Significant Side Branch Research Articles

Experiência inicial com a extensão de cateter-guia ExpressmanTM em um centro terciário de cardiologia de alto volume

Background: Guide catheter extensions provide increased support in complex percutaneous coronary interventions. The ExpressmanTM is a novel guide catheter extension and the objective was to assess the impact of its use on procedural success and complications in a high-volume reference center. Methods: We analyzed data from all consecutive procedures in which the ExpressmanTM guide catheter extension was used. The decision to use a guide catheter extension was at operator’s discretion. Device success was defined as the successful positioning of the guide catheter extension in the coronary vessel and procedural success was defined as <20% residual stenosis and TIMI 3 flow, with no loss of significant side branches. Major adverse cardiac and cerebrovascular events were defined as the composite of all-cause death, myocardial infarction, target vessel revascularization and stroke. Results: From April 2022 to January 2023, 34 procedures were included. The majority of the patients were male (59%) and the mean age was 66.5 years. Guide catheter extension use was not planned pre-procedure in 17 procedures (50%). The most common reasons for guide catheter extension use were target vessel angulation or tortuosity and unfavorable coronary ostium position. Device success was obtained in 88% and revascularization success in 91%. There were three side branch occlusions. During in-hospital clinical follow-up, no major adverse cardiac and cerebrovascular events or major bleeding occurred. Conclusion: The device success and procedural success were high and the rate of complications was low. Guide catheter extension use as bailout technique in complex anatomies allowed procedural success in the vast majority of otherwise untreatable patients.

Relationship between modifiable atherosclerotic cardiovascular risk factors and coronary artery bifurcation lesion

Abstract Background: Modifiable atherosclerotic cardiovascular disease risk factors are hypertension, diabetes mellitus, dyslipidemia, cigarette smoking, and obesity; the term coronary artery bifurcation is used when a coronary artery divides into two hemodynamically important branches or when the main branch has a hemodynamic significant side branch, bifurcation lesion represent 20% or more of coronary artery stenoses undergoing angiography. Objectives: To evaluate the relationship of hypertension, diabetes, dyslipidemia, cigarette smoking, and obesity to coronary bifurcation disease. Materials and Methods: In a cross-sectional study conducted in the Iraqi Center for Heart Diseases from May 2020 to May 2021, a total of 140 adult patients (70 cases with coronary bifurcation lesions and 70 control cases with non-bifurcation lesions) with angiography-documented stenotic coronary artery disease (CAD) were defined. Case demographics and modifiable CAD risk factors were addressed. Results: In the bifurcation group, the non-bifurcation lesion was mostly an associated angiographic finding (82%). The most significantly correlated atherosclerotic risk factor with bifurcation lesion compared to non-bifurcation lesion was diabetes, followed by systemic hypertension. Dyslipidemia was the most common prevalent risk factor, equally distributed in both groups. Smoking and obesity were distributed nearly equally in both groups. Conclusion: There is a significant relationship between diabetes and hypertension with coronary bifurcation lesions compared to non-bifurcation lesions.

OCT Guidance in Bifurcation Percutaneous Coronary Intervention.

Coronary bifurcation is defined by the European Bifurcation Consensus as a coronary artery stenosis adjacent to the origin of a significant side branch. Its anatomy is composed of 3 different segments: proximal main vessel, distal main vessel and side branch. Coronary artery bifurcation lesions are encountered in approximately 15-20% of all percutaneous coronary interventions and constitute a complex subgroup of lesions characterized by lower procedural success rates and higher rates of adverse outcomes. In recent years, a growing focus in the European and Japanese bifurcation club meetings has been the emerging role of intravascular imaging, in guiding successful bifurcation percutaneous coronary interventions (PCI). In this review we will present the main ways optical coherence tomography (OCT) can be used to improve outcomes during bifurcation PCI.

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

Techniques and Evidence for Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: An Ongoing Journey

Safety and Efficacy of Intracoronary Brachytherapy Protocol for Resistant In-Stent Restenosis

The aim of our prospective study is to evaluate the safety and the long-term clinical efficacy of Intracoronary Brachytherapy (ICBT) for In-stent Restenosis utilizing a prespecified interventional and radiation protocol.Single center prospective analysis of patients undergoing ICBT with at least 2 prior layers of coronary stents compared to patients undergoing balloon angioplasty alone. Per our protocol, the first step is to perform an intravascular ultrasound (IVUS) study to evaluate the lesion for degree of calcification, etiology of ISR, length of the lesion and diameter of the vessel. Then, laser atherectomy is performed using 0.9, 1.4- or 1.7-mm catheters for 3 runs. Percutaneous transluminal coronary angioplasty (PTCA) of the culprit lesion with a 1:1 sized cutting balloon is performed. Then, ICBT is performed and IVUS is repeated to confirm appropriate MLA. Target Vessel Revascularization rates within one year of ICBT will be assessed. Periprocedural complications will be assessed for up to 72 hours. Side branch occlusion: > 50% stenosis of the side-branch of the target vessel during/immediately after completion of ICBT. Absence of TIMI III flow distally in the target vessel after ICBT will also be assessed.Results for our project are forthcoming however we have completed 32 brachytherapy treatments in our laboratory since 2016 and their results are presented herein. Significant side branch occlusion occurred in only 4 cases (13%). Distal slow flow or no flow occurred in 3 cases (9%). TIMI 3 flow was restored in all 3 cases. TVR occurred in only 3 cases (9%). Bleeding complications occurred in 3 cases, 2 patients had a hematoma and one had bleeding at the access site. Only one case required one unit of blood transfusion. Acute renal failure occurred in one case. There were no 30-day readmissions to our hospital for any of the patients who received ICBT. 30-day survival was observed in all 32 patients. The 8 patients who qualified for ICBT during the same time period of January 2016 to December 2020 but had PTCA alone or atherectomy and PTCA had TVR observed in 5/8 cases (63%); This was significantly higher than in those patients who underwent ICBT (P < .001). Side branch occlusion did not occur in any of the 8 cases. None of the cases had a distal slow flow or no flow phenomenon. None of the patients had acute renal failure. There were no 30-day readmissions and all of the patients survived to 30 days.In-stent restenosis of DES is an important clinical issue. Intracoronary brachytherapy is a safe and well tolerated treatment option that may serve as a form of therapy for high-risk patients with recurrent ISR of DES. At our high-volume institution we have created a systematic protocol for ICBT. We look forward to updating the clinical results from our prospective study.

Unprotected left main coronary artery stenting: true vs. non true bifurcation lesions; a single-centre experience

Abstract Aims We investigated the impact of bifurcation lesions involving a side branch lesion combined with a main branch stenosis on clinical outcomes after percutaneous coronary intervention (PCI) on unprotected left main coronary artery (ULM). Methods and results We defined “true” bifurcation lesions as significant (&amp;gt;50%) side branch stenosis associated with a significant main branch lesion, either proximal or distal, according to the Medina classification (1.1.1, 1.0.1 or 0.1.1 lesions). “Non true” lesions were defined by absence of significant side lesions, or significant side lesions without concomitant main branch stenosis. We compared patients with “non-true” bifurcation lesions (N=132; 56%) with those with “true” bifurcation lesions (N=105; 44%) in their 12-month incidence of target vessel failure (TVF) (composite of (i) cardiac death related to target vessel; (ii) myocardial infarction related to target vessel, or (iii) ischemia-driven target vessel revascularization), death from any cause, target lesion revascularization (TLR) and stent thrombosis (ST). TVF occurred in 56 patients (24%) (figure 1). Patients with “true” bifurcation lesions had a significantly higher risk of TVF than those with “non-true” bifurcation lesions (HR 2.39; 95% CI 1.39–4.11, P=0.002). “True” bifurcation lesions were also associated with a higher risk of all cause of death (HR, 2.54; 95% CI, 1.09–5.94; P=0.031) and TLR (HR, 2.33; 95% CI, 1.1–4.94, P=0.027). 'True' bifurcation lesions, diabetes mellitus, as well as cardiogenic shock, were independently associated with an increased risk of TVF (figure 2). Of note, the SYNTAX score I was not identified as an independent predictor of TVF. The stenting strategy (1 vs 2 stents) did not show any significant association with the outcome. Conclusions Patients with ULM and “true” bifurcation lesions who undergo PCI have a worse clinical outcome than those with “non-true” bifurcation lesions. Funding Acknowledgement Type of funding sources: None. Figure 1. Kaplan-Meier curves for TVFFigure 2. Independent predictors of TVF

Retrograde chronic total occlusion percutaneous coronary intervention using single catheter: A single centre registry

ObjectivesTo analyse the feasibility, safety and procedural outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) through retrograde approach using single catheter. MethodsOur study was a retrospective observational study that enrolled patients who underwent retrograde CTO PCI using a single catheter between June 2016 and February 2020. Clinical success was defined as successful completion of CTO PCI without associated in-hospital major clinical complications like death, myocardial infarction, stroke or urgent revascularisation. Technical success was defined as successful completion of CTO PCI using single catheter and minimum diameter stenosis of <30% with thrombolysis in myocardial infarction (TIMI) flow grade 3, without significant side branch occlusion, flow-limiting dissection, distal embolization, or angiographic thrombus. ResultsTotally 102 patients underwent retrograde CTO PCI during the study period. Out of which, 15 cases were attempted using single catheter. Mean age of the population was 59.1 ± 8.9 years (males: 86.7%) and the left ventricular ejection fraction (LVEF) was (61% ± 9.1%). Mean number of diseased arteries was 2.1 ± 0.7, length of the CTO was 25.5 ± 7.4 mm and J-CTO score was 2.3 ± 0.7. We achieved a technical success rate of 73.3% using single catheter, and the overall clinical success (Including single catheter and ping pong) was obtained in 86.7% cases. One patient (6.7%) developed cardiac tamponade and none of study population required dialysis for contrast induced acute kidney injury (CI-AKI) ConclusionsRetrograde CTO PCI using single catheter is a technically challenging procedure when compared with other CTO PCI. Our study demonstrated acceptable outcomes which is comparable to other antegrade and retrograde CTO PCI registries.

Association of Acute Procedural Results With Long-Term Outcomes After CTO PCI.

The aim of this study was to determine the association of procedural outcomes with long-term mortality and myocardial infarction (MI) after chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The association between acute procedural results and subsequent outcomes has received limited study. Between January 2010 and December 2013, a total of 2,659 CTO PCI patients were consecutively enrolled. Procedural results were categorized into 3 groups: 1) optimal recanalization, with reperfusion of the occluded vessel and side branches (if any) with TIMI (Thrombolysis In Myocardial Infarction) flow grade 3; 2) suboptimal recanalization, meeting any of the following criteria: persistence of significant side branch occlusion, final TIMI flow grade 1 or 2, or residual percentage diameter stenosis >30%; and 3) procedural failure (i.e., failure to cross a lesion with a balloon angioplasty catheter). The primary outcome was the 5-year composite endpoint of cardiac death and MI. Overall, optimal recanalization was achieved in 1,562 patients (58.7%), suboptimal recanalization was achieved in 399 patients (15.0%), and recanalization failed in 698 patients (26.3%). The 5-year incidence of the primary outcome was significantly higher in the suboptimal recanalization group compared with the optimal recanalization and the failure groups (10.1% vs. 6.5% vs. 6.3%; p=0.046), which was driven mainly by higher risk for MI. In subgroup analysis, significant side branch occlusion was associated with numerically higher risk for 5-year MI (hazard ratio: 1.55; 95% confidence interval: 0.99 to 2.43; p=0.054). In this large cohort of CTO PCI patients, suboptimal recanalization was associated with significantly higher long-term incidence of cardiac death and MI compared with optimal recanalization or procedural failure.

Characteristics, predictors and outcomes after unprotected left main stem primary percutaneous coronary intervention

Abstract Background Reports about outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for unprotected left main (ULM) coronary artery are limited. We aimed to investigate the characteristics, in-hospital and the long-term outcomes of these patients. Methods From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 111 pts (0.96%) who undergone primary PCI for ULM culprit lesion. The short- and the long-term outcomes in this subset was evaluated and compared to 9463 (82.5%) patients undergoing pPCI for lesions located in other segments (Non-LM group). Technical success was defined as final TIMI 3 flow in both, left main and distal vessels, anterior descending and circumflex artery, without significant residual stenosis (&amp;gt;20% following balloon angioplasty or stent implantation) and side branch compromise (residual stenosis &amp;gt;75%). Results Patients with ULM were older and more likely to present as Non-ST-elevation MI (77% vs. 93%; p&amp;lt;0.000) and in cardiogenic shock (40% vs. 2.2%; p&amp;lt;0.000), having less occlusive disease with TIMI 0–1 flow prior to PCI (44% vs. 78%; p&amp;lt;0.000) compared to Non-LM patients. Also, greater procedure complexity was observed with longer lesions &amp;gt;20mm (50% vs. 29%; p&amp;lt;0.000), more intraluminal thrombus (86% vs. 45%; p&amp;lt;0.000), greater number (1,48±0,9 vs. 1,28±0,7; p&amp;lt;0.01) and longer stents (30,5±15,8 vs. 27,4±14,3; p=0.028), more GP IIb/IIIa inhibitors (32% vs. 23%; p=0.022), intra-aortic counterpulsations (7% vs. 0.6%; p&amp;lt;0.000) and contrast media used (202±96 vs. 172±66; p&amp;lt;0.000) in ULM group. Despite obtaining comparable rates of final TIMI 3 flow in main branch (91.9% vs. 95.4%; p=0.084), patients with LMCA had significantly higher in-hospital (27% vs. 4.7%: p&amp;lt;0.000), and one-year all-cause mortality (41% vs. 11%: p&amp;lt;0.000), but for the remaining duration of clinical follow-up (available for 97.8% pts, median duration 51±37 months) survival rates were comparable between ULM and Non-LM pts (18% vs. 15%: p=0.506) (Figure 1). Regression analysis showed that final TIMI 3 in main branch at 30 days (HR 0.05 [95% CI 0.005–0.604]; p=0.018), while peri-procedural cardiogenic shock (hazard ratio (HR) 8.3 [95% CI 2.5–28.1]; p=0.001), creatinine clearance &amp;lt;60 ml/min (HR 7.5 [95% CI 2.3–25.1]; p=0.001) and technical success (HR 0.16 [95% CI 0.45–0.57]; p=0.005) at 5 years, independently predicted mortality in ULM patients. Conclusions Despite performance of primary PCI, patients with MI due to ULM lesions are associated with worse in-hospital and one-year mortality but following that period mortality was comparable to control group. Suboptimal final coronary flow best predicted the 30 day, while peri-procedural cardiogenic shock, renal dysfunction at admission and suboptimal technical procedure result, predicted long-term mortality in these patients. Figure 1 Funding Acknowledgement Type of funding source: None

Comparison of coronary bifurcation lesions stenting techniques- a network meta-analysis

Abstract Background Coronary bifurcations lesions (CBL) are account for 15–20% of all percutaneous coronary interventions (PCI) and constitute a major challenge for interventionists in terms of procedural success rate and long-term cardiac events. Based on data from multiple randomized trials and registries, current guidelines advocate the use of provisional side branch (SB) stenting strategy for the majority of CBL's. However, for true or complex CBL's (long side branches lesions, difficult side branches access or high risk of side branches compromise), which account for up to 25% of CBL's, this strategy may by unsafe and ineffective due to a potential risk of intraprocedural or long-term occlusion of a significant side branch and a two-stenting technique may be needed in order to achieve optimal results. Up to date, the optimal two- stenting technic for CBL remains in debate. Accordingly, our aim was to compare different stenting techniques in coronary bifurcation lesions. Methods We performed a MEDLINE search for randomized controlled trials (RCT) and observational studies comparing stenting techniques in CBL's with reported clinical outcomes. Mixed treatment comparison model generation was performed to directly and indirectly compare culotte, T and protrusion (TAP), crush and provisional techniques Results A total of 13 RCT and 12 observational studies were identified including 6806 patients, among whom 1,201 were treated with cullotte, 2,731 with crush, 797 with TAP and 2077 with provisional stenting. The Bayesian hierarchical random-effects model demonstrated a significant reduction in target lesion revascularization (TLR) rate with crush techniques compared with provisional technique (OR 0.64 95% CI 0.42–0.97) along with a trend for reduction in major adverse cardiovascular (MACE) events (OR 0.75, 95% CI 0.55–1.02). TAP and culotte techniques did not show similar results. Equality of other endpoints, including mortality, myocardial infarction and re-stenosis was found between all CBL's techniques (Figure 1). Discussion Our findings suggest improved outcomes with crush technique compared to other double stenting techniques in terms of TLR with a trend towards MACE reduction. Further research is required to determine the optimal stenting technique for coronary bifurcations lesions along with the utility of imaging and physiology in this complex subset. Figure 1. Comparison of double stentin techniques Funding Acknowledgement Type of funding source: None

Jailed balloons for side branch protection: a review of techniques and literature

Coronary bifurcation lesions are commonly encountered, and side branch compromise is a major complication of these bifurcation interventions. Jailing a wire in the side branch is the most common method of significant side branch protection. Jailing a balloon in the side branch is a less well known and seldom practiced strategy of side branch preservation but tends to have lower occlusion rates as compared to conventional jailed wires. Various modifications have been applied to the original jailed balloon technique to further improve side branch patency. Complications arising from this technique have been limited to case reports only and relate mainly to calcified vessels.

Phase-field modeling of complex dendritic structures in constrained growth of hexagonal close-packed crystals.

We perform the phase-field modeling to investigate the growth pattern selections of the complex dendritic structures in constrained growth with different solidification and orientation conditions. The results show that hexagonal close-packed (hcp) crystals emerge as dendritic and cellular arrays in different planes, originating from the specific hcp anisotropy that allows different growth preferences between the basal and cylindrical planes. A morphological transition of the titled dendrites to tip-splitting dendrites arises reflecting the competition between the preferred orientation induced primary growth and the misorientation induced sidebranching formation. Furthermore, the dendritic patterns exhibit sharper tips and the more significant sidebranches, while the cellular pattern is changed from the symmetric cells to the tip-splitting cells, and to seaweeds with the increase of anisotropy strength, indicating the competitive mechanism of the in-plane anisotropy induced growth promotion and the out-plane anisotropy induced growth restriction. We expect to understand the growth competition, the morphology selection, as well as the orientation dependence of the complex dendritic structures in the three-dimensional (3D) constrained growth.

Invited commentary

Invited commentary

Dedicated bifurcation stents – Mechanistic, hardware, and technical aspects

Percutaneous coronary intervention (PCI) in bifurcation lesions is associated with lower success rate, higher acute complication rates and higher event rates in follow-up.The reason for this higher than usual complication rate relates to the relationship between anatomy, flow, and atheroma distribution in bifurcation lesions.Further, stenting these lesions can be a prolonged procedure and can be technically more demanding. The most common complication is the loss of significant side branch (SB). Main vessel (MV) stenting may enhance the carina displacement and atheroma shift across the SB ostium leading to SB ostium narrowing.Finally, complications, if they occur, are more difficult to manage. Dedicated bifurcation stent has been developed to overcome the number of limitations associated with conventional bifurcation PCI. The main advantage of most dedicated bifurcation stents is to allow the operator to perform the procedure on a bifurcation lesion without the need to rewire the SB.

Treatment of Complex Aorta Diseases by Multilayer Stents

Purpose: The aim of our study was to evaluate the role of multilayer stents (MLS) in the therapeutic arsenal of complex aortic pathologies for frail patients combining several comorbidities that are initially objected to the conventional surgical treatment. Materials and methods: Since March 2012, we conducted a monocentric prospective study on a series of 41 procedures, performed on 41 aortic lesion locations in 38 patients treated with multilayer stents. The series was divided into four groups. The first group included 21 cases: 20 thoracoabdominal aneurysms and one aneurysm of the entire descending thoracic aorta. The second group included 7 cases of juxta/infra renal aneurysms, the third group included 5 cases of false aneurysms and the fourth group included 8 cases of aortic dissecting hematoma (first subgroup: 6 cases) or extended dissections (second subgroupe: 2 cases).Three patients were treated during the same operation for a double aneurysm location (thoracic and abdominal in 2 cases and aortic arch and thoracic aorta in the 3rd case). Results: The series included 25 men and 13 women with an average age of 63 years (40-84 years). The procedures were performed under local anesthesia in 3 cases, loco regional in 19 cases and general anesthesia in 16 cases. The average hospital stay was 7 days (4-14 days).The technical placement of the MLS was successful for the 41 procedures. No paraplegia, no stroke and no mesenteric ischemia occurred. Three complications related to the surgical approach were treated surgically with success. Two patients had post-operative renal failure for which one required dialysis. The 30-day mortality in relation to the aneurysm was 3% (one case of rupture in the first postoperative day) and unrelated to the aneurysm 3% (one case of massive myocardial infarction after the procedure). For an average follow up of 12 months (1-20 months) mortality unrelated to the aneurysm was 25% (9 deaths) and 0% in relation to the aneurysm. Among the 38 remaining aortic lesions treated and followed, the aneurismal sac was not feeded in 14 cases (63%) with 6 out of 20 cases in group 1(30%), 3 out of 6 cases in group 2(50%), 3 out of 4 cases in group 3 (75%) and finally 2 out of 6 cases in the first subgroup of group 4 (33%). The aneurismal sac is not feeded in 19 cases (50 %), including 14 out of 20 cases in group 1 (70%), 2 out of 6 cases in group 2 (33%), 1 out of 4 cases in the group 3(25%) and 2 out of 6 cases in the first subgroup of group 4 (33%). Two cases of extensive dissections treated remained stable without aneurismal changes. Three cases are recent: 1 out of 6 cases in group 2 (17%) and 2 out of 6 (33%) in the first subgroup of group 4 (33%). Visceral arteries and supraaortic trunks remained patent in all the 38 cases. Conclusion: MLS may be an option treatment for dissections and complex aortic aneurysms in frail patients with high surgical risk. Our results showed that better results are obtained for false aneurysms and true aortic aneurysms without involvement of significant side branches.

Definitions and classifications of bifurcation lesions and treatment.

This article introduces the new terminology proposed by the European Bifurcation Club in order to simplify the identification, description, localisation and measurement of coronary bifurcation lesions as well as the selection of appropriate treatment strategies. A bifurcation lesion is a coronary artery narrowing occurring adjacent to, and/or involving, the origin of a significant side branch that you do not want to lose. The very simple Medina classification is intended for exchange and clinical research purposes. It is combined with a clear side branch definition and is associated with multiple measurement and imaging modalities, which take into account the complexity of lesions and treatments. Dedicated angiography as well as 3D angiography and multislice computed tomography are absolutely necessary for measurement of the bifurcation angles. The MADS (Main, Across, Distal, Side) classification is based on the final position of the stents in the bifurcation and on the order in which stents are implanted according to a strategy reflecting lesion and technique complexity. Although this classification still seems exhaustive, it does not involve the numerous guide and balloon manoeuvres, which would require a thorough a posteriori electronic classification of all inherent specific technical details.

Strategy of FFR-guided Coronary Intervention for Jailed Side Branch Offered Better Outcome in Patients with Coronary Bifurcation Lesions

OBJECTIVES:To compare the efficacy of two treatment strategies, Fraction Flow Reserve (FFR) guided coronary intervention and the conventional method (angiographic guided only) in treating jailed side branch in patients with coronary bifurcation disease. Efficacy will be determined by clinical outcomes (cardiac death, myocardial infarction (MI), target vessel revascularization (TVR) at the 6 months follow-up.MATERIAL AND METHODS:This prospective analytic design study included a total of 26 patients with de novo, coronary bifurcation disease with significant side branch lesions after successful drug eluting stent implantation of the main branch. All patients were recruited between June and December 2011 from Bangkok Metropolitan Administrative Medical College and Vajira Hospital. After main branch stenting we 2:1 randomly assigned patients to undergo side branch intervention guided by angiography alone or FFR measurement. The FFR-guided group only received side branch intervention if the FFR was 0.75 or less.RESULTS:Of the 26 patients, 8 were randomly assigned to FFR guided PCI and 18 to the conventional (CI) group. The baseline characteristics of the two groups were similar. Similarly, there was no significant difference in the baseline angiographic profiles and procedural characteristics between these two groups. Among the FFR group, 3 patients (37.5%) still had FFR &lt; 0.75 after side-branch kissing balloon so side-branch stenting was performed with provisional T-stent technique in all three patients. In the CI group, 11 patents (61.11%) had side branch stenting with two (18.18%) in culotte technique, four (36.36%) in T stent technique and five (45.46%) in crush technique. At 6 months, one of eighteen patients (5.50%) in the CI group died from frank pulmonary edema and cardiogenic shock. None of the FFR group died during this period. Two (11.10%) in the CI group had target vessel revascularization from side branch in-stent restenosis. There was no statistical difference in major cardiovascular events (cardiac death, MI, TVR) between the two groups during the 6 month follow-up period (p = 0.08). CONCLUSION: FFR guided coronary intervention in patients with bifurcation lesion may reduce mortality and target vessel revascularization at 6 months and may be considered as a reasonable optional technique.

Coronary Bifurcations: Still the Touchstone of Drug-eluting Stents and Bioresorbable Vascular Scaffolds?

Coronary bifurcation lesions that involve significant side branches represent a particularly challenging subset of target lesions for percutaneous coronary interventions. Besides the necessity for the interventional cardiologist to often perform technically demanding interventions with more procedural steps, clinical outcome following percutaneous coronary intervention has usually been somewhat inferior. For more than two decades, coronary bifurcation lesions represent a serious touchstone for both interventional cardiologists and various types of stents and vascular scaffolds. The use of first-generation drug-eluting stents (DES) has reduced the incidence of restenosis following percutaneous coronary intervention of bifurcation lesions as compared to bare metal stents. In a first, small-sized study by Colombo et al, a numerically lower rate of angiographic restenosis was seen in bifurcated lesions treated with a single DES in the main vessel. In the meantime, pooled data of the Nordic Bifurcation and the British Bifurcation Coronary studies, both using first-generation Cypher DES (Cordis; Waaren, New Jersey, United States), have clearly demonstrated at 9-month follow-up that clinical outcome is superior following a simple approach with provisional Tstenting of the side branch vs a complex approach. In addition, the Nordic Bifurcation study has shown that long-term outcome (up to 5 years) following bifurcation stenting with a simple approach was at least as good as the outcome of a complex approach. The aforementioned studies were performed with the first-generation Cypher stent that had a closed-cell design. The results of several in vitro studies and bench tests suggest that DES with different stent materials and designs may act differently in the setting of bifurcation stenting. Moreover, the coatings of various DES types show significant dissimilarities in mechanical properties, which may be relevant during kissing balloon inflations that apply a significant shear stress to the coatings of DES. Consequently, the assessment of clinical outcome

Bifurcation angioplasty using ‘sleeve technique’ [modified minicrush] for non-left-main coronary bifurcation lesions

Bifurcation angioplasty using two stent strategies is always challenging in the Catheterization laboratory to perform and thus, many randomized control trials of bifurcation angioplasty comparing two stent versus single stent have shown provisional angioplasty as a simple strategy with low major adverse cardiac events [MACE] rates. But bifurcation lesions with significant side branch lesions needs a different strategy and often require two stent strategies. Different complex techniques of two stent techniques are described but they are complex to perform with high rate of acute stent thrombosis and major adverse cardiac events [MACE] rate. We describe two cases of bifurcation lesion with the significant side branch disease for which we performed modified crush technique [Sleeve technique] which is technically simple to perform with least major adverse cardiac events [MACE] rate.

78 First year experience of a dedicated "radial lounge" for patients undergoing elective percutaneous coronary procedures

Introduction The potential to achieve safe early mobilisation and same day discharge on a consistent basis after radial artery access has provided us with the opportunity to make a step change in the way we deliver elective care to patients undergoing percutaneous coronary procedures. We designed a dedicated “radial lounge” to accommodate patients before and after their procedure with the aim of minimising the feeling of “hospitalisation” that accompanies most encounters with health services. The lounge is a day case unit that has no beds, only chairs, and televisions but no cardiac monitors. Patients remain in their clothes throughout their hospital visit. Here we report our first year′s experience of this facility. Methods: The study population comprised all patients who attended the radial lounge between July 2009–June 2010 for coronary angiography or percutaneous coronary intervention (PCI). Patients were suitable for the radial lounge if they were elective cases who had a satisfactory radial pulse and no pre-procedure contraindication to same day discharge. Patients were excluded if they had any of the following: an unsuitable radial pulse, planned femoral access, prior coronary artery bypass surgery, or the requirement for an overnight hospital stay for planned complex/high risk PCI, renal impairment, or social reasons. The final decision regarding route of arterial access was left to the operator. Results In the one year study period, 1548 patients were managed in the radial lounge. 1109 patients underwent coronary angiography, 114 (10.2%) of whom also had a pressure wire or intravascular ultrasound, and 439 underwent PCI. This represented approximately 88% of our unit′s elective angiograms and 60% of our elective PCIs. Among the patients who underwent angiography, 938 (84.5%) were performed radially and 1076 (97.0%) were discharged from the radial lounge on the same day as their procedure. Among the PCI patients, 359 (81.8%) were performed radially and 372 (84.7%) were discharged the same day. The PCI group included 326 (74.3%) patients who had a single vessel treated, 105 (23.9%) who had two vessels or a bifurcation with a significant side branch treated, and 8 (1.8%) patients who had three vessels treated. There were no deaths or arrhythmias in the radial lounge. Requirement for overnight admission was significantly more common after femoral access compared with radial access for both angiography (4.1% vs 2.8%; p Conclusions A dedicated radial lounge free of cardiac monitors is a safe environment in which to manage most patients before and after elective coronary angiography and PCI. The lack of monitoring necessitates patient selection but this does not prevent the lounge being suitable for the majority of elective patients. Femoral access is associated with a significantly greater requirement for overnight admission.