Side Branch Occlusion Research Articles

Pipeline Diameter Significantly Impacts the Long-Term Fate of Jailed Side Branches during Treatment of Intracranial Aneurysms.

Although covered side branches typically remain patent acutely following Pipeline Embolization Device embolization of intracranial aneurysms, the long-term fate of these vessels remains uncertain. We therefore elected to investigate factors that may influence the long-term patency of these covered side branches. We retrospectively evaluated the long-term patency of side branches covered by the Pipeline Embolization Device at our institution during treatment of intracranial aneurysms with at least 6 months of conventional angiography follow-up. Procedural and anatomic factors that might influence the fate of covered side branches were explored. One hundred forty-eight Pipeline Embolization Device treatments in 137 patients met the inclusion criteria. In 217 covered side branches, 29 (13.4%) were occluded on follow-up, and 40 (18.4%) were stenotic. All stenoses and occlusions were asymptomatic. In the entire cohort and in the largest subset of ophthalmic arteries, a smaller Pipeline Embolization Device diameter was associated with branch vessel occlusion (P = .001, P = .013). When we considered stenotic and occluded side branches together, smaller Pipeline Embolization Device size (P = .029) and administration of intraprocedural abciximab (P = .03) predicted side branch stenosis/occlusion, while anterior choroidal branch type (P = .003) was a predictor of gross side branch patency. A smaller Pipeline Embolization Device diameter is associated with delayed side branch stenosis/occlusion following Pipeline Embolization Device treatment, likely due to the higher metal density of smaller caliber devices. Although hemodynamic factors, including the potential for collateral flow, are still paramount in determining the fate of covered side branches, the amount of metal coverage at the side branch orifice also plays an important role.

Assessment of Predictors of Side Branch Occlusion after Main Vessel Stenting in Coronary Bifurcation Lesions in Patients Undergoing Percutaneous Coronary Intervention.

To determine the frequency of side branch (SB) occlusion during percutaneous coronary intervention (PCI) with stenting of bifurcation lesions and to assess the predictors of side branch occlusion in local population. Cross-sectional study. Cardiac Catheterization Lab, Rawalpindi Institute of Cardiology, Rawalpindi, from July 2016 to January 2017. A total of 200 patients fulfilling the inclusion criteria were included in the study with non-probability consecutive sampling technique. Variables like diameters and lesion lengths of main vessel and side branch were recorded using quantitative coronary analysis software (QCA). The SB occlusion was defined as <3 TIMI score following main vessel PCI with stenting. The data was analysed using SPSS version 21.0. Mean age (years) of the study population was 52.27 ±13.33 including 180 (90.0%) male and 20 (10.0%) female patients. SB occlusion was observed in 15 (7.5%) of cases. Mean SB diameter was significantly larger in cases without SB occlusion than those with SB occlusion (2.06 ±0.09 vs. 2.17 ±0.26, p=0.003). Similarly, SB lesions were significantly shorter in length in those without SB occlusion than those with SB occlusion (3.53 ±0.51 and 4.66 ±3.11, p<0.001). However, mean MV diameter (mm) and mean MV lesions length (mm) in both the groups were statistically not significant. Mean SB diameter and lesion length are useful predictors of SB occlusion during stenting of bifurcation lesions in the local population.

TCT-217 Stenting of Coronary Bifurcation Lesions with Bioresorbable Everolimus-Eluting Scaffolds- longterm outcome from Poznan Bifurcation-Absorb Registry

The data concerning the use of bioresorbable vascular scaffolds(BRS) in coronary bifurcation lesions are limited. Given the complexity of the procedure and the potential risk of side branch (SB) complications or occlusion after BRS implantation, it is imperative to evaluate the efficacy and long-

Prevalence and Outcomes of Percutaneous Coronary Interventions for Ostial Chronic Total Occlusions: Insights From a Multicenter Chronic Total Occlusion Registry

BackgroundOstial chronic total occlusions (CTOs) can be challenging to recanalize. MethodsWe sought to examine the prevalence, angiographic presentation, and procedural outcomes of ostial (side-branch ostial and aorto-ostial) CTOs among 1000 CTO percutaneous coronary interventions (PCIs) performed in 971 patients between 2015 and 2017 at 14 centres in the US, Europe, and Russia. ResultsOstial CTOs represented 16.9% of all CTO PCIs: 9.6% were aorto-ostial, and 7.3% were side-branch ostial occlusions. Compared with nonostial CTOs, ostial CTOs were longer (44 ± 33 vs 29 ± 19 mm, P < 0.001) and more likely to have proximal-cap ambiguity (55% vs 33%, P < 0.001), moderate/severe calcification (67% vs 45%, P < 0.001), a diffusely diseased distal vessel (41% vs 26%, P < 0.001), interventional collaterals (64% vs 53%, P = 0.012), and previous coronary artery bypass graft surgery (CABG) (51% vs 27%, P < 0.001). The retrograde approach was used more often in ostial CTOs (54% vs 29%, P < 0.001) and was more often the final successful crossing strategy (30% vs 18%, P = 0.003). Technical (81% vs 84%, P = 0.280), and procedural (77% vs 83%, P = 0.112) success rates and the incidence of in-hospital major complication were similar (4.8% vs 2.2%, P = 0.108), yet in-hospital mortality (3.0% vs 0.5%, P = 0.010) and stroke (1.2% vs 0.0%, P = 0.030) were higher in the ostial CTO PCI group. In multivariable analysis, ostial CTO location was not independently associated with higher risk for in-hospital major complications (adjusted odds ratio 1.27, 95% confidence intervals 0.37 to 4.51, P = 0.694). ConclusionsOstial CTOs can be recanalized with similar rates of success as nonostial CTOs but are more complex, more likely to require retrograde crossing and may be associated with numerically higher risk for major in-hospital complications.

Balloon embedded bifurcation stenting with single stent for side branch protection – Preliminary results from an Indian population

BackgroundIntervention for bifurcation lesions is associated with increased risk of adverse events and includes acute side branch (SB) occlusion during main branch (MB) stenting. This acute occlusion of side branch can often be catastrophic for the patient. We here in describe our experience in Indian population with a technique which can be incorporated into bifurcation stenting to reduce or almost eliminate the incidence of side branch occlusion. Method and results70 patients with bifurcation lesion were included in the study and underwent a balloon embedded bifurcation stenting with a semi inflated balloon placed across the SB ostium. Angiographic and procedural success were achieved in all the patients. TIMI 3 flow was achieved in both the MB and SB in all cases and there was no incidence of dissection or acute occlusion of SB. Mean fluoroscopy time and contrast volume was similar to that of conventional bifurcation stenting. ConclusionThe present study suggests that balloon embedded bifurcation stenting with a semi inflated balloon to protect the SB is feasible, not associated with procedural adverse events and successful in minimising or almost eliminating the incidence of acute side branch occlusion.

Aorto-renal Bifurcation Stenting in a Juvenile Non-specific Aorto-Arteritis: case report

Takayasu Arteritis (TA) is a granulomatous inflammation of unknown aetiology affecting the aorta and its major branches with usual affliction among patients younger than 50 years and rarely among children. We present a 7-years old boy referred for evaluation of hypertension. He had a significant blood pressure difference between right arm, left arm and lower limbs. Computed tomography imaging of thorax and abdomen showed stenosis of left subclavian artery, left renal artery and juxtareanl aorta which was subsequently confirmed on aortogram. He underwent percutaneous endovascular therapy with aorto-renal bifurcation stenting with reduction of blood pressure and gradient. Renal angioplasty with stenting remains a challenging procedure in patients with tight ostial lesion, and juxtarenal aortic involvement in lieu of precise stent placement and avoiding side branch occlusion.

Aorto-renal bifurcation stenting in a juvenile non-specific aorto-arteritis: case report

Takayasu Arteritis (TA) is a granulomatous inflammation of unknown aetiology affecting the aorta and its major branches with usual affliction among patients younger than 50 years and rarely among children. We present a 7-years old boy referred for evaluation of hypertension. He had a significant blood pressure difference between right arm, left arm and lower limbs. Computed tomography imaging of thorax and abdomen showed stenosis of left subclavian artery, left renal artery and juxtarenal aorta which was subsequently confirmed on aortogram. He underwent percutaneous endovascular therapy with aorto-renal bifurcation stenting with reduction of blood pressure and gradient. Renal angioplasty with stenting remains a challenging procedure in patients with tight ostial lesion, and juxtarenal aortic involvement in lieu of precise stent placement and avoiding side branch occlusion.

TCTAP A-134 Clinical and Anatomical Predictors of Side Branch Problems in True Bifurcation Lesions Treated by Provisional Strategy

One of the most common approach to manage coronary bifurcated-lesions (CBL) is the provisional stenting. Main drawbacks of provisional is the risk of side branch (SB) occlusion causing ischemia and technical troubles. ![Figure][1] The main aim of the study was to elaborate the important

Prewire channel stent: a novel stent for bifurcation lesions in a pig model

Avoiding side branch occlusion is challenging when treating bifurcation lesions. A newly designed stent system called the prewire channel stent (PWCS) with a side channel positioned between the metallic mesh material and the balloon is introduced. We aimed to compare the time taken to position the PWCS against that for a conventional stent. The PWCS and a conventional stent were used in a pig model. The time taken from the starting point with the stent outside the body to reaching the bifurcation of the vessel ready for further procedures such as balloon dilatation through the stent mesh opening and double kissing balloon technique, etc., was compared in the conventional stent and PWCS groups. The time taken in the PWCS stent group included the time from sending the stent from outside the body to the desired position of the bifurcation of the vessels of the heart, releasing the stent and pulling back the balloon (SB time). The time taken in the conventional stent included the time from sending the stent from outside the body to the desired position of the bifurcation of the vessels of the heart, releasing the stent, pulling back the balloon (SB time), and wire exchange (WE time). The SB times for the PWCS and the conventional stent groups were not different (28.5±3.8 vs. 25.25±0.75 seconds, n=4). The PWCS group did not have "wire exchange," and had no WE time, which was 28.5±5.7 seconds in the conventional stent group. The total time spent in the PWCS group was 28.5±3.8 seconds, which was shorter than the 53.75±6.2 seconds (n=4, p<0.05) in the conventional stent group. The PWCS makes "wire exchange" in the side branch (SB) unnecessary and it can be as easily manipulated as a conventional stent.

Validation of the V-RESOLVE (Visual Estimation for Risk prEdiction of Side Branch OccLusion in Coronary Bifurcation interVEntion) score system.

This study sought to validate the V-RESOLVE score system. The V-RESOLVE score was developed to predict the risk of side branch (SB) occlusion after stenting in the main vessel (MV) of coronary bifurcation lesions based on visual estimation of the angiographic data, but it needed to be validated. From January to June 2013, 1,286 patients with 1,820 bifurcation lesions undergoing elective intervention with provisional strategy were included. Angiographic data before MV stenting were reviewed, and the V-RESOLVE score was calculated. SB occlusion was defined as any decrease in thrombolysis in myocardial infarction (TIMI) flow grade or the absence of flow in the SB after MV stenting. The statistical performance of the prediction model was assessed by its discrimination, calibration, and clinical usefulness. SB occlusion occurred in 222 (12.20%) of 1,820 bifurcation lesions. The discrimination of the V-RESOLVE score for the validation cohort was good [C-statistic: 0.80, 95% confidence interval (CI) 0.77-0.84]. Regarding calibration performance, the calibration-in-the-large was -0.03 (95% CI: -0.181 to 0.12), while the combined predictive effect was slightly enlarged (calibration slope: 1.25, 95% CI: 1.081-1.41) and, mainly attributed to the stronger predictive effect of the diameter stenosis of the SB before MV stenting. Stratified by the V-RESOLVE score, the SB occlusion rate was significantly higher in the high-risk group (26.18%) than in the non-high-risk group (3.48%). The V-RESOLVE score system is a useful tool to help risk prediction for SB occlusion and decision-making in bifurcation intervention.

Prevention of minor myocardial injury after elective percutaneous coronary intervention: comparison of ticagrelor versus clopidogrel

Background: Elective percutaneous coronary intervention (ePCI) may cause minor elevation of cardiac enzymes, so-called minor myocardial injury (MMI) which can be due to different pathophysiological mechanism (e.g. distal embolisation, side branch occlusion, increased platelet activation triggered by the intracoronary metallic stents). We aimed to compare the effectiveness of ticagrelor versus clopidogrel for the prevention of MMI and major adverse clinical events (MACEs) after ePCI.Methods: Study population consisted of two groups of patients based on the treatment: Group I, receiving clopidogrel (n = 104), Group II, receiving ticagrelor (n = 96). Cardiac troponin I (cTnI), CK-MB were studied before and 12 hours after the procedure. Elevation of cTnI greater than 0.06 ng/ml was considered as MMI. All patients were also evaluated for the MACEs (death, myocardial infarction, stroke and transient ischaemic attack).Results: Fifty-two of 200 patients (26%) had MMI after the procedure. The minor myocardial injury was significantly more prevalent in clopidogrel group than that of ticagrelor group (33% vs. 19%, p = .03). Myocardial infarction (MI) and MACEs were significantly higher in the clopidogrel group (15% vs. 6%, for MI, p = .04; 16% vs. 6%, for MACEs, p = .03, respectively). Multivariate analysis demonstrated antiplatelet treatment, saphenous graft intervention, type-C lesion as independent predictors of MMI.Conclusions: Present study showed that the combination of ticagrelor and aspirin was more effective than combination of clopidogrel and aspirin in decreasing MMI and MACEs after elective stenting.

Treatment with 48-mm everolimus-eluting stents : Procedural safety and 12-month patient outcome.

Lesion length is amajor predictor of adverse outcomes after percutaneous coronary intervention. Long lesions often require multiple stents with variable overlap, which increases the probability of geographical miss and the incidence of mechanical complications, such as side-branch occlusion, restenosis, and stent thrombosis. These pitfalls may be avoided by use of an ultra-long device. We retrospectively assessed the performance of the 48-mm Xience Xpedition everolimus-eluting stent (EES) at our institution. Atotal of 123 patients (mean age: 60.94years, n= 93 [76%] male) with 129 lesions were identified. Lesions (n= 69, 53.5%) were located in the left anterior descending artery, the right coronary artery (n= 47, 36.4%), and the circumflex artery (n= 8, 6.2%); 83 lesions involved amajor side branch. The majority were treated with aprovisional single-stent strategy. Other characteristics included significant tortuosity in 15lesions (11.6%) and moderate-to-heavy calcification in 46lesions (35.7%). In all cases, balloon pre-dilatation was performed before stent insertion. Successful delivery and deployment of the 48-mm EES device was achieved in 100% of the patients. The mean number of stents per lesion was 1.4, while the mean total stent length was 58± 17.3 mm and mean stent diameter, 3.00± 0.67 mm. The procedural success rate was 99.2%. The 30-day major cardiac adverse event (MACE) rate was 0.8%, while the 12-month MACE was 3.3%. The Xience 48-mm EES device appears to be safe and efficacious with alow clinical event rate at the 12-month follow-up. Where feasible, this would support the use of the ultra-long 48-mm platform in lieu of multiple overlapping shorter devices.

Side Branch Occlusion Determinants in Bifurcation Lesions Treated with Provisional Stenting Technique

It is well known that because of turbulence flow and shear stress, bifurcation sites of coronary arteries are vulnerable to atherosclerotic disease. Bifurcation lesions comprise 15% to 20% of all coronary lesions. Bifurcation lesions are treated by either using provisional or double stent technique. The main drawback of provisional stenting is side branch occlusion. We aimed to investigate the predictors of side branch occlusion in provisional stenting technique. We enrolled 803 patients (231 female, 572 male, average age 60.5 ± 12.0) whose bifurcation coronary lesions treated by provisional stenting in Adana Numune Education and Training Centre. Demographic, angiographic and interventional data’s are recorded. 182 patients (22.7%) admitted to hospital with stable angina and 621 (77.3%) with acute coronary syndrome (or unstable angina). 582 (72.5%) patients had left anterior descending artery, 166 (20.7%), circumflex and 55 (6.8%) right coronary artery as the culprit vessel. Side branch occlusion occurred in 52 patients (6.5%). Need for side branch intervention occurred in 160 patients. The predictors of need for side branch intervention were, multivessel disease, type of main branch stent, oversize of stent, presence of side branch disease before intervention, TIMI frame count (TFC) and the alpha angle. In conclusion multivessel disease, type of main branch stent, oversize of stent, presence of side branch disease before intervention, TIMI frame count (TFC) and the alpha angle were independent predictors of need for side branch intervention.

Effect of Side Branch Predilation in Coronary Bifurcation Stenting With the Provisional Approach - Results From the COBIS (Coronary Bifurcation Stenting) II Registry.

Whether side branch (SB) predilation before main vessel (MV) stenting is beneficial is uncertain, so we investigated the effects of SB predilation on procedural and long-term outcomes in coronary bifurcation lesions treated using the provisional approach.Methods and Results:A total of 1,083 patients with true bifurcation lesions undergoing percutaneous coronary intervention were evaluated. The primary outcome was a major adverse cardiovascular event (MACE): cardiac death, myocardial infarction, or target lesion revascularization. SB predilation was performed in 437 (40.4%) patients. Abrupt (10.5% vs. 11.3%; P=0.76) or final SB occlusion (2.7% vs. 3.9%; P=0.41) showed no differences between the predilation and non-predilation groups. The rates of angiographic success (69.1% vs. 52.9%, P<0.001) and SB stent implantation (69.1% vs. 52.9%, P<0.001) were significantly higher in the predilation group. During a median follow-up of 36 months, we found no significant difference between the groups in the rate of MACE (9.4% vs. 11.5%; P=0.67) in a propensity score-matched population. In subgroup analysis, patients with minimal luminal diameter of the parent vessel ≤1 mm benefited from SB predilation in terms of preventing abrupt SB occlusion (P for interaction=0.04). For the treatment of true bifurcation lesions, SB predilation improved acute angiographic and procedural outcomes, but could not improve long-term clinical outcomes. It may benefit patients with severe stenosis in the parent vessel.

Understanding the Coronary Bifurcation Stenting.

Coronary bifurcation stenting is still complex and associated with a high risk of stent thrombosis and restenosis even with contemporary techniques. Although provisional approach has been proved to be the standard strategy of treatment, There is still lack of evidences for multiple steps of the procedure. For so many years we have been focused on the optimization of side branch (SB), but the clinical outcome is mostly dependent on the main vessel (MV) stenting. The optimal expansion of MV stent without the compromise of SB is the ultimate goal to achieve in the coronary bifurcation stenting. Understanding the anatomy and physiology of coronary bifurcation lesion should be the most important step to this goal. The relationship of vessel diameter between branches and the anatomical and functional significance of plaque shift and carina shift are two most important concepts to understand. They are the science behind the predictors of SB occlusion, and the rationale of proximal optimization technique and final kissing ballooning. This specific review will be devoted to review those concepts as well as clinical evidences to support them.

Assessment of human placenta as an ex-vivo vascular model for testing of liquid embolic agent injections with adjunctive techniques

PurposeThis project sought to test the utility of post-delivery human placenta (HP) as a vascular model for liquid embolic agent (LEA) simulation, along with adjunctive techniques.Materials and methodsTwelve LEA injections...

Incidence, predicting factors, and clinical outcomes of periprocedural myocardial infarction after percutaneous coronary intervention for chronic total occlusion in the era of new-generation drug-eluting stents.

This study aimed to examine predictors and clinical outcomes of periprocedural myocardial infarction (PMI) after chronic total occlusion (CTO) intervention. There are limited data on the clinical implications of PMI after CTO intervention in the new-generation drug-eluting stent (DES) era. We enrolled 337 patients who underwent CTO intervention and met the study criteria. We evaluated the incidence and predictors of PMI, defined as an increase in creatine kinase-MB ≥3× the upper limit of normal (ULN) after intervention and compared the occurrence rates of major adverse cardiac and cerebrovascular events (MACCE, defined as the composite of cardiac death, myocardial infarction, stent thrombosis, target-vessel revascularization, or cerebrovascular accidents) between the PMI and non-PMI groups. PMI occurred in 23 (6.8%) patients after CTO intervention. Significant independent predictors were previous bypass surgery [odds ratio (OR) = 5.52, 95% confidence interval (CI) = 1.17-25.92; P = 0.03], Japan-CTO score ≥3 (OR = 7.06, 95%CI = 2.57-19.39; P < 0.001), side branch occlusion (OR = 4.21, 95%CI = 1.13-15.66; P = 0.03), and longer procedure time (OR = 4.18, 95%CI = 1.35-12.99; P = 0.01). During a median follow-up of 29.6 months, the PMI group had a significantly higher MACCE rate than the non-PMI group (23.7 vs. 5.6%, P = 0.008 by log-rank test). PMI was an independent predictor of MACCE (HR = 4.26, 95%CI = 1.35-13.43; P = 0.01). The MACCE rate gradually increased in a CK-MB-dependent fashion and was highest in patients with ≥10× ULN (P = 0.005). Previous bypass surgery, high Japan-CTO score, side branch occlusion, and longer procedure time were strongly related to PMI occurrence after CTO intervention. PMI was significantly associated with worse clinical outcomes in the new-generation DES era.

Modified jailed balloon technique for bifurcation lesions.

We propose a new systematic approach in bifurcation lesions, modified jailed balloon technique (M-JBT), and report the first clinical experience. Side branch occlusion brings with a serious complication and occurs in more than 7.0% of cases during bifurcation stenting. A jailed balloon (JB) is introduced into the side branch (SB), while a stent is placed in the main branch (MB) as crossing SB. The size of the JB is half of the MB stent size. While the proximal end of JB attaching to MB stent, both stent and JB are simultaneously inflated with same pressure. JB is removed and then guidewires are recrossed. Kissing balloon dilatation (KBD) and/or T and protrusion (TAP) stenting are applied as needed. Between February 2015 and February 2016, 233 patients (254 bifurcation lesions including 54 left main trunk disease) underwent percutaneous coronary intervention (PCI) using this technique. Procedure success was achieved in all cases. KBD was performed for 183 lesions and TAP stenting was employed for 31 lesions. Occlusion of SV was not observed in any of the patients. Bench test confirmed less deformity of MB stent in M-JBT compared with conventional-JBT. This is the first report for clinical experiences by using modified jailed balloon technique. This novel M-JBT is safe and effective in the preservation of SB patency during bifurcation stenting.

TCT-824 Prediction of Side Branch Occlusion in Percutaneous Coronary Intervention by Coronary Computed Tomography - CT Bifurcation Score as a Novel Tool for Predicting Risk of Intraprocedural Side Branch Occlusion

Side branch occlusion is one of the major technical hurdles in the percutaneous coronary intervention of bifurcation lesion. We investigated whether preprocedural coronary computed tomography angiography could predict intraprocedural SB occlusion. A total of 260 bifurcation lesions were enrolled

Treatment of Intracranial Aneurysms With the SILK Embolization Device in a Multicenter Study. A Retrospective Data Analysis.

BACKGROUNDFlow-diverter technology has become an important stent-based embolization tool in the treatment of complex cerebrovascular pathology. We report here the experience of 4 Spanish centers with using the SILK flow-diverter (SFD) device.OBJECTIVETo evaluate the safety and efficacy of using the SFD in the endovascular treatment of intracranial aneurysms with complex morphology.METHODSWe retrospectively examined a prospectively maintained database of patients treated with SFD devices between July 2008 and December 2013 at 1 of 4 institutions in Spain. Data regarding patient demographics, aneurysm characteristics, and technical procedure were analyzed. Angiographic and clinical findings were recorded during the procedure and at 12 months postoperatively.RESULTSA total of 175 SFD devices were implanted in 157 patients (women/men: 119/38; mean, median, and range of age: 56.2, 56.7, and 19-80 years, respectively), who were treated in a delayed manner (3-6 months from the event) for 180 aneurysms (165 unruptured and 15 ruptured). Adverse events (acute and delayed) were observed in 28.7% of cases (45/157), and most were resolved (19.1%; 30/157). Six months after the procedure, total morbidity and mortality were 9.6% (15/157) and 3.2% (5/157), respectively. Long-term imaging follow-up showed complete occlusion, neck remnants, and residual aneurysm in 78.1% (100/128), 14.0% (18/128), and 7.8% (10/128) of cases, respectively.CONCLUSIONSThe SFD device is an effective tool for the treatment of challenging aneurysms, and allows complete occlusion within a year of the procedure in most patients, with morbidity and mortality comparable to those previously reported for similar devices.