Acute side branch (SB) occlusion after main vessel (MV) stenting remains a challenging complication of bifurcation PCI, particularly when conventional true-lumen rewiring attempts fail. In such scenarios, operators face limited standardized bailout options, and guidance on decision-making is scarce. We retrospectively analyzed a highly selected single-center case series of patients with acute stent-jailed SB occlusion refractory to conventional rewiring who underwent chronic total occlusion (CTO)-derived subintimal bailout recanalization. A predefined technical framework was applied. Angiographic results were assessed using Thrombolysis in Myocardial Infarction(TIMI) flow, and angiography-derived quantitative flow ratio (QFR) was used as physiological confirmation of reperfusion. Among 9,832 PCI procedures performed between 2019 and 2023, 15 consecutive patients met the inclusion criteria. Subintimal SB recanalization was achieved in all cases, resulting in restoration of TIMI 3 flow. Postprocedural SB QFR was successfully obtained in all patients, with a mean value of 0.91 ± 0.04; all exceeded the predefined ischemic threshold (QFR ≥ 0.80). No procedure-related perforation, tamponade, or device entrapment was observed. Limited follow-up angiography and QFR data, available in two patients, demonstrated stable or improved functional values. In a highly selected case series managed at an experienced center, a structured subintimal bailout framework appears feasible for the treatment of acute stent-jailed SB occlusion when conventional rewiring fails. Integration of QFR provides objective physiological confirmation of SB reperfusion and may assist in procedural decision-making. These findings should be considered hypothesis-generating and warrant validation in larger, prospective studies.

The purpose of this study was to develop and validate a predictive model to assessing the risk of side branch flow impairment (SBFI) following stent implantation in patients with non-left main coronary bifurcation lesions (CBLs). This model aims to provide preprocedural risk stratification and inform the selection of interventional strategies. Coronary artery bifurcation lesions constitute a particularly complex subtype of coronary artery disease that is frequently encountered in practice. Compared with non-bifurcation lesions, they are associated with greater procedural complexity and risk of procedure-related complications. Data from 830 patients with CBL who underwent percutaneous coronary intervention (PCI) in the Affiliated Hospital of Chengde Medical University from January 2022 to December 2023 were retrospectively collected. The least absolute shrinkage and selection operator regression methods were used to screen variables, and multivariate logistic regression was used to establish a predictive model. A nomogram was built based on these factors and internally verified using the bootstrap resampling method. The C-statistic was used to verify and evaluate the discriminative ability of the model; the calibration curve was drawn, and the decision curve analysis (DCA) was performed to evaluate the calibration degree, clinical net benefit, and practicability of the model. The primary endpoint was SBFI, defined as a transient or persistent reduction in thrombolysis in myocardial infarction (TIMI) flow grade in a branch vessel following stent implantation in a major non-left main coronary artery. A nomogram was constructed using the selected predictors of SBFI, which included age, plaque location ipsilateral to the SB, TIMI flow grade before main vessel (MV) stenting, and N-terminal pro-brain natriuretic peptide (NT-proBNP). The discriminatory ability of the model, as assessed by the area under the curve (AUC), was 0.651. The robustness of the model was evaluated through internal validation with 1000 bootstrap replicates, resulting in a corrected AUC of 0.641. The calibration curve, evaluated by the Hosmer-Lemeshow test, showed good agreement between predictions and observations (χ2 = 5.765, P = 0.674). Finally, DCA indicated that the model provided clinical net benefit over a threshold probability range of 0.19-0.45. We developed and validated a predictive model for SBFI after PCI in non-left main bifurcation lesions. The model exhibited modest discriminative ability, calibration, and a positive net benefit on DCA, suggesting that it may serve as a valuable risk stratification tool in clinical practice.

Dual free flap reconstruction: A configuration-based algorithm using parallel and serial designs.

Reverse crush and culotte are commonly used strategies in case of side branch (SB) compromise after main vessel (MV) stenting during provisional bifurcation percutaneous coronary intervention (PCI). The aim of this study is to compare the technical and procedural outcomes and safety of reverse crush versus (vs.) culotte technique in cases of SB compromise following MV stenting during provisional bifurcation PCI. We analyzed 43 PCIs (43 patients) with SB compromise after MV stenting during provisional strategy from the PROGRESS-BIFURCATION registry that were treated with reverse crush or culotte. Of 43 PCIs (43 patients) with SB compromise after MV stenting during the provisional strategy, 29 (67%) were treated with reverse crush and 14 (33%) with culotte. Reverse crush and culotte patients had similar baseline characteristics. Reverse crush was more likely to be used in the left anterior descending artery (LAD) and in smaller bifurcation angles (45° [37.50, 60.00] vs. 70° [45.00, 80.00], p = 0.017). Culotte was more frequently used in the left main coronary artery (LMCA). Reverse crush cases had smaller proximal (3.25 [3.00, 3.50] vs. 4.00 [3.00, 5.00] mm, p = 0.028) and distal (3.00 [2.50, 3.00] vs. 3.50 [3.00, 4.00] mm, p = 0.013) MV diameter, smaller SB diameter (2.50 [2.25, 2.50] vs. 3.00 [2.50, 3.50] mm, p < 0.001) and longer proximal MV (10.00 [5.00, 20.00] vs. 5.00 [0.00, 10.00] mm, p = 0.003) and SB (10.00 [8.00, 12.00] vs. 4.00 [0.00, 10.00] mm, p = 0.002) lesions. SB total occlusion was a more frequent trigger for escalation to a two-stent strategy in the reverse crush group compared with the culotte group (42.3% vs. 0.0%, p = 0.016). Patients treated with the reverse crush technique were less likely to require escalation to a third stenting strategy compared with those treated with culotte (4.0% vs. 21.4%, p = 0.04), but had longer procedural time (102.00 [77.00, 144.00] vs. 60.00 [45.00, 110.00] min), p = 0.012). There was no difference in technical (100% vs. 100%, p = 1.00), procedural (96.6% vs 100%, p = 1.00) success, periprocedural major adverse cardiac events (MACE) (3.4% vs. 0.0%, p = 1.00) or long-term MACE (HR 0.59, 95% CI 0.12-2.92, p = 0.50) between reverse crush and culotte cases. Most cases of SB compromise during provisional MV stenting were treated with reverse crush, but periprocedural and long-term outcomes were similar between reverse crush and culotte.

Percutaneous interventions of coronary bifurcation lesions (BLs) remain technically challenging with possible complications including significant side branch (SB) occlusion (SBO). We aimed to assess the predictive value of additional lesion characteristics to the RESOLVE (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion)-score for prediction of SBO. This observational study included patients with coronary BLs subtending sizable SB (≥2 mm in diameter), planned for provisional stenting. SBO was defined as impairment of SB flow after main vessel stenting. Quantitative coronary angiographic and procedural data were recorded, and the RESOLVE-score was calculated for all BLs. In-hospital and 6-month major adverse cardiovascular events (MACE) were reported. The study included 510 patients with 556 BLs. SBO occurred among 107 patients (21.0%) involving 109 BLs (19.6%). True BLs (odds ratio [OR], 6.05; 95% confidence interval [CI], 3.07-11.91; p<0.001), high thrombus burden (OR, 2.88; 95% CI, 1.56-5.31; p=0.001), and high RESOLVE-score (OR, 3.41; 95% CI, 1.85-6.28, p<0.001) were the only independent predictors of SBO among lesion-related variables. Combined true BLs, high thrombus burden, and the RESOLVE-score showed better discrimination for SBO than the RESOLVE-score only (area under the curve [AUC] difference, 0.04; p=0.01). SBO showed significantly higher rates of in-hospital and 6-month MACE (log-rank p=0.001) and was among the independent predictors for follow-up MACE (hazard ratio, 3.27; 95% CI, 1.41-7.62; p=0.006). A predictive model comprising true BLs, high thrombus burden, and the RESOLVE-score showed better discrimination for SBO than the RESOLVE-score only.

Coronary bifurcation lesions remain prone to side-branch (SB) ostial restenosis. Kissing balloon inflation (KBI) is the standard for provisional stenting but induces mechanical injury. Drug-coated balloons (DCB) may pharmacologically inhibit neointimal hyperplasia to improve long-term patency. To evaluate mechanistic vascular healing and luminal changes at the SB after adjunctive SB-DCB versus SB-conventional balloon treatment using high-resolution serial optical coherence tomography (OCT). The randomized OCVC-BIF trial compared adjunctive SB-DCB (n=149) to Non-DCB (n=150) following main-vessel stenting and protocolled KBI. The present pre-specified study was restricted to those patients who completed evaluable follow-up OCT pullbacks (n=221). Endpoints included the SB volume change and the main vessel stent healing parameters. There is no significant difference in the ostium, minimum SB area, and SB volume between the DCB and Non-DCB groups post percutaneous coronary intervention (PCI). Serial OCT analysis showed that the DCB group exhibited lumen volume gain at SB of 0.14±5.64 mm3 from post PCI to 9-month follow-up, whereas the Non-DCB group showed a mean loss of -2.15±9.51 mm3. Although difference reached statistical significance in the prespecified parametric analysis (p=0.042), in sensitivity analysis using the Wilcoxon rank-sum test, the difference was attenuated (0.45 [-3.83, 4.00] in DCB vs -0.65 [-5.00, 2.50] in Non-DCB, p=0.093). While in the DCB group, SB lumen volume change from immediately after PCI to follow-up was not statistically significant (p=0.81), the Non-DCB group demonstrated a statistically significant reduction in SB lumen volume (p=0.03). At 9 months, the incidence of uncovered and malapposed struts was low and comparable between groups across all segments. Adjunctive SB-DCB treatment after KBI showed no adverse effect on main-vessel stent healing and a possible signal toward preservation of SB lumen. These findings may support the mechanistic feasibility of this strategy in selected bifurcation lesions. (Japan Registry of Clinical Trials: 052200077).

Plain Language SummaryThis study looked at patients with a serious type of liver cancer called hepatocellular carcinoma (HCC), which had also spread into the main blood vessel of the liver (called portal vein tumor thrombus, or PVTT). The goal was to see if adding a local treatment directed at the liver tumor to the standard medication therapy could help patients live longer. We studied 478 patients; 374 received the combination of local and medication therapy, while 104 received medication therapy alone. To ensure a fair comparison, we used a statistical method to match patients in both groups with similar characteristics. We found that patients who received both the local treatment and medication lived significantly longer. Their median overall survival was 15.7 months, compared to 5.9 months for those on medication alone. The time before their cancer worsened was also longer (7.0 months vs. 3.6 months). Patients with more advanced disease in the main portal vein (called Vp4) and those with moderately reduced liver function (Child-Pugh B) saw the greatest benefit from the combined approach. Although side effects like low blood counts and liver enzyme changes were more common with the combined treatment, they were generally manageable. This study suggests that for patients with this advanced form of liver cancer, combining a local therapy with standard medications is a more effective strategy than using medications alone.

Accurate vessel segmentation and plaque detection in coronary angiography (CAG) images are crucial for the intelligent diagnosis of coronary artery disease. To address the performance bottlenecks of existing deep learning methods in handling complex vascular topology, small branches, and low-contrast plaques, this study proposes a deep learning-assisted diagnostic system based on an enhanced Pyramid Scene Parsing Network (PSPNet). By incorporating a Multi-scale Feature Fusion (MSF) module, a Convolutional Block Attention Module (CBAM), and a Wavelet Feature Enhancement Module (WFEM), the system significantly improves the perception of multi-scale vascular structures and the focus on minute plaque regions. Evaluated on a dataset comprising 1,200 clinical CAG images, the proposed system achieved Dice coefficients of 94.8% and 90.8% for main vessel and small branch segmentation, respectively. In the plaque detection task, it attained a precision of 89.1%, a recall of 86.5%, an F1-score of 87.8%, and an AUC value of 92.4%, outperforming current mainstream segmentation models. Ablation studies confirmed the effectiveness and synergistic contributions of each proposed module. This system enables a fully automated pipeline from image preprocessing to segmentation, detection, and visual analysis. It not only provides a high-precision and robust technical solution for the intelligent diagnosis and risk assessment of coronary artery disease but also advances the development of interpretable, end-to-end assisted diagnostic systems for complex medical imaging.

Drug-Coated Balloon Angioplasty vs Drug-Eluting Stents in Noncomplex Coronary Bifurcation Lesions: The REC-CAGEFREE I Trial.

Modified TAP versus TAP stenting by IVUS guidance in patients with coronary bifurcation lesions.

The European bifurcation club randomized trial of stepwise provisional stenting vs drug-coated balloon therapy for nonleft main true coronary bifurcations: The EBC DCB trial.

Abstract Iatrogenic pulmonary vein stenosis (PVS) is a rare but serious complication of atrial fibrillation ablation, occurring in 1–4% of cases. Its clinical manifestations such as dyspnea, recurrent pulmonary infections and hemoptysis are often nonspecific, leading to delays in diagnosis and treatment, that can significantly impair patients' quality of life. This study presents the first Polish experience with percutaneous PVS treatment and introduces an novel therapeutic model for managing this challenging condition. Six patients diagnosed with PVS were analyzed. Diagnosis was confirmed using computed tomography (CT) and transesophageal echocardiography (TEE), which played a crucial role in the evaluation process. All patients were qualified for percutaneous intervention. Procedures were performed in general anestesia under TEE guidance for precise transeptal puncture. After introducing the steerable sheath into the left atrium balloon angioplasty with selfexpandable stent implantation was performed under intravascular ultrasound guidance. A total of nine pulmonary veins were successfully recanalized with the implantation of nine stents (mean diameter : 9.6 [4–14], mean lenght 27.6 [20–40] mm), restoring blood flow and leading to significant clinical improvement. In one patient, the procedure was terminated with balloon angioplasty due to the developed network of collaterals and the lack of technical possibilities to recanalize the main vessel. The present study highlights both the diagnostic challenges associated with PVS and the effectiveness of a minimally invasive percutaneous approach. The proposed treatment model, developed as part of this innovative project, lays the foundation for a comprehensive therapeutic program for iatrogenic PVS in Poland, aiming to improve early detection, optimize management strategies, and enhance patient outcomes.For image description, please refer to the figure legend and surrounding text.

Background/Objectives: Coronary bifurcation lesions (CBLs) are common, and the treatments remain nuanced. Side branch (SB) patency is a key determinant of clinical success in CBL intervention. In this paper, data exploring the routine use of drug-coated balloons (DCBs) in the SB is presented as an alternative to standard plain old balloon angioplasty (POBA). Methods: A meta-analysis was performed comparing DCBs in the SB to POBA after drug-eluting stent (DES) implantation in the main vessel (MV) of a true CBL. Outcomes including myocardial infarction (MI), target lesion revascularisation (TLR), cardiac death, and late lumen loss (LLL) up to 1 year post-procedure are reported. Results: Six studies comprising of 1982 patients were included in the analyses. Patients were predominantly male, and the mean age was >60 years. Four studies included patients with acute coronary syndrome. The primary outcomes were a statistically significant reduction in MI rate (OR 0.38, 95% CI 0.19-0.76, p = 0.006), and in the TLR rate (OR 0.45, 95% CI 0.23-0.87, p = 0.02) in the DCB group compared to the control. There was no significant difference in cardiac death. Furthermore, there was a significant reduction in SB LLL in the DCB group (Mean difference -0.22mm, 95% CI -0.33--0.11mm, p = 0.0001). Conclusions: Following DES implantation in the MV of a true CBL, this analysis demonstrated that DCBs in the SB is superior to POBA in reducing MI, TLR, and LLL of the SB. Large, randomized trials are required to consolidate the role of DCB in the treatment of CBL.

Isolated ostial side branch (SB) lesions (Medina 0.0.1) have traditionally been considered clinically minor because of their angiographically simple appearance and the limited myocardial territory supplied by most SBs. As a result, they have been underrepresented in clinical trials, creating an unmet need for evidence-based assessment and treatment strategies. This review summarizes emerging data demonstrating that Medina 0.0.1 lesions are not benign. Contemporary registries consistently report high rates of target lesion failure, comparable to true bifurcation lesions. These outcomes are driven by unique anatomical and physiological characteristics of the SB ostium, including disturbed flow, negative remodeling, elastic recoil, and frequent underestimation of disease severity by angiography. Intravascular imaging and physiological assessment often reveal occult plaque burden, hidden main vessel involvement, or clinically relevant ischemia. Clinically, these findings support an individualized approach, with a provisional strategy as the default and selective use of drug-coated balloons in carefully chosen cases. This article redefines Medina 0.0.1 lesions as a distinct high-risk entity and highlights the need for dedicated prospective studies.

Recently, drug-coated balloons (DCB) have emerged as a promising alternative for side branch treatment in coronary bifurcation lesions, in combination with drug-eluting stent (DES) implantation in the main vessel, the hybrid DCB approach. We aimed to evaluate clinical outcomes in patients treated with the hybrid DCB approach and to compare this strategy with other bifurcation techniques. A systematic review and meta-analysis. MEDLINE and EMBASE were searched up until January 2025. We included randomised controlled trials and observational studies investigating clinical outcomes in patients treated with the hybrid DCB approach for coronary bifurcation lesions. Two independent reviewers extracted data and assessed the risk of bias. The outcome of interest was the combined endpoint of cardiac death, myocardial infarction (MI) or target lesion revascularisation (TLR) at the longest available follow-up. Crude event rates, stratified by treatment strategy, were provided for the overall incidence of the primary endpoint. Furthermore, we conducted meta-analyses on the combined endpoint, comparing different bifurcation percutaneous coronary intervention (PCI) strategies. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. 13 studies, consisting of 2393 patients, were included in our systematic review. Investigated techniques were the hybrid DCB approach in all studies, and a two-stent strategy or the combination of DES in main vessel and balloon angioplasty (BA) in the side branch as potential comparators. Median follow-up duration was 12 months (IQR 7.5-12). The combined endpoint of cardiac death, MI or TLR was found in 5.6% in the hybrid DCB group, 15.4% in the two-stent group and in 10.0% in the BA group. The pooled analyses, including three and two studies, respectively, showed that the hybrid DCB approach was associated with a lower risk of the composite endpoint of cardiac death, MI or TLR when compared with a two-stent strategy (7.9% vs 15.4%; risk ratio (RR): 0.53; 95% CI 0.33 to 0.85) and compared with BA in the side branch (5.6% vs 10.0%; RR: 0.57; 95% CI 0.37 to 0.88). The certainty of the evidence was graded as very low. The results of this systematic review and meta-analysis suggest that the hybrid DCB approach is a feasible and promising treatment approach for bifurcation lesions, when compared with other bifurcation PCI strategies. However, the results should be interpreted cautiously as the certainty of evidence was graded as very low, underlining the importance of larger trials to confirm these findings. CRD420250651469.

BACKGROUNDThe de Winter (dW) pattern, sign, and syndrome is an ST-elevation myocardial infarction (STEMI) equivalent. The first two forms describe the electrocardiographic characteristics of this phenomenon, while dW syndrome additionally has symptoms indicative of acute coronary syndrome. Emerging evidence suggests that dW pattern precedes or alternates with STEMI patterns.AIMTo improve the recognition of the dW pattern, dW sign, or dW syndrome, urge early aggressive treatment, and determine whether sex matters, by integrating contemporary knowledge through a systematic scoping review and data analysis.METHODSA comprehensive search was conducted across PubMed/MEDLINE and Google Scholar (November 2008 to June 2025), and literature data were analyzed. This scoping review adhered to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews checklist.RESULTSA total of 322 patients presenting with dW pattern were identified. Most patients were young males. Risk factors were primarily smoking, hypertension, and dyslipidemia. Sixteen cardiac arrest events occurred during hospitalization. The main culprit vessel was the left anterior descending artery (LAD) at 88.5%. Compared with the younger group, older patients had more LAD (84% vs 80%) and right coronary artery involvement (4% vs 1.0%). Left main coronary artery occlusion was more prevalent in the younger group (5.0% vs 2.4%). The frequency of total or near-occlusion of LAD and left main coronary artery was similar in the two age groups. Males showed a higher rate of severe LAD stenosis than females did (45.2% vs 17.7%). dW pattern followed by STEMI was noted in 40 cases, STEMI followed by dW pattern in 8 cases, and simultaneous STEMI and dW pattern in 10 cases. The overall mortality rate was 3%.CONCLUSIONdW pattern, dW sign, and dW syndrome are commonly used interchangeably describing the dW phenomenon. Patients presenting with this phenomenon have unique demographics, risk factors, pathophysiology, and angiographic characteristics (i.e., distinct culprit lesions and coronary artery involvement). Early identification with a high index of suspicion is crucial and necessitates urgent intervention.

Design of IKISS-LM Randomized Controlled Trial

As the main blood vessel in our body, the aorta needs to be both strong and flexible. This balance comes from three main parts: elastic layers that allow the aorta to stretch, strong fibers that prevent tearing, and cells that sense and respond to changes in blood pressure and other signals. When any of these components are altered, the aorta may stiffen or weaken, which can interfere with normal blood flow. In this study, we developed a clear and consistent way to measure the structure of the aortic wall using microscope images. The approach examines how thick the elastic layers are and how far apart they lie, the size and orientation of cell centers, and how straight or wavy structural fibers appear. It also estimates how much of each component is present in the aortic wall. Because the same steps are applied each time, results can be fairly compared across different conditions. Overall, this tool transforms detailed images into simple measurements, helping scientists understand how the aorta changes in health and disease.

BackgroundThe primary mechanism underlying side branch (SB) ostial compromise following main vessel (MV) stenting is the MV carina shift. However, the association between plaque characteristics or distribution and SB compromise remains unclear in patients with left main (LM) bifurcation lesions.MethodsA total of 123 patients with LM bifurcation lesions were included in the final analysis. Preprocedural optical coherence tomography (OCT) assessment of the LM-to-left anterior descending artery (LAD) segment was performed, and patients were treated with a single-stent crossover technique. Quantitative coronary angiography was performed to evaluate LM, LAD, and proximal left circumflex artery (LCX). Left circumflex artery ostium (LCX-OS) compromise was defined as residual stenosis > 50% after MV stenting.ResultsLCX-OS compromise was observed in 33 patients in this study. Compared to the no compromise LCX-OS group, the compromise group had a higher frequency of plaque distribution in the LAD (90.9% vs. 65.6%, p < 0.001), more prominent calcified plaque characteristics (60.6% vs. 24.4%, p < 0.001), and a smaller LAD-LCX angle (81.2 ± 20.1 vs. 98.0 ± 25.7, p = 0.001). Adjusted multivariate logistic regression analysis revealed that plaques distributed in the proximal LAD (OR, 6.119; p = 0.011), calcified plaque (OR, 6.511; p = 0.001), and the LAD-LCX angle (OR, 0.966; p = 0.003) were independent predictors of LCX-OS compromise.ConclusionsPlaque in the proximal LAD, presence of calcified plaque, and a smaller LAD-LCX angle may contribute to LCX-OS compromise following MV stenting in patients with LM bifurcation lesions. OCT has emerged as a promising tool for preprocedural risk stratification in LM bifurcation percutaneous coronary intervention, helping to mitigate the risk of LCX-OS compromise.

Left main coronary trifurcations pose specific challenges for percutaneous coronary intervention due to complex anatomy and lack of standardized approaches. We assess to evaluate the stent conformations achieved by different adaptations to trifurcations of stepwise provisional stenting in a bench test. Percutaneous coronary intervention procedures were performed in silicon trifurcation models using standard equipment. After main vessel stenting and proximal optimization technique, side branch (SB) rewiring was conducted via same-cell (SAC) or neighboring-cell (NEC) under optical coherence tomography guidance. SBs dilation was then performed using either simultaneous trissing or serial kissing balloon techniques. Following repeat proximal optimization technique, stent expansion and apposition were assessed with optical coherence tomography and micro-computed tomography. All 4 technique combinations were feasible and resulted in satisfactory stent expansion and apposition. Micro-computed tomography analysis showed that trissing improved expansion at the polygon of confluence compared to serial kissing (mean 23.7 vs. 21.1 mm²; P = 0.043), while SAC rewiring yielded better expansion at the distal main vessel ostium than NEC (mean 10.3 vs. 9.6 mm²; P = 0.003). Rewiring technique determined the conformation of the stent at the level of SBs takeoff: NEC produced 2 stent fenestrations and SAC a single stent fenestration (with a minimal area significantly smaller than the sum of the 2 achieved by NEC: 16.4 mm² vs. 27.9 mm²; P = 0.019). All provisional stenting strategies tested were technically feasible for left main trifurcations. SB rewiring and ballooning technique influenced stent configuration, particularly the number and size of fenestrations, but had limited impact on overall stent expansion and apposition.