Side Branch Occlusion Research Articles

The efficacy of modified jailed balloon technique for true bifurcation lesions.

To evaluate the short-, long-term clinical and angiographic outcomes after treatment of true bifurcation lesions using a modified jailed balloon technique (MJBT). Percutaneous coronary intervention (PCI) for true bifurcation lesions has high risk for adverse events. Side branch (SB) occlusion is one of the most serious complications. Therefore, novel strategies to avoid SB occlusion during main branch stenting and to keep its patency are important. Between February 2015 and February 2018, 328 patients with 349 true bifurcation lesions underwent PCI using MJBT. True bifurcation lesions were defined as Medina classifications (1.1.1), (1.0.1) or (0.1.1) lesions. We investigated the procedural and long-term clinical outcomes. Furthermore, angiographic outcomes were assessed at follow-up diagnostic angiography. The mean age of patients was 71.6 ± 9.9 years. Procedural success was achieved in all patients; postoperative SB occlusion was noted in only one patient (0.3%). The cumulative incidence of all-cause death was 23 patients (7.0%) in the follow-up period (median 717 days). Target lesion revascularization was performed in 19 patients (5.8%) with 23 lesions (6.6%), and 0.6% of myocardial infarction and 0% of definite stent thrombosis were observed. Angiographic follow-up was performed in 243 patients (74.1%); the percent diameter stenosis in SB was not significantly different between after the index procedure and follow-up angiography. This MJBT is safe and effective in preserving SB patency for true bifurcation lesions. Furthermore, long-term clinical and angiographic outcomes after MJBT are feasible.

Impact of Side-Branch Predilation on Angiographic Outcomes in Non-Left Main Coronary Bifurcation Lesions.

Despite the high prevalence of coronary bifurcation lesions in routine interventional cardiology practice, the best strategy for managing this challenging lesion subset remains debatable. Due to potential for complications, the routine practice of side-branch (SB) predilation is controversial. An electronic search was performed of online databases up until April 2018 for studies reporting periprocedural angiographic outcomes comparing provisional main-branch stenting with and without SB predilation. Random-effects model odds ratios (ORs) were calculated. Eight studies were selected for a qualitative review, with 47.3% (1367/2890) of included subjects having angiographic outcomes following SB predilation reported. Of these, four studies included details of periangiographic outcomes comparing two groups. Bifurcation lesions stented without SB predilation demonstrated lower odds of requiring further SB intervention compared with lesions receiving upfront SB predilation (OR, 2.44; 95% confidence interval [CI], 1.71-3.47; I²=21%; P<.001). No difference was demonstrated regarding final SB TIMI flow <3, SB dissection, or intraprocedural SB occlusion. Although the odds of performing final kissing-balloon inflation were in favor of the group without SB predilation (OR, 1.62; 95% CI, 1.11-2.37; I²=61%; P=.01), there was no statistical difference in long-term major cardiovascular outcome (MACE) between the two groups (risk ratio, 1.29; 95% CI, 0.94-1.75; I²=11%; P=.33). SB predilation during coronary bifurcation percutaneous coronary intervention did not alter overall procedural angiographic outcomes. However, SB predilation is associated with increased SB intervention, including increased requirement for SB stenting, without demonstrable long-term MACE benefit, compared with a standard strategy without SB predilation.

The hybrid algorithm in treatment of coronary chronic total occlusions - MSWiA Lublin CTO 5-year registry.

IntroductionTreatment of chronic total occlusions (CTO) despite improvement in techniques and results over the last years still seems to be limited to a small number of centres and operators. Application of the hybrid strategy may support further spread of CTO percutaneous coronary intervention (PCI) and increase procedural success rates.AimOur single-centre prospective ongoing registry aims to provide details and results of recanalizations of coronary CTO performed according to the hybrid algorithm in a series of consecutive patients.Material and methodsBetween January 2015 and September 2019 the clinical and procedural data of CTO PCI procedures on consecutive patients were collected. Lesion complexity was assessed according to the Multicenter CTO Registry of Japan (J-CTO) score: 0 – easy, 1 – intermediate, 2 – difficult, ≥ 3 – very difficult and PROGRESS score. Strategies applied were classified as: antegrade wire escalation (AWE), antegrade dissection and re-entry (ADR), retrograde wire escalation (RWE) and retrograde dissection and re-entry (RDR). Angiographic success was defined as < 30% residual stenosis with TIMI 3 flow. Angiographic and clinical complications were reported.ResultsTwo hundred sixty-six patients were included and 285 procedures were performed in total. Success rate was 87.7% (calculated per procedure) and 92.5% (calculated per patient). Four patients underwent successful staged double CTO recanalization. Fifteen patients out of 31 primary failures underwent a second attempt with a 73% success rate (11/15). Fifty-two patients (18.2%) were referred for a second attempt from other institutions. Mean J-CTO score was 2.6 (13 cases with J-CTO of 0, 41 cases with J-CTO of 1, 80 cases with J-CTO of 2, and 151 cases with J-CTO ≥ 3) and the success rate was respectively 92.3%, 95.1%, 91.3% and 83.4%. Higher complexity of occlusion required a higher number of applied strategies including retrograde access in over a quarter of cases. Complete revascularization was achieved in 215 (75.4%) cases. In-hospital MACCE rate was 3.5% – 1 patient died due to acute kidney injury complications, 9 (3.2%) patients sustained myocardial infarction (1 STEMI due to side branch occlusion). All 7 (2.5%) coronary perforations (Ellis 1 and Ellis 2) were treated conservatively and we recognised 10 (3.5%) cases of acute kidney injury (one dialysis).ConclusionsThe hybrid algorithm in CTO PCI can be successfully applied with good early results and low complication rates. Higher complexity CTOs require more procedural strategies with a significantly lower success rate in very difficult cases.

Microcatheter-Protected Orbital Atherectomy for Severely Calcified Bifurcation Coronary Artery Disease With Single-Guiding Catheter Technique

Bifurcation coronary artery intervention may increase the risk of occlusion of an angulated side branch due to the plaque shift while treating (balloon, atherectomy, or stent) the main branch. Although debulking with atherectomy may reduce this risk, side branch compromise is still of concern. The

Accuracy of RESOLVE score derived from coronary computed tomography versus visual angiography to predict side branch occlusion in percutaneous bifurcation intervention

IntroductionVisually estimated angiographic V-RESOLVE score was developed as a simple and accurate prediction tool for side branch (SB) occlusion in patients undergoing coronary bifurcation intervention. Data on the use of coronary computed tomography angiography (coronary CTA) for guiding percutaneous coronary intervention in bifurcation lesions is scarce. ObjectivesWe aimed to validate the ability of quantitative CTA-derived RESOLVE score for predicting SB occlusion in coronary bifurcation intervention and to compare its predictive value with that of the angiography-based V-RESOLVE score. MethodsWe included 363 patients with 400 bifurcation lesions. Angiographic V-RESOLVE score and CTA-derived RESOLVE score were calculated utilizing the weights from the QCA-based RESOLVE score. The scoring systems were divided into quartiles, and classified as the non-high-risk group and the high-risk group. Accuracy was assessed using areas under the receiver-operator characteristic curve (AUC). SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction flow grade (including the absence of flow) in the SB after main vessel stenting. ResultsIn total, 28 SB occlusions (7%) occurred. CTA-derived RESOLVE and V-RESOLVE scores achieved comparable predictive accuracy (0.709 vs. 0.752, respectively, p = 0.531) for predicting SB occlusion, and the analysis of AUC for each constituent element of the scores did not show any significant difference between CTA and visual angiography. The total net reclassification index was −18.6% (p = 0.194), and there were no significant differences in the rates of SB occlusion in the non-high-risk group (4.9% vs. 3.8%, p = 0.510) and the high-risk group (13.8% vs. 18.6%, p = 0.384) between CTA-derived RESOLVE and V-RESOLVE scores. ConclusionsThe quantitative CTA-derived RESOLVE score is an accurate and reliable alternative to the visually estimated angiographic V-RESOLVE score for prediction of SB occlusion in coronary bifurcation intervention. Clinical trial registrationURL: https://www.clinicaltrials.gov. Unique identifier: NCT03709836.

Calcific lesion preparation for coronary bifurcation stenting.

Bifurcating coronary lesions are a very common challenge in interventional cardiology because of the technical complexity in their treatment, the risk of side branch occlusion and an overall worse outcome when compared to non-bifurcating lesions. The presence of calcifications represents further complexity due to the difficulty in device delivery and stent expansion as well as enhanced risk of side branch occlusion. Rotational and orbital atherectomy, scoring and cutting balloons, coronary lithoplasty are available tools which have been introduced over the last three decades to overcome such issue. Nevertheless, their application in different contexts of bifurcations presents specific caveats and the studies directed at comparing such techniques have never been expressly oriented in the subset of the bifurcating lesion. In this paper, we review these devices and their usefulness in bifurcations by analyzing consistent data from clinical trials, and we propose a practical algorithm for the treatment of severely calcified bifurcating lesions according to their anatomical features.

Endoscopic Stenting in Hilar Cholangiocarcinoma: When, How, and How Much to Drain?

Hilar cholangiocarcinoma (HCCA) involves a complex anatomical region where bile ducts, arteries, and veins create a complex network. HCCA can lead to biliary strictures at the main hepatic confluence, involving the right and left radicles. Endoscopic drainage of jaundiced patients with HCCA is challenging and carries a high risk of infective complications. HCCA needs a careful multidisciplinary evaluation to assess the indication and purposes (preoperative/palliative) of the biliary drainage. Biliary drainage in HCCA needs to be planned by magnetic resonance cholangiography in order to study the biliary anatomy and perform a target drainage of the intrahepatic ducts above the malignant hilar stricture; all the opacified intrahepatic ducts above the hilar stricture must be drained to reduce septic complications. Drainage of >50% of the liver volume is important to obtain bilirubin reduction and less complications, but atrophic liver segments (identified by CT scan) do not require drainage due to the increased risk of cholangitis. When preoperative biliary drainage is planned, plastic stents must be inserted. Self-expandable metal stents are indicated for palliative purposes and should be placed only when a complete liver drainage is possible; only uncovered metal stents are indicated to drain malignant hilar strictures to avoid side-branch occlusion.

TAA 6. Staging Procedures, Cerebrospinal Fluid Drainage, Selective Neuromonitoring, and Use of Conduits During Complex Endovascular Aortic Repair in Patients With High Risk of Spinal Cord Injury

Spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR) and thoracoabdominal aortic aneurysm (TAAA) repair is a devastating complication. Outcomes improved significantly after 2015, when we revised our spinal cord protection strategy. This study describes a single experience of SCI prevention in patients who have had endovascular repair. A prospectively maintained database of patients having repair using standard, branched/fenestrated stent grafts at a single university center was reviewed. We optimized the implantation procedure, including the early restoration of pelvic and lower limb perfusion by precannulated devices and temporal conduits. The left subclavian artery was routinely revascularized before coverage. Procedures for extent thoracic and II and III TAAAs were staged. The aim was also to maintain controlled perfusion to the sac before complete exclusion. In cases of TEVAR, the first step was subclavian revascularization, then endograft deployment, and the next step was proximal occlusion of the left subclavian artery with a plug. For the TAAA, strategies used for staging included placement of the thoracic component; branch/fenestration device deployment, maintaining perfusion to the sac by delayed completion of either one of the stent graft side branches, perfusion branches, or contralateral iliac limb extension; and complete exclusion after side branch occlusion test and motor and somatosensory evoked potential monitoring (Fig). The current policy was to place a spinal drain; the mean arterial pressure is raised to >90 to 100 mm Hg, and the hemoglobin level is maintained at 10 g/dL. Twenty-nine patients (median age, 73 years; 24 male patients; 20 TEVARs and 9 branched/fenestrated endovascular aneurysm repairs) underwent endovascular repair. No death or neurologic symptoms or signs related to SCI were registered at 30 days. Temporary iliofemoral conduits were used in 16 limbs in 14 patients. One patient had a ≥75% decrease in motor and somatosensory evoked potential amplitude, and the complete exclusion of the sac was delayed for 2 more weeks. No patients developed late SCI or mortality. This series illustrates the importance of a dedicated institutional protocol aimed at ensuring the intraoperative maneuvers to avoid perioperative paraplegia. This study aimed to demonstrate the possible protective effects of ischemic preconditioning on the preservation of spinal cord function after segmental and sequential artery occlusion.

Prediction of side branch occlusions in percutaneous coronary interventions by coronary computed tomography: the CT bifurcation score as a novel tool for predicting intraprocedural side branch occlusion.

Side branch (SB) occlusion is one of the major technical hurdles in the percutaneous coronary intervention (PCI) of bifurcation lesions. Our aim was to investigate whether preprocedural coronary computed tomography angiography (CCTA) could predict intraprocedural SB occlusion. A total of 260 bifurcation lesions were enrolled from 246 patients who underwent CCTA before elective bifurcation PCI. Quantitative plaque analysis was performed in the main vessel (MV) and SB. Intraprocedural SB occlusion occurred in 42 lesions (16%). These lesions were characterised by SB plaque, calcified plaque in the MV, low attenuation plaque in the main proximal segment or SB, and a ratio of MV to SB ostium area >4.3, which constituted a point-based CT bifurcation score. The CT bifurcation score was cross-validated, outperforming any angiographic Medina classification or RESOLVE score (c-statistics=0.749 versus 0.631 to 0.551; p<0.05 for all). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CT bifurcation score ≥1 were 90%, 42%, 23%, 96%, and 50%, respectively. Comprehensive CCTA assessment was able to predict intraprocedural SB occlusion better than the current angiographic classification or scoring system. The CT bifurcation score may thus be a helpful guide for selecting the optimal bifurcation PCI strategy.

FREQUENCY AND CAUSES OF PERIPROCEDURAL MYOCARDIAL INFARCTION IN COMPLEX CORONARY INTERVENTIONS

Objective: To examine the frequency and cause sof periprocedural myocardialinfarction (PMI) in complex coronary interventions. Methodology: This cross sectional study was conducted at catheterizationlaboratory of Gulab Devi Chest Hospital, Lahore in 6 months duration from June2016 to January 2017. Patients aged between 30 to 80 years undergoingcomplex coronary interventions were included. Blood samples for creatinekinase-MB evaluation were drawn at three different times i.e. Once beforeprocedure, 8-10 and 24 hours after the procedure. CKMB level >3× ULN wasconsidered as PMI. Association of different factors with PMI was also observed. Results: A total of 72 consecutive patients were included in the study.Mean ageof patients was 53.65+11.84 years. There were 56(77.78%) males. PMI wasdetected in 14 (19.44%)patients, with 3–5× ULN in 13.88% and >5× ULN in5.55% of patients. Statistics of study showed that revascularization of left mainstem lesion (1.38 % vs 0 %, p=0.04), in-stent restenosis (2.77 % vs 1.38 %,p=0.03) and procedural complications such as side branch occlusion(1.38%vs0%, p=0.04) and slow/no reflow (4.16 % vs 1.38 %, p=0.004)weresignificantly associated with CKMB elevation following complex coronaryintervention. Conclusion: PMI is common in patients undergoing complex coronaryinterventions. Key Words: Complex coronary intervention, Creatine kinase MB, No reflow,Periprocedural myocardial infarction.

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.

The JOTEC iliac branch device for exclusion of hypogastric artery aneurysms: ABRAHAM study

ObjectiveHypogastric artery aneurysms (HAAs) are rare but life-threatening in cases of rupture. Open or endovascular techniques traditionally aimed at occluding the hypogastric artery (HA) have considerable risk of pelvic ischemia. Iliac branch devices (IBDs) are indicated for aortoiliac aneurysms; however, they have also been used lately for HAAs. Currently, there are no reports about patient outcomes focusing on HAA therapy using IBDs. We retrospectively analyzed early and midterm outcomes using IBDs for HAAs. MethodsPatients who received IBDs for HAAs at our department from January 1, 2012, through March 1, 2018, were included. Exclusion criteria were as follows: no HA involvement, emergency procedures, and HA stent grafting without IBD. Perioperative and follow-up data were collected from medical records. ResultsThere were 18 IBDs (only IBD, n = 4; IBD + endovascular aneurysm repair [EVAR], n = 7; IBD ± EVAR + side branch occlusion, n = 7) implanted into 14 male patients (76 ± 4 [70-83] years). There were no intraoperative complications, and the technical success rate was 100%. After 19 ± 11 (2-39) months of follow-up, two hybrid (external iliac artery occlusion, n = 1; EVAR graft kinking, n = 1) and four endovascular reinterventions due to two type IB (side branch coiling + stent graft extension) and two type IIIB (stent grafting) endoleaks were required. One IBD-related type II endoleak revealed constant aneurysm diameters during follow-up. One small type IB endoleak was self-limited. Estimated freedom from reintervention was 31% ± 23% at 2.7 years. The clinical success and patency rate was 100%. The IBD-related mortality was 0%. ConclusionsThe IBD for HAA shows good early and midterm results. Adequate sealing of HA landing zones and side branch occlusion are technically challenging but crucial to prevent type IB and type II endoleaks.

Sirolimus-eluting BiOSS LIM dedicated bifurcation stent in the treatment of unprotected distal left main stenosis.

Proximal optimization technique (POT) has been proposed to adapt the conventional drug-eluting stent (DES) with the fractal anatomy of the bifurcation. However, only few DES are labeled for post-expansion beyond 5.0 mm. Furthermore, recrossing in the side branch (SB) through the main vessel (MV) stent cells may be challenging. To compare the sirolimus-eluting, balloon-expandable dedicated bifurcation stent BiOSS LIM DES versus the second generation DES in the treatment of distal unprotected left main coronary arteries (ULMCAs) lesions. Forty-two consecutive patients with distal ULMCA lesions were treated with the BiOSS LIM (BiOSS LIM group) in our center. A matched-group of patients treated with second-generation DES was selected from our database (Control group). The primary endpoint was the procedural complication rate, including (a) SB occlusion, defined as intraprocedural TIMI flow grade <3 immediately after MV stenting; and/or (b) trouble in SB access, defined as the need of ≥2 guidewires or a failure to recross in the SB trough the MV stent cells. The need of POT in the two groups was also analyzed. The primary endpoint occurred in four (9.5%) patients in the BiOSS LIM group and in 13 (31%) in the Control group (p = 0.028; OR = 4.25; 95% confidence interval: 1.25-14.43). POT was performed more often in the Control group (71% vs. 35%; p = 0.004). Compared to conventional DES, the BiOSS LIM stent (1) facilitates SB recrossing and (2) fits well with the fractal anatomy of the left main bifurcation.

Novel Insights of Jailed Balloon and Jailed Corsair Technique for Percutaneous Coronary Intervention of Bifurcation Lesions.

The optimal technique for percutaneous coronary intervention (PCI) of a bifurcation lesion remains uncertain. JBT/JCT techniques are now emerging for protection of the side branch (SB). We aimed to compare jailed balloon (JBT) and jailed Corsair (JCT) techniques to the conventional jailed wire technique. We analyzed 850 consecutive patients (995 bifurcation lesions), who underwent PCI. The bifurcation lesions were classified as jailed wire (-), jailed wire (+), JBT, and JCT. We assessed temporary thrombolysis in myocardial infarction (TIMI) flow grade ≤2, permanent TIMI flow grade ≤2 in the SB, and SB occlusion related myocardial infarction and compared these endpoints with inverse probability treatment weighted analysis. The percentage of each group is as follows: jailed wire (-); 44.7%; jailed wire (+) 50.9%; JBT 1.7%; JCT 2.7%. The Corsair could not be delivered with a stent because of severe calcifications (3.7%) and a jailed balloon was entrapped with the stent after dilatation (5.9%). Compared to the jailed wire (+), JBT/JCT had a higher percentage of true bifurcations, arterial sheath size ≥7 Fr, and a lower proportion of wire recrossing (all, P < 0.05). After adjustment, temporary and permanent TIMI flow grade ≤2 in the SB, and SB occlusion related myocardial infarction were not significantly different (OR: 1.08, CI: 0.32-3.71, P = 0.90; OR: 0.88, CI: 0.11-6.91, P = 0.91; OR: 1.94, CI: 0.23-16.5, P = 0.55 respectively). Our data could not prove the efficacy of JBT/JCT, but revealed novel insights about these techniques. A larger study is necessary to prove the efficacy of JBT/JCT.

Development and validation of a risk scoring system based on baseline angiographic results by visual estimation for risk prEdiction of side-branch OccLusion in coronary bifurcation InterVEntion: The baseline V-RESOLVE score.

We aimed to adapt the visual estimation for Risk prEdiction of side-branch OccLusion in coronary bifurcation interVEntion (V-RESOLVE) score to enable risk prediction for side-branch (SB) occlusion using only baseline coronary angiogram data. The V-RESOLVE score, which comprises angiographic factors at baseline and after lesion preparation, is a validated tool for predicting SB occlusion risk in coronary bifurcation intervention. To develop and validate the new scoring system, we used data pertaining to 1,545 patients and another 1,286 consecutive patients. Baseline V-RESOLVE was derived from V-RESOLVE by replacing the two pre-stenting angiographic factors with the corresponding preprocedural characteristics, while maintaining the scoring standard itself. We evaluated the diagnostic performance of baseline V-RESOLVE for predicting SB occlusion and preformed risk stratification with characterization of non-high-risk and high-risk lesions. The area under the receiver operating characteristic curves was similar between baseline V-RESOLVE and V-RESOLVE (0.735 vs 0.756, P = 0.191), with good calibration for baseline V-RESOLVE (Hosmer-Lemeshow P = 0.714). Upon categorization by the baseline V-RESOLVE score, high-risk lesions (score: 14-43) demonstrated significantly higher rate of SB occlusion than did non-high-risk lesions (score: 0-13) (17.31% vs 4.74%, P < 0.01). Considering the V-RESOLVE-based risk stratification as reference, baseline V-RESOLVE had an integrated discrimination index of -1.81% (P = 0.052), and net reclassification improvement of -3.34% (P = 0.509). Upon validation, baseline V-RESOLVE provided satisfactory diagnostic performance and risk stratification. Baseline V-RESOLVE predicts SB occlusion in coronary bifurcation intervention based solely on the preprocedural angiographic results.

Long-term treatment effect and adverse events of a modified jailed-balloon technique for side branch protection in patients with coronary bifurcation lesions

BackgroundPercutaneous coronary interventions (PCI) of bifurcation lesions is technically challenging and associated with lower success rates and higher frequency of adverse outcomes. In the present study, we aimed to evaluate the immediate and long-term treatment effect and adverse events of a new modified jailed-balloon technique on side branch (SB) during PCI on coronary bifurcation lesions.MethodsThis was a prospective study of 60 patients (49 males, 11 females, mean age 66 ± 10 years) with coronary bifurcation lesions treated at the Beijing Hospital between September 2014 and October 2015. They underwent main vessel (MV) stenting and modified jailed-balloon technique on the SB. All patients were followed with hospital visits at 9 months. Angiographic success, major adverse cardiac events (MACE), SB occlusion, and angina were evaluated.ResultsThe majority of the patients had acute coronary syndrome (91.7%) and Medina 1.1.1. bifurcation lesions (71.7%). After MV stenting, thrombolysis in myocardial infarction (TIMI) 3 flow was established 100% of MV and 93.3% of SB. No SB occlusion occurred. The jailed SB balloon and wire could be successfully removed in all patients without damage or entrapment. The majority (91.7%) of patients achieved Canadian Cardiovascular Society I stage. There was no MACE during in-hospital stay and 9-month follow-up.ConclusionThe modified JBT provided high rate of procedural success, excellent SB protection during MV stenting, and excellent immediate and long-term clinical outcomes.

The Relation Between Optical Coherence Tomography-Detected Layered Pattern and Acute Side Branch Occlusion after Provisional Stenting of Coronary Bifurcation Lesions.

Layered pattern (presumed to be healed plaque after a thrombotic event) can be observed by optical coherence tomography (OCT). We sought to assess the ability of OCT-detected plaque composition to predict acute side branch (SB) occlusion after provisional bifurcation stenting. This is a retrospective observational study using pre-intervention OCT in the main vessel to predict Thrombolysis in Myocardial Infarction (TIMI) flow grade ≤1 in a SB (diameter ≥ 1.5 mm) after provisional bifurcation stenting. OCT-detected layered pattern was defined as plaque with a superficial layer that had a different optical intensity and a clear demarcation from underlying tissue. Overall, 207 patients with stable coronary disease were included. SB occlusion occurred in 26/207 (12.6%) bifurcation lesions. Operators decided not to perform additional treatment, and TIMI flow did not improve to ≥2 in cases with SB occlusion. The prevalence of OCT-detected layered pattern was more common in lesions with versus without SB occlusion (88.5% versus 33.7%, p < 0.0001); OCT-detected layered pattern was more often located on the same side of the SB (73.9% versus 21.3%, p < 0.0001) circumferentially compared to lesions without SB occlusion. Multivariable analysis showed that OCT-detected layered pattern was an independent predictor of SB occlusion (odds ratio 18.8, 95% confidence interval 5.1-68.8, p < 0.0001) along with true bifurcation lesion and wider angiographic bifurcation angle. The presence of an OCT-detected layered pattern near its ostium was a strong predictor of SB occlusion after provisional bifurcation stenting.

Predictors of side branch compromise in calcified bifurcation lesions treated with orbital atherectomy.

The aim of the study was to identify the predictors of side branch (SB) compromise in severely calcified bifurcation lesions treated with orbital atherectomy (OA). SB compromise remains a major complication of bifurcation lesion percutaneous coronary intervention (PCI). Higher prevalence of lipid-rich plaques and spotty calcification by optical coherence tomography (OCT) and SB ostial stenosis by angiography have been previously suggested as predictors of SB occlusion after main vessel (MV) stenting. Patients with chronic stable angina and severely calcified bifurcation lesions, in whom provisional stenting strategy was planned, were enrolled in the study. OA was used for lesion preparation in all cases. OCT imaging of the MV was performed before and after stenting. SB compromise was defined as a composite of SB occlusion (TIMI flow grade ≤ 2) and SB intervention after MV stenting. Thirty stable CAD patients with 30 severely calcified bifurcation lesions were included in the study. Twelve patients (40%) had a compromised SB after MV stenting. Compromised SB was characterized by a greater angiographic diameter stenosis (55.4 ± 8.1% vs. 35.0 ± 14.4%, P < 0.01) and a smaller minimal lumen diameters (0.79 ± 0.17 vs. 1.12 ± 0.30 mm, P = 0.002) before PCI compared to noncompromised SB. The prevalence of OCT lipid-rich plaques was low and did not differ between the groups (18 vs. 19%, P = 0.68). There was no difference in other OCT plaque characteristics including the presence of spotty calcification. The severity of SB ostial disease and not MV plaque morphology contributed to SB compromise in severely calcified bifurcation lesions.

Carina Bifurcation Angle and Side Branch Occlusion in Coronary Bifurcation Lesions Intervention: Angiographic Lesions Characteristic Role in Determining Its Relation.

Side branch occlusion has been implicated as a complication after percutaneous coronary intervention in coronary bifurcation lesions. The role of carina bifurcation angle as one of the characteristics of the coronary bifurcation lesions in causing side branch occlusion after percutaneous coronary intervention is still debated. This study aims to assess the correlation between carina bifurcation angles as one of the characteristics of the coronary bifurcation lesions and side branch occlusion in elective percutaneous coronary intervention. This is a cross-sectional study which utilizes CAAS 5.1 software to measure carina bifurcation angle. We collected 113 lesions in 108 patients that met the inclusion criteria from January 2016 to October 2016. Side branch occlusion occurred in 15 lesions (13.3%), with median carina bifurcation angle 19.17 degrees ( p < 0.001). Multivariate analysis showed there is a correlation between carina bifurcation angle with side branch occlusion, OR (odds ratio) 0.86 (95% CI [confidence interval]: 0.80-0.92) with ≤ 33.71 degrees cut off value. Increased risk of side branch occlusion was found in small carina bifurcation angle.

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.