772 at low-to-moderate thrombotic risk. Patients treated with prasugrel had less comorbidities and risk factors than those treated with clopidogrel, both in the high and low-to-moderate thrombotic risk strata. Patients at high thrombotic risk had higher rates of both ischemic and bleeding events at 90 days and at 1 year. Patients treated with prasugrel had a lower adjusted risk of MACE at 1 year (HR 0.86, 95% CI 0.77–0.96), with no significant interaction between effect estimates and thrombotic risk. However, after stratifying the study population by the number of risk factors, there was a significant interaction for a greater reduction in MACE with prasugrel in patients with ≤1 thrombotic risk factor. Conversely, there were no differences in major bleeding among patients treated with prasugrel and clopidogrel. Conclusions Patients with ACS at high thrombotic risk who undergo PCI are at increased risk of adverse events. Prasugrel, although mainly reserved to patients with lower burden of comorbidities, reduced the risk of ischemic events both in patients at high and low-to-moderate thrombotic risk as compared with clopidogrel. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo and Eli Lilly and Company Clinical outcomes at 1 year.Impact of number of risk factors

Management of bifurcation culprit lesion in the setting of anterior ST elevation myocardial infarction

Abstract Introduction Coronary bifurcation lesions are considered one of the challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis. However, there is limited data about the proper management of such lesions in the setting of myocardial infarction as most bifurcation lesion studies excluded patients with acute coronary syndrome (ACS). Aim To compare in-hospital and mid-term outcomes of single-stent and two-stents strategy in the management of bifurcation culprit lesions in patients presenting with anterior STEMI Methods This retrospective multi-center study included all consecutive patients presented with anterior STEMI who underwent primary PCI between January 2017 and December 2019, coronary angiography showed true bifurcation lesion with sizable side branch that can be managed by stenting. Patients with left main bifurcation lesion, patients indicated for urgent CABG, or patients in cardiogenic shock were excluded. Included patients were divided into two main groups according to the stenting strategy either single or two stents strategy. Six months of follow up data were collected by telephone calls and the examination of medical records Results Out of 1355 anterior STEMI patients presented between January 2017 and December 2019, 158 patients (11.6%) were identified to have bifurcation culprit lesions with a sizable diagonal branch. The baseline characteristics and angiographic findings were similar in both groups except for higher side branch involvement in the two stents group (83.31%± 11.20 and 71.88%±15.05, t=−5.39, p&amp;lt;0.001). Mean fluoroscopy time (23.96±8.90 vs 17.81±5.72 min) and contrast volume (259.23±59.45 vs 232.58±96.18 ml) were significantly higher in two stents group than single stent group (p=0.049). However the angiographic success rates (residual stenosis ≤30% and restoration of TIMI flow grade II or III) were comparable (96.8% vs 99%, MC p=0.151). There is no significant difference regarding the overall incidence rate of MACCE in both groups 6 months following the index procedure (13.9% vs 16.9%, FEp=0.698), with no difference between different bifurcation stenting techniques in patients managed with two stents Conclusion Although two stents strategy in the setting of STEMI is much complex with more fluoroscopy time and contrast volume, the procedural success rate and the incidence of complications between two groups were comparable on the medium-term follow up Funding Acknowledgement Type of funding sources: None.

Feasibility, safety and long term outcomes of complex left main bifurcation treatment using the nano inverted t stenting: a multicentre registry

Abstract Background The role of double stenting techniques in distal bifurcation left main (LM) disease has gaining interest over the latest years. Purpose We present the 3-year multicentre registry outcomes of dual stenting using ultra-thin strut stents and the Nano Inverted-T (NIT) technique in complex unprotected true LM bifurcation disease. Methods We analysed the procedural and medical data of consecutive patients enrolled between 1st January 2014 and 1st December 2019 in a multicentre registry for complex LM bifurcation disease treated with the double stenting technique called NIT due contraindications and/or refusal to surgical treatment. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel MI (TVMI) and clinically driven target lesion revascularization (TLR). Results Among two hundred-ninety-five patients (138 males, mean age 70.3±12.8 years), post-operative success was achieved in 100% of cases. Contrast volume, procedural time, and radiation exposure were 139.2±23.4 ml, 15.3±4.9 min, and 1080±1034 cGy/m2 (Figure), respectively. At a mean follow-up of 39.5±0.6 months TLF rate was 6.1% (n=18) while TLR and cardiovascular mortality rates were 3.0 (n=9) and 2.6% (n=8), respectively. Clinically driven angiographic follow-up was available in 26.4% of patients at a mean time from the procedure of 7.5±0.4 months. Clinically restenosis rate was 3.3%. Conclusions Revascularization of complex LM bifurcation disease using the NIT double stenting technique resulted feasible and safe with a low incidence of TLF, excellent survival rate and no stent thrombosis. Figure 1.The NIT technique is based on the use of ultra-thin strut (≤80 micron) stents and double stenting starting with side branch stenting frst. The side branch stent is precisely positioned with one possibly only strut protruding into the main vessel which is balloon crushed before the implantation of the main branch stenting. The Proximal optimization technique (POT)–snuggle kissing–POT sequence is mandatory to ensure the coverage of the side branch ostium by both side branch and main branch stents. Snuggle kissing was performed placing the LCX balloon with the proximal marker at the middle rather than at the proximal marker of the LM-LAD balloon, in order to minimize the elliptical deformation of the LM stent. Funding Acknowledgement Type of funding sources: None. Figure 1