Percutaneous Coronary Intervention For Bifurcation Lesions Research Articles

Abstract 4140163: Initial Experience with Mini-Crush Versus Double Kissing Crush in Bifurcation Percutaneous Coronary Intervention: Insights from PROGRESS-BIFURCATION registry

Background: There is limited data on use of the mini-crush technique in two-stent bifurcation percutaneous coronary intervention (PCI). Methods: This retrospective, observational, cohort study was performed across 6 centers in the United States, Russia, and Turkey between 2013-2024, as part of the Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). We evaluated procedural characteristics of patients who underwent bifurcation stenting using the mini-crush technique and compared it with those who were treated with double kissing (DK) crush. Results: Of 1,138 PCIs involving 1,499 lesions, 46 (4.04%) were performed using the mini-crush technique and 147 lesions (12.91%) using the DK crush technique. Baseline characteristics of the patients were similar in both groups. There was no difference between mini-crush versus DK-crush in technical success (100.0% versus 98.6%; p=0.99), procedural success (95.1% versus 97.1%, p=0.62), procedural complications (10.9% versus 14.7%, p=0.51), or in-hospital major adverse cardiovascular events (MACE) (6.5% versus 5.7%, p=0.73). In contrast, mini-crush technique was associated with shorter procedure time (79.00 vs 116.50 minutes; p<0.001; Figure 1A), fluoroscopy time (23.50 vs 30.35 minutes, p=0.002; Figure 1A), and lower contrast volume (150 versus 109 milliliters; p<0.001; Figure 1B), and air kerma radiation dose (1.11 vs 1.71 gray; p=0.024; Figure 1C). Conclusion: In patients undergoing PCI for bifurcation lesions, the mini-crush technique had similar rates of procedural complications and in-hospital MACE as compared with the DK crush technique but required less contrast volume, fluoroscopy time, radiation dose, and procedural time.

Impact of Prolonged Dual Antiplatelet Therapy After Bifurcation Percutaneous Coronary Intervention in Patients with High Ischemic Risk.

The aim of this study was to evaluate the impact of prolonged dual antiplatelet therapy (DAPT) on clinical outcomes in patients undergoing percutaneous coronary interventions (PCI) for bifurcation coronary lesions. A total of 1000 patients who underwent PCI for coronary bifurcation lesions and had clinical follow-up were divided into two groups based on the duration of DAPT: DAPT >12 months and DAPT ≤12 months). Patients who experienced a myocardial infarction, required repeat PCI, or died within 1 year after the initial procedure were excluded. Among the 1000 eligible patients, 394 patients received DAPT for > 12 months (39.4%). Most patients in our study presented with chronic coronary disease (61%). The majority of patients in our study (62.8%) had a low bleeding risk.The median follow-up duration was 35 months (interquartile range 20.6-36.5). There were no significant differences in the major adverse cardiovascular events (MACE) between groups of prolonged DAPT (>12 month) and DAPT ≤12 months (18.8% vs. 14.9%, p = 0.11). Patients with clinical features of high ischemic risk (HIR) had a significantly increased risk of MACE (hazard ratio [HR] 1.92, 95% confidence interval [CI] 1.12-3.26, p = 0.015) when compared with patients without clinical features of HIR. Compared with DAPT ≤12 months, extended DAPT (>12 months) did not improve outcomes in patients with clinical (HR 1.24, 95% CI 0.90-1.72, p = 0.19) and technical features (HR 1.04, 95% CI 0.67-1.63, p = 0.85) of HIR. In this multicenter real-world registry, administration of DAPT for more than 12 months in patients who have undergone PCI for bifurcation lesion is not associated with a reduced incidence of MACE in long-term follow-up. ClinicalTrials.gov identifier no. NCT03450577.

Percutaneous coronary intervention involving coronary bifurcation is associated with higher mortality and complications.

Percutaneous coronary intervention (PCI) in patients with bifurcation lesions is associated with higher complexity and adverse outcomes. The goal of this study was to evaluate the inpatient outcomes of patients with PCI of bifurcation lesions. The National Inpatient Sample (NIS) database, years 2016-2020, was studied using ICD 10 codes. Patients undergoing PCI for bifurcation lesions were compared to those undergoing PCI for non-bifurcation lesions, excluding chronic total occlusion lesions. We evaluated post-procedural inpatient mortality and complications. PCI in patients with bifurcation lesions was associated with higher mortality and post-procedural complications. A weighted total of 9,795,154 patients underwent PCI; of those, 43,480 had a bifurcation lesion. The bifurcation cohort had a 3.79% mortality rate, and the rate in those with non-bifurcation lesions was 2.56% (OR, 1.50; CI: 1.34-1.68; P<0.001). Upon conducting multivariate analysis, which adjusted for age, sex, race, and significant comorbidities, PCI for bifurcation lesions remained significantly associated with a higher mortality rate compared to non-bifurcation lesion PCI (OR, 1.68; 95% CI, 1.49-1.88; P<0.001). Furthermore, PCI for bifurcation lesions was associated with higher rates of myocardial infarction (OR, 2.26; 95% CI, 1.68-3.06; P<0.001), coronary perforation (OR, 7.97; 95% CI, 6.25-10.17; P<0.001), tamponade (OR, 3.46; 95% CI, 2.49-4.82; P<0.001), and procedural bleeding (OR, 5.71; 95% CI, 4.85-6.71; P<0.001). Overall, post-procedural complications were 4 times more in patients with bifurcation lesions than in those without (OR, 4.33; 95% CI, 3.83-4.88; P<0.001). Using a large, national inpatient database, we demonstrate that both mortality rates and post-procedural complication rates were significantly higher in patients undergoing PCI for bifurcation lesions than in those undergoing PCI for non-bifurcation lesions.

Double kissing inflation outside the stent versus jailed balloon technique for coronary bifurcation lesions

Abstract Background Side branch (SB) occlusion remains challenging in percutaneous coronary intervention (PCI) for bifurcation lesions even in the era of jailed balloon technique (JBT). Our previous single-arm study introduced a novel method to protect SB named double kissing inflation outside the stent (DKo), which features twice inflation of the protective balloon kissing with the stent balloon and post-dilation balloon. Objective To confirm whether DKo can protect SB better than JBT in a large sample of bifurcation lesions. Methods This retrospective, single-center cohort study enrolled 875 consecutive patients underwent bifurcation PCI either in DKo (n=209) or JBT group (n=666). The primary endpoint was transient SB loss after removal of the protective balloon. The secondary endpoints included rates of SB rewiring, final kissing balloon inflation (FKBI), SB stenting, final SB loss, and peri-procedural myocardial infarction (PMI). Results Transient SB loss occurred in only 1 patient (0.5%) in DKo but 32 patients (4.8%) in JBT (p&amp;lt;0.005). Transient loss in JBT group was triggered by rewiring (n=21), post-dilation (n=8) and severe dissection (n=3). DKo caused lower rates of rewiring (0.5% vs. 13.8%, p&amp;lt;0.001), FKBI (0.5% vs. 7.7%, p&amp;lt;0.001) and PMI (0.5% vs. 2.9%, p=0.045). SB stenting and final SB loss showed a lower tendency in DKo [0% vs. 0.8%, p=0.21; 0% vs. 1.2%, p=0.11]. DKo was the only protector against transient SB loss [odds ratio=0.08, 95% confidence interval (0.01-0.59), p=0.013]. Conclusion DKo protects SB better than JBT in PCI for bifurcation lesions. Randomized controlled studies are required to confirm the long-term benefit.

Outcomes of drug eluting stents vs. drug eluting balloons. A single center experience

Abstract Introduction Drug eluting stents (DES) are considered the default treatment option in the current era of percutaneous coronary interventions (PCI). Nevertheless, the use of drug eluting balloons (DEB) remains highly relevant, especially in the setting of in stent restenosis (ISR), and de-novo small vessel disease or bifurcation lesions. Material and method Among 17,630 consecutive PCI procedures performed in our tertiary medical center between 2010 and 2021, we identified 16,435 procedures performed using DES and 1,195 using DEB. Endpoints included mortality and major adverse cardiac events [MACE: death, myocardial infarction (MI), target vessel revascularization (TVR), and coronary artery bypass surgery (CABG)] at 1 year. Propensity score matching was used to create a well-balanced cohort. Results and discussion: Mean age was similar (65.7±12.1 vs. 65.8±11.1, p=0.85), but less female patients (16.7% vs. 21.2%, p&amp;lt;0.01) were observed in the DEB group. DEB patients presented with higher rates of diabetes, hypertension, and prior CABG (62.1% vs. 48.1%, 84.9% vs. 73.2% and 18.3% vs. 10.1% respectively, p&amp;lt;0.01 for all), as compared to DES patients. There were also higher rates of PCI for bifurcation lesions and in-stent restenosis (18.3% vs. 15.1% and 56.0% vs. 7.8% respectively, p&amp;lt;0.01 for both) in the DEB group. After propensity and adjustment for confounders, 370 matched pairs were compared. 1-year MACE rates were significantly higher (HR-1.51, 95%CI 1.04-2.18, p=0.03) in the DEB group, as compared to the DES group. This was driven by higher MI (6.8% vs. 1.9%, p&amp;lt;0.01), TVR (20.5% vs. 11.4%, p&amp;lt;0.01) and CABG (12.2% vs. 7.3%, p=0.02) rates in the DEB group. Adjusted rates of 1-year mortality (HR-1.20, 95%CI 0.75-1.67, p=0.45) did not differ between the two groups. Conclusions Treatment with DEB was associated with increased MACE at 1-year, driven by higher rates of MI, TVR and CABG, as compared to DES.Freedom from MACE

Sex-Specific Differences in Clinical Outcomes in Patients With Coronary Bifurcation Lesions.

Coronary bifurcation lesions are frequent challenging findings during percutaneous coronary intervention (PCI). Contemporary evidence has explored the potential sex-specific differences in patients undergoing PCI. In the present meta-analysis, we compared clinical outcomes of patients undergoing bifurcation PCI between women and men. Using the random-effects method, we compared the clinical outcomes of patients with a coronary bifurcation lesion following PCI between women and men. The results were reported using relative risk (RR) and 95% confidence interval (CI). Baseline comorbidities and mean age were compared between the 2 studied groups. Four observational studies comprising 30,684 patients (8898 women and 21,786 men) were included in the meta-analysis. Women were significantly older than men with a relatively higher prevalence of baseline comorbidities. After using adjusted data from 2 out of 4 available studies, performing PCI for bifurcation lesions in women was not associated with an increased risk of mortality (RR 1.33, 95% CI, 0.78-2.29), myocardial infarction (RR 1.22, 95% CI, 0.41-3.61), target lesion revascularization (RR 1.06, 95% CI, 0.40-2.81), stent thrombosis (RR 0.99, 95% CI, 0.09-10.52), and stroke (RR 1.19, 95% CI, 0.64-2.22). Women were at higher risk of major bleeding compared to male counterparts (RR 2.23, 95% CI, 1.73-2.89). The present study showed no difference in the risk of adverse clinical outcomes except the risk of bleeding between genders with coronary bifurcation lesions. Future studies with adjustment of age and baseline comorbidities are needed to confirm these findings.

Predictors of Side Branch Obstruction Following Stenting of the Main Vessel in Coronary Bifurcation Lesions

INTRODUCTION: Percutaneous coronary intervention (PCI) of bifurcation lesions is complicated by the presence of side branch blockage, which contributes to a low procedural success rate and an elevated rate of adverse cardiac events. A shift in the position of the carina and plaque buildup have been proposed as possible causes of SB occlusion. 1,2 It is estimated that between 15-20% of PCI procedures are done to address lesions at coronary bifurcations.3-5 Multiple randomized clinical trials have concluded that an interim stenting procedure should be used for routine bifurcation stenting. 6-11 &#x0D; AIM AND OBJECTIVE: To assess the predictors of side branch obstruction following stenting of the main vessel in coronary bifurcation lesions.&#x0D; MATERIAL AND METHODS: Total 300 patients were enrolled with coronary bifurcation lesions who were undergoing PCI and had at least one major SB. Major SB definition was the same as what had been found in other studies: diameter ?2.0mm. Patients with SB stenting before MV stenting, LMS disease, or in-stent restenosis were excluded. Using quantitative coronary analysis (QCA) software, all of the baseline and procedure characteristics were analyzed. The Student's t-test was used to compare continuous data. A p-value &lt; 0.05 was considered significant.&#x0D; RESULTS: Out of 300 patients, side branch blockage was found in 23 (7.6%) of the patients. The patients were distributed into two groups based on whether they had SB occlusion (SBO) or not. Mean age (years) in the study was 50.36+12.54 in SBO group and 50+30.34 in no-side-branch occlusion (NSBO) group. There were 19(82%) male and 4(18%) female patients in SBO group and 215(77%)male and 62(23%) female in NSBO group. Diameter stenosis of side branch before MV stenting (55%+20 vs30+25%), side branch diameter (2.1+0.3 vs2.2+0.2), bifurcation angle (70+20degree vs 45+22 degree, p=&lt;0.01) and lower TIMI flow in side branch were found significant predictors of major side branch occlusion.&#x0D; CONCLUSION: The bifurcation angle, diameter stenosis of the SB, side branch diameter before to main vessel stenting, and TIMI flow grade of the SB prior to MV stenting were all predictive of severe SB occlusion following MV stenting. As a result, these criteria should be considered when designing PCI for bifurcation lesions in order to increase procedure success.&#x0D; KEYWORDS: Side branch obstruction, stenting, coronary bifurcation lesions.

Percutaneous Coronary Intervention of Bifurcation Lesion

Bifurcation lesion whether it is left main (LM) stem disease with left main to left anterior descending artery (LM-LAD) or left main to left circumflex (LM-LCX), LAD-Diagonal or LCX-Obtuse marginal or right coronary artery- posterior descending artery (RCA-PDA); are not uncommon lesion type that needs to be revascularized either by percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) to establish the coronary flow and relieved patient anginal symptoms. Even though, many of the literature maintained non-inferiority of bifurcation lesion PCI over CABG and is Class IIb indication for PCI by coronary stent. In literature, bifurcation lesions commonly encountered in PCI and are regarded as most technically challenging lesions to treat, in up to 20% of PCI cases. With the advent of interventional procedures and the availability of cardiac catheterization laboratory facilities, skilled interventionist, many of the Bangladeshi patients are being treated for coronary artery diseases (CAD). With the advent of drug eluting stents, availability of IVUS (Intravascular Ultrasound), FFR (Fractional Flow Reserve) and individual expertise, treating bifurcation lesion may not be difficult task. Interventionist must be expert enough in doing PCI, before to proceed for bifurcation lesion PCI. We need to work together to develop common consensus in developing updated skill in treating bifurcation lesion which will prove bifurcation PCI in our population. Cardiovasc j 2022; 14(2): 168-175

Impact of directional coronary atherectomy followed by drug-coated balloon strategy to avoid the complex stenting for bifurcation lesions.

Although the simple single stenting rather than complex double stenting is recommended on percutaneous coronary intervention (PCI) for bifurcation lesions, double stenting cannot always be avoided. We investigated the impact of directional coronary atherectomy (DCA), followed by drug-coated balloon (DCB) treatment to reduce the number of stents and avoid complex stenting in PCI for bifurcation lesions and short-term patency. DCA treatment without stents was attempted for 27 bifurcation lesions in 25 patients, of those, 26 bifurcation lesions in 24 patients were successfully treated and 3-month follow-up angiography and optical coherence tomography (OCT) were performed. Sixteen lesions (59.3%) were related to left main trunk distal bifurcations, and 7 (25.9%) were true bifurcation lesions. Among the true bifurcation lesions, 4 lesions (57.1%) needed 1 stent, and the other 3 lesions (42.9%) needed no stents. Among the non-true bifurcation lesions, 1 lesion (5.0%) needed bailout stent and other lesions (95.0%) needed no stents. According to DCA followed by DCB treatment, the angiographic mean diameter stenosis improved from 65.5 ± 15.0% to 7.8 ± 9.8%, and the mean plaque area in intravascular ultrasound improved from 80.4 ± 10.5% to 39.0 ± 11.5%, respectively. Angiographic and OCT late lumen loss values were 0.2 ± 0.6mm and 1.4 ± 1.9mm, respectively. No patient had in-hospital major adverse cardiac events (MACE) and 3-month MACE. In conclusion, compared with standard provisional side branch stenting strategy, DCA followed by DCB treatment might reduce the number of stents, avoid complex stenting for major bifurcation lesions and provide good short-term outcomes.

Research Progress of Percutaneous Interventional Therapy For Bifurcation Lesions of Coronary Heart Disease

Compared with non-bifurcation lesions, even if the new generation of percutaneous coronary intervention (PCI) technology is used to treat coronary bifurcation lesions, the incidence of adverse cardiovascular events is still higher. The evaluation of related clinical data and computer virtual modeling before surgery can guide the implementation of bifurcation PCI in a more precise manner. The new understanding of bifurcation PCI may further improve the clinical prognosis and outcome of patients with bifurcation disease. This review aims to summarize the assessment methods of PCI for coronary heart disease non-left main bifurcation disease and the treatment plan supported by clinical evidence. The treatment plan depends on three parameters: the diameter of the three parts of the bifurcation lesion; the length of the lesion and plaque distribution; and the angle of the bifurcation. To this day, the best technique for PCI for bifurcation lesions is still controversial, and a personalized approach using temporary collateral stent implantation schemes seems to be suitable for 75% to 95% of patients. For more complex bifurcation lesions, it may be necessary to use two stents at the same time. More and more evidence supports the practicability of the DK-crush technique.

Baseline troponin-T is powerful predictor of mortality after coronary bifurcation stenting

Abstract Introduction Considerable progress has been made in the treatment of coronary bifurcation stenosis. Anatomical characteristics of the lesion, however, fail to give information about the functional significance of the bifurcation stenosis. There is no study that systematically establishes the baseline functional significance of coronary stenosis and its effect on procedural and clinical outcomes. Methods Patients with significant angiographically bifurcation lesions defined as diameter stenosis &amp;gt;50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). If FFR was ≤0.80 the lesion was considered functionally significant, and patients underwent PCI. For the group with FFR &amp;gt;0.80 – intervention was deferred. All patients were followed-up for vital status every 3 months. Cox regression analysis was performed to identify independent predictors of all-cause and cardiovascular death. The local ethics committee approved the study and patients signed informed consent for participation into registry. Results For mean follow-up of 38±18 months (median 40, IQR 23–55 months) all-cause mortality was numerically lower: 8.5% (n=7/82) in deferred group and 12.6% in stented group (n=11/76, p=0.387). The cardiac mortality was also numerically lower, but statistically not significant (9.8%, n=8/82 vs. 11.5%, n=10/88, p=0.714). On multivariate model, independent predictors were mitral regurgitation &amp;gt;1st degree – HR=1.778 (CI 1.100–2.874, p=0.019); dyslipidemia HR=0.765 (CI 0.594–0.985, p=0.038); hemoglobin concentration – HR=0.976 (CI 0.964–0.988, p&amp;lt;0.001); pre-PCI serum troponin ≥0.010 ng/ml – HR=2.702 (CI 1.451–5.032, p=0.002). On multivariate analysis, the following factors were identified as independent predictors of cardiac mortality: age – HR=1.035 (CI 1.009–1.062, p=0.009); diabetes – HR=1.789 (CI 1.089–2.962, p=0.024); dyslipidemia treated with statin – HR=0.667 (CI 0.515–0.863, p=0.002); LV posterior wall thickness – HR=1.230 (CI 1.062–1.424, p=0.006); mitral regurgitation more than 1st degree – HR=1.763 (CI 1.065–2.917, p=0.027); troponin pre-PCI ≥0.010 ng/ml – HR=2.498 (CI 1.228–5.081, p=0.011); true bifurcation lesion – HR=1.820 (CI 1.026–3.229, p=0.040); SBBARI score &amp;lt;10% – HR=1.715 (CI 1.049–2.804, p-0.031). Conclusion Baseline high-sensitive troponin T value is a strong predictor for both all cause and cardiac mortality in patients undergoing coronary bifurcation lesion PCI. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Alexandrovska University Hospital

Feasibility and Safety of the Left Distal Radial Approach in Percutaneous Coronary Intervention for Bifurcation Lesions.

Recently, the left distal radial approach (DRA) for percutaneous coronary intervention (PCI) has been shown to be a feasible option, but there are limited data regarding the feasibility of performing bifurcation PCI via the left DRA. Therefore, this study aimed to describe our experience with the contemporary left DRA to perform PCI of bifurcation lesions. Between December 2017 and December 2019, we identified 106 patients treated with bifurcation PCI via the left DRA. We evaluated the success rate of PCI, access-site complications including major bleeding requiring surgery or transfusion, hematoma, distal and forearm radial artery occlusion, and 30-day mortality. Eleven patients (10.4%) treated with left main bifurcation and true bifurcations accounted for 39.6% of cases, with the left anterior descending artery/diagonal branch being the most frequent bifurcation site (57.5%, 61/106). PCI was performed using a 6-French guiding catheter in 101 (95.3%) cases. Successful PCI for bifurcation lesions via the left DRA was achieved in all 106 patients without access-site cross-over. There was no major bleeding, distal and forearm radial artery occlusion, forearm hematoma, or mortality at 30 days. The left DRA is a safe and feasible alternative access site for bifurcation PCI in selected patients.

Impact of sex on outcomes of bifurcation lesion percutaneous coronary intervention: results from a single-centre prospective registry.

Coronary bifurcation lesions are technically and clinically more challenging compared to nonbifurcation lesions. Sex-related differences in diagnostic and invasive therapeutic coronary procedures have been described in the literature. Our objective was to assess the impact of sex on outcomes of bifurcation lesion percutaneous coronary intervention (PCI). Our data were taken from a prospective registry of consecutive patients undergoing PCI for bifurcation lesions at our medical centre between 2004 and 2019. We compared rates of death and major adverse cardiac events (MACE) between men and women at 1 year and 3 years. MACE comprised cardiac death, myocardial infarction, target vessel revascularization or stroke. A total of 1209 patients were included, 948 (78.4%) were male and 261 (21.6%) were female. Women were older (mean age 69.7 ± 11 years vs. 63.1 ± 11 years, P < 0.01), and had more comorbidities than men. Female patients had more angiographically calcified (38.1% vs. 30.1%, P = 0.017) lesions. At 1-year follow up, there was no significant difference of MACE (18.8 vs. 15.2%, P = 0.183) or all-cause mortality (5.7% vs. 3.9%, P = 0.242) between sexes. At 3-year follow up, there was a significantly higher rate of MACE in women (29.1% vs. 22.5%, P = 0.026), this was driven by a significantly higher all-cause mortality (13.8% vs. 6.5%, P < 0.01). Women undergoing bifurcation PCI are older and have more comorbidities than their male counterparts. Intermediate term follow-up outcomes are similar between sexes. Poorer long-term outcomes of women are likely due to baseline higher risk profile.

Pericardial Tamponade Caused by Rotational Atherectomy Ablation Grinding Through a Barrier Stent Protruding From the Diagonal Artery: A Case Report

Rotational atherectomy (RA) has been described in case reports to be effective in ablating under-expanded stents. We present a case of calcified bifurcation lesion percutaneous coronary intervention (PCI), in which the branch stent protruding into main branch blocked the balloon getting through, and the following RA led to pericardial tamponade. The first stent was deployed from the proximal of left anterior descending artery (LAD) to the proximal of diagonal for an 80-year-old man who suffered from non-ST-elevation myocardial infarction to make a Culotte dual stent PCI. The operator failed to make balloon get through the struts protruding into LAD lumen anyway. After RA drill through the LAD lumen, it showed an excellent angiographic outcome. Stent deployment in LAD was successful, but pericardial tamponade occurred in a short time. After pericardiocentesis was performed under fluoroscopic guidance, the patient was uneventful. After 1 year, the follow-up coronary computed tomography (CT) angiography showed no in-stent restenosis, stent fracture or disrupted struts protruding outside of the vessel’s outline of LAD and the first diagonal (D1). This case shows stents’ RA could be dangerous in grinding across the stents’ lateral hole in an unsymmetrical lumen. Although RA could be a useful remedy in the situation of under-expansion of implanted stents, the debulking should be performed for longitudinal stent ablation and cautiously performed for bifurcation lesion in which the protruding stents from side branch were unsymmetrically blocking the path. J Med Cases. 2021;12(6):230-232 doi: https://doi.org/10.14740/jmc3678

Abstract 13499: Percutaneous Coronary Intervention for Bifurcation Lesions in Patients With Acute Coronary Syndrome

Introduction: Percutaneous coronary intervention (PCI) for the treatment of bifurcation lesions in acute coronary syndrome (ACS) setting is a high-risk procedure and is associated with higher periprocedural complications and a lower procedural success rate. Hypothesis: We assessed the hypothesis that PCI for bifurcation stenting in ACS is safe and effective as in non ACS condition. Methods: Out of 986 patients who underwent PCI for ACS, 144 (14.6%) patients having bifurcation lesion were included in study. Provisional stenting was favored whenever feasible (86.8%), elective bifurcation stenting (2 stent strategy) was reserved for significant long segment side branch involvement (13.2%). Occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis, was observed during follow up. Results: LAD bifurcation was the most common lesion (49.3%), most common Medina class was 1, 1, 1 (52.1%), 70.8% of the procedures were done transradially, angiographic success rate for main vessel was 97.9% and there was no periprocedural mortality or stroke. There was no significant difference regarding risk factors (age, hypertension, diabetes mellitus, dyslipidemia and smoking history; p &gt; 0.05) between 1 stent and 2-stent groups. Median Syntax score was 14(IQR 10-20) in 1 stent group and 22(IQR 17-25) in 2 stent group. The 2-stent group had higher proportion of left main coronary involvement as compared to 1 stent group (47.4 vs 24.8%). Crush was preferred elective 2-stent strategy as compared to TAP in provisional approach (used in 73.7 and 62.5%). Final kissing balloon inflation was used in 38.4% patients in 1- stent group, while it was utilised in all patients with 2- stent approach. Post procedural side branch diameter stenosis (by QCA) differed significantly between the 2 groups (1-stent vs 2-stent, 34.9 vs 6.4%).The rate of MACE was similar in both groups ( total 7 MACE events; median follow-up of 18 months) but radiation dose and contrast volume utilization were significantly more in 2-stent group. Conclusions: PCI for bifurcation lesions had acceptable success and MACE rate even during ACS settings and whenever feasible, provisional stenting should be preferred approach.

Methods for endovascular treatment of bifurcation lesions of coronary arteries: commonly used techniques

In everyday operating practice, the endovascular surgeon often encounters complex lesions of the coronary arteries, in particular bifurcation lesions. Percutaneous coronary interventions (PCI) is technically difficult in these cases and has always been associated with lower procedural success rates and poorer clinical outcomes than non-bifurcation lesions. The introduction of antiproliferative coated stents into clinical practice significantly improved the results and gave impetus to the development of various treatment techniques. The provisional technique for implanting one stent into the main branch remains the approach of choice for most bifurcation lesions. The choice of the most effective technique for each individual bifurcation is important. The use of a two-stent technique is an acceptable approach for some forms of bifurcation lesions. However, a large amount of metal in the artery wall, as a rule, remains uncovered in the lumen of the vessel during this tactic, which is especially true for the risk of stent thrombosis. New techniques and special bifurcation stents may possibly overcome some limitations of the using two stents and revolutionize the management of PCI of bifurcation lesions of the coronary arteries in the future.

Angioplastie des lésions coronaires de bifurcation en 2019 : questions brûlantes ?

Coronary bifurcations are involved in 15–20% of all percutaneous coronary interventions (PCI) and remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate as well as long-term cardiac events. The optimal management of bifurcation lesions is still debated but involves careful assessment, planning and a sequential provisional approach. The preferential strategy for PCI of bifurcation lesions remains to use main vessel (MV) stenting with a proximal optimisation technique (POT) and provisional side branch (SB) stenting as a preferred approach. Final kissing balloon inflation is not recommended in all cases. In the minority of lesions where two stents are required, careful deployment and optimal expansion are essential to achieve a long-term result. Intracoronary imaging techniques (IVUS, OCT) and FFR are useful endovascular tools to achieve optimal results.

Prognostic significance of the Medina classification in bifurcation lesion percutaneous coronary intervention with second-generation drug-eluting stents.

The Medina classification is the most widespread method to describe bifurcation lesions. However, little is known regarding its prognostic impact. Therefore, the aim of this study is to assess the prognostic significance of the Medina classification following percutaneous coronary intervention (PCI). From a prospective registry of 738 consecutive patients undergoing PCI for bifurcation lesions, 505 were treated with second-generation drug-eluting stents (DES). Of these, 407 (80.6%) presented with "true bifurcation" (TB) lesions (Medina class 1.0.1, 1.1.1, 0.1.1) and 98 (19.4%) in all other categories ("non-true bifurcation" = NTB). We compared rates of death and major adverse cardiac events (MACE: cardiac death, myocardial infarction, or target vessel revascularization) at 12months and 3years. Patients with TB had lower rates of previous bypass surgery (7.4% vs. 11.2%, p = 0.043). TB lesions were more likely to be calcified (33.9% vs. 28.6%, p = 0.003) and ulcerated (8.8% vs. 4.1%, p < 0.01). At 12months, mortality was numerically higher for TB PCI (4.1% vs. 2.1%, p = 0.052) and MACE rates were higher (19.2% vs. 10.2%, p < 0.001). At 3years, both all-cause death (10.1% vs. 5.1%, p = 0.002) and rates of MACE (37.2% vs. 17.6%, p < 0.001) were higher for TB PCI. After performing regression analysis, TB remained an independent predictor for poor outcomes (OR-2.28 at 12months, CI 1.45-9.50, p = 0.007, OR-3.75 at 3years, CI 1.52-6.77, p = 0.001 for MACE). In conclusion, TB lesions, according to the Medina classification, portend worse prognosis for patients undergoing bifurcation PCI. This may guide prognostication and decision-making in treatment.

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

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

Balloon-stent kissing technique versus jailed wire technique for interventional treatment of coronary bifurcation lesions: Comparison of short- and long-term clinical outcomes.

Side-branch occlusion is a serious complication of provisional one-stent strategies used to treat coronary bifurcation lesions. The aim of the study was to compare the short- and long-term clinical outcomes between the balloon-stent kissing technique (BSKT) and jailed wire technique (JWT) in patients with non-left coronary bifurcation lesions.This prospective, double-blinded, randomized controlled study enrolled 89 consecutive patients (aged 18–85 years) with 90 true bifurcation lesions (hemadostenosis ≥70%; bifurcation angle <90°; Medina classification 1.1.1, 1.0.1, or 0.1.1) who underwent percutaneous coronary intervention (PCI) at the Zhongshan Hospital Affiliated to Dalian University (China) between January 2013 and May 2016. The patients were randomly divided into the BSKT (44 patients, 45 lesions) and JWT (45 patients, 45 lesions) groups. The intervention was conducted according to technical requirements using a single-stent strategy. Operative success rate, occurrence of complications, postoperative quantitative coronary angiography, and incidence of perioperative and long-term major adverse cardiovascular events (MACEs) were compared between groups.The intervention success rate was 100% in both groups. After main-branch stenting, the BSKT was associated with significantly lower rates of side-branch occlusion (0% vs 15.6%, P < .05) and side-branch post-processing (8.9% vs 26.7%, P < .05) than the JWT. The BSKT was associated with significantly lower degrees of postoperative proximal main-branch residual stenosis (6.1 ± 5.1% vs 9.6 ± 8.6%, P < .05) and side-branch ostial stenosis (51.6 ± 20.6% vs 70.3 ± 20.8%, P < .05) than the JWT. The incidence of perioperative MACEs was significantly lower in the BSKT group than in the JWT group (0% vs 13.3%, P < .05). Patients were followed for a mean duration of 19.0 ± 6.1 months. The occurrence rates of long-term MACEs, angina of Canadian Cardiovascular Society grade ≥2, and severe heart failure were not significantly different between groups.The BSKT is a safe and effective technique that may have advantages over the JWT with regard to protection of the side-branch during PCI for bifurcation lesions.