Single Stent Strategy Research Articles

Impact of stent strut link location in proximal balloon edge dilation technique for bifurcation percutaneous coronary intervention.

The single-stent strategy has generally been accepted as the default approach to bifurcation percutaneous coronary intervention. We have proposed the proximal balloon edge dilation (PBED) technique to prevent stent deformation during side branch (SB) dilation. This bench study aimed to evaluate the impact of stent link location and stent design on stent deformation, obstruction by stent struts at a jailed SB ostium, and incomplete stent apposition in the proximal optimization technique (POT)-PBED procedure. A coronary bifurcation model was used. We intentionally set the absence or presence of stent link on the carina (link-free or link-connect) under videoscope observation and compared stent parameters between 3- and 2-link stents (n = 5 each, n = 20 total). In the link-free group, the SB jailing rate of 3-link stents was significantly higher than that of 2-link stents (15.5 ± 5.1% vs. 6.6 ± 1.2%, p = 0.009). In the link-connect group, the SB jailing rate of 3-link stents was significantly lower than that of 2-link stents (30.0 ± 4.5% vs. 39.0 ± 2.6%, p = 0.009). In the bifurcation segment, the rate of incomplete stent apposition was significantly lower for 3-link stents of the link-connect group than for 2-link stents of the link-connect group (3.3 ± 4.2% vs. 19.0 ± 7.8%, p = 0.009). For both stent designs, ellipticity ratio was higher for link-connect group than link-free group. Link location as well as stent cell design greatly impacted stent deformation during the POT-PBED procedure.

Single-stent strategy for left coronary artery bifurcation lesions in patients with chronic ischemic heart disease: protocol of a randomized trial

Aim. This study aims to compare the intraoperative, immediate postoperative and long-term postoperative results of stenting followed by final kissing balloon angioplasty (FKB) and without FKB for left coronary artery (LCA) bifurcation lesions in patients with chronic ischemic heart disease.Material and methods. We plan to perform an open-label, prospective, randomized, single-center, cohort trial that will include 40 patients with left main coronary artery bifurcation lesion, who will undergo stenting procedure followed by FKB or without FKB, using the second-generation drug-eluting stents. Randomization into two groups will be done after performing coronary angiography, confirming the inclusion criteria and the absence of non-inclusion criteria and signing a written consent in 2 copies. Group 1 — stenting followed by FKB. Group 2 — stenting without FKB. The total follow-up period is 24 weeks. It is planned to contact by phone on 30th and 180th day (±7 days) of postoperative period to obtain the information about patient condition, general survival rate, the events of combined controlled points and drug therapy. During 2d phone contact, on 180th day (±7 days), a patient will be invited to undergo multispiral computed tomography of the coronary arteries.The primary combined end-point: cardiac death, nonfatal myocardial infarction, acute cerebrovascular accident and the repeat target vessel revascularization. The secondary combined end-point: thrombosis and stent restenosis.Conclusion. Our study will optimize the approach to the choice of stenting strategy (with or without FRB) for left main coronary artery bifurcation lesions in patients with chronic ischemic heart disease.

P38 SINGLE VERSUS DOUBLE STENTING IN NSTEMI PATIENTS WITH COMPLEX LEFT MAIN BIFURCATION DISEASE

Abstract Background Among patients with non–ST–segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long–term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target–vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results Four hundred and forty–five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow–up of 37.1 months (IQR 22.1–39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long–term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2–stent strategy.

Serial changes of the side-branch ostial area after single crossover stenting with kissing-balloon inflation

PurposeWe aimed to investigate the serial change of the side-branch ostial area (SBOA) depended on the wire-position before Kissing-balloon inflation (KBI) in the single-stent strategy for bifurcation lesions separately in the left main coronary artery (LMCA) and in non-LMCA.MethodsPatients who underwent a single-stent KBI for a bifurcation lesion and had OCT images at the timing of the rewiring, at the post-procedure, and at the 9-month follow-up were extracted from the 3D-OCT Bifurcation Registry, which is a multicenter-prospective registry of patients with a percutaneous coronary intervention for a bifurcation lesion under OCT guidance. The SBOA was measured by dedicated software, and the rewiring position at the side-branch ostium after crossover stenting was assessed by three-dimensional-optical coherence tomography (3D-OCT). The optimal rewiring was defined as link-free-type and distal rewiring. The relationship between the optimal rewiring and the serial change of the SBOA was investigated separately in LMCA and non-LMCA cases.ResultsWe examined 75 bifurcation lesions (LMCA, n = 35; non-LMCA, n = 40). The serial changes of the SBOA with the optimal rewiring were not significantly different regardless of LMCA and non-LMCA (LMCA:3.96 to 3.73 mm2, p = 0.38; non-LMCA:2.16 to 2.21 mm2, p = 0.98), whereas the serial changes of the SBOA with the sub-optimal rewiring were significantly reduced (LMCA:6.75 to 5.54 mm2, p = 0.013; non-LMCA:2.28 mm2 to 2.09 mm2, p = 0.024). There was no significant difference in clinical events between the optimal and sub-optimal rewiring group regardless of the LMCA and non-LMCA.ConclusionThe side-branch ostial area dilated with the optimal rewiring position in a bifurcation lesion treated with single crossover stenting and kissing-balloon inflation was preserved regardless of whether the bifurcation was in the LMCA or a non-LMCA.

Comparison of Sequential POT-Side-POT and Kissing Balloon Techniquesin Patientswith Coronary Bifurcation Lesions Treatedwith Single-Stent Strategy; Which One is Simple and Safe? Propensity Score Analysis.

Background:It is unknown whether the novel POT-side-POT technique is more useful than the commonly preferred kissing balloon inflation in patients with non-complex coronary bifurcation lesions treated with a single-stent strategy. The aim of this study was to compare the efficacy of POT-side-POT and kissing balloon inflation techniques in one-stent strategy for non-complex coronary bifurcation lesions.Methods:In this study, 283 patients were retrospectively analyzed (POT-side-POT group, n = 149; KBI group, n = 134). Primary endpoints of the study were defined as follows: in-hospital and 30-day mortality, contrast-induced acute kidney injury, stent thrombosis, side branch dissection, and need for side-branch stenting. Characteristics of patients at baseline were balanced by using propensity score inverse probability weighting.Results:Procedure time (minute, 30.6 ± 8.5 vs. 34.3 ± 11.6; P = .003) and contrast volume (milliliter, 153.7 ± 42.4 vs. 171.1 ± 58.2; P = .004) were significantly lower in POT-side-POT group. Besides, side branch residual stenosis and number of patients with >50% side branch residual stenosis remained significantly higher in POT-side-POT group both in general and true bifurcation subgroup analysis (20.3 ± 19.8% vs. 16.5 ± 16.4%, P = .022; 11.9% vs. 5.7%, P = .013 and 24.1 ± 23.2% vs. 18.8 ± 18.7%, P = .033; 17.6% vs. 6.6%, P = .005; respectively). Combined clinical adverse outcomes were similar between groups. Side branch dissection (10.2% vs. 20.1%, P = .001) and need for side branch stenting (12.6% vs. 19%, P = .040) reached statistically significance in kissing balloon inflation group after adjustment.Conclusion:POT-side-POT may be a simple and safe technique with a shorter procedure time and lower incidence of adverse clinical events in non-complex coronary bifurcation lesions treated with single-stent strategy.

Single versus Double Stenting in NSTEMI Patients with Complex Left Main Bifurcation Disease.

Background: Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long-term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods: We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results: Four hundred and forty-five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow-up of 37.1 months (IQR 22.1-39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions: Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long-term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2-stent strategy.

Prognostic Impact of New-Onset Atrial Fibrillation After Single or Double Stent Left Main Bifurcation PCI.

Incidence and prognostic value of new-onset atrial fibrillation after single versus double stent strategy in bifurcation left main disease has not been yet investigated. We retrospectively analyzed the procedural and medical data of patients referred to our center for complex left main bifurcation disease, treated using crossover provisional stenting, T or T-and-Protrusion, Culotte, and Nano-inverted-T techniques between January 1, 2008, and May 1, 2018. Multivariate Cox-regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of new-onset atrial fibrillation during the follow-up period. Five hundred two patients (316 males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. At a mean follow-up of 37.1 ± 10.8 months (range: 22.1- 39.3 months); Target lesion failure rate was 10.1%. Stent thrombosis and cardiovascular mor- tality were observed in 1.2% and 3.6% in of cases, respectively. New-onset atrial fibrillation occurred in 23 out of 502 patients (4.6%). Patients with new-onset atrial fibrillation resulted more frequently female, older, obese, and diabetic and more frequently experienced target lesion failure and cardiovascular death. New-onset atrial fibrillation-free survival favored single versus double stent technique and among double stent techniques nano-inverted-T tech- niques compared to the others. Single stent strategy had a lower risk of new-onset atrial fibril- lation compared to double stent technique on multivariate analysis (Hazard Ratio (HR): 1.14, 95% CI: 1.10-1.19, P < .001 vs. HR: 1.28, 95% CI: 1.23-1.32, P < .0001). New-onset atrial fibrillation in distal left main bifurcation disease treated with per- cutaneous coronary intervention had a low incidence but resulted more frequently after double than after single stenting technique and was associated with worse outcomes.

P80 PROGNOSTIC IMPACT OF NEW ONSET ATRIAL FIBRILLATION AFTER SINGLE OR DOUBLE STENT LEFT MAIN BIFURCATION PCI

Abstract Objective Incidence and prognostic value of new onset atrial fibrillation (NOAF) after single versus double stent strategy in bifurcation Left Main (LM) disease has not been yet investigated. Methods We retrospectively analysed the procedural and medical data of patients referred to our center for complex LM bifurcation disease, treated using Cross–over provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT) techniques between January 1st, 2008 to May 1st 2018. Multivariate Cox–regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of NOAF during the follow–up period. Results Five hundred and two patients (316 males, mean age 70.3±12.8 years, mean Syntax score 31.6±6.3) were evaluated. At a mean follow–up of 37.1±10.8 months (range 22.1–39.3 moths), Target lesion failure (TLF) rate was 10.1%. Stent thrombosis and Cardiovascular mortality were observed in 1.2% and 3.6% in of cases, respectively. NOAF occurred in 23 out of 502 patients (4.6%). Patients with NOAF resulted more frequently female, older, obese, diabetic and more frequently experienced TLF and cardiovascular death. NOAF free survival favoured single versus double stent technique and among double stent techniques NIT compared to the others. Single stent strategy had a lower risk of NOAF compared to double stent technique on multivariate analysis (HR: 1.14, 95% CI: 1.10–1.19, p &amp;lt; 0.001 vs HR: 1.28, 95% CI: 1.23–1.32, p &amp;lt; 0.0001). Conclusions NOAF in distal LM bifurcation disease treated with PCI had a low incidence but resulted more frequent after double than after single stenting technique and associated with worse outcomes.

Stenting techniques for coronary bifurcation disease: a systematic review and network meta-analysis demonstrates superiority of double-kissing crush in complex lesions

ObjectiveThis study was aimed to compare different stenting techniques for coronary bifurcation disease (CBD).BackgroundPercutaneous coronary intervention (PCI) remains controversial for CBD; over the years, several stent techniques for bifurcation lesions have been used. Current guidelines recommend a provisional single-stent strategy as the preferred method for coronary artery bifurcation lesions. However, several randomized controlled trials (RCT) indicated that two-stent techniques showed better clinical outcomes.MethodsWe systematically searched Embase, PubMed, and Web of Science to include RCTs. The primary endpoint was the major adverse cardiovascular event (MACE). Secondary outcomes were cardiac death, myocardial infarction (MI), target-lesion or target-vessel revascularization (TLR or TVR), and definite or probable stent thrombosis (ST). Finally, we used 26 RCTs and a total of 7257 individuals were randomly assigned to one of the 6 stent techniques and included in this network meta-analysis.ResultsIn our network meta-analysis, double-kissing (DK) crush was significantly more superior to other 5 stent techniques in MACEs: OR vs. provisional 0.40 (95% CI 0.28–0.55); vs. culotte 0.40 (95% CI 0.26–0.60). DK crush ranked the most effective treatment for MACE (100%), MI (75%), ST (83%), and TLR (100%) in the rank probabilities analysis. In patients with complex bifurcation lesion defined by DEFINITION criteria, DK crush was notably more efficacious than provisional, culotte, and T-stenting/T-stenting and protrusion (TAP) in MACEs (OR vs. provisional 0.26, 95% CI 0.13–0.52) and TLR (OR vs. provisional 0.24, 95% CI 0.10–0.58).ConclusionCompared with other stenting techniques, DK crush had a lower incidence of MACEs in CBD. DK crush was significantly associated with a lower rate of MACEs in patients with complex bifurcation lesions defined by the DEFINITION criterion.Graphical abstract

Feasibility and Outcomes of Left Main to Branch Vessel PCI with Novel Tapered Coronary Stent in a Tertiary Care Centre: A Real World Experience.

To assess the safety and efficacy of Novel tapered (BioMime™ Morph) sirolimus- eluting stent (SES) for left main PCI in a real-world scenario. Currently, no data is available on clinical usefulness of tapered ultrathin stents in left main PCI. This was a prospective, non-randomised, single centre study carried out between February 2018 and May 2020 at a tertiary cardiac care centre in southern India. The study included patients treated with BioMime Morph tapered stent for distal de novo LMB lesion or ostial LAD/LCX lesions with significant size disparity between reference segments based on the eligibility criteria. Primary endpoint of the study was the cumulative incidence of major adverse cardiovascular events (MACE) composed of cardiac death, myocardial infarction, and clinically driven target-lesion revascularisation at follow-up. A total of 41 patients (average age of 54.83±9.81 years) were included in the study. Average SS-2 score was 23.17±5.42. Majority of the lesions (n=31; 75.61%) were of medina class (0.1.0). Provisional single stent strategy was adopted for treatment of LMB lesions. TIMI flow-3 was achieved in 40 patients (97.56%). Median clinical follow-up was 20 months (range 6-34 months). There was no periprocedural complication or MACE during follow-up. Tapered stents may be an acceptable alternative for LM intervention in an anatomical subset of patients with tapered vessels.

Comparative analysis of sequential pot-side-pot and kissing balloon techniques in patients with coronary bifurcation lesions treated with single stent strategy: propensity score analysis

Abstract Objectives It is unknown whether the novel re-POT technique is more effective than commonly preferred kissing balloon inflation (KBI) in patients with non-complex coronary bifurcation lesions (CBL) treated with single-stent strategy. Our aim was to compare the efficacy of re-POT and KBI techniques in one-stent strategy of non-complex CBL. Methods 283 patients were retrospectively analyzed (re-POT group, n=149; KBI group, n=134). Primary end-points of the study were defined as; in-hospital and 30-day mortality, contrast induced acute kidney injury (CI-AKI), stent thrombosis (ST), side branch (SB) dissection and need for SB stenting. Characteristics of patients at baseline were balanced by using propensity score inverse probability weighting (IPW). Results Procedure time (minute, 30.6±8.5 vs 34.3±11.6; p=0.003) and contrast volume (mL, 153.7±42.4 vs 171.1±58.2; p=0.004) were significantly lower in re-POT group. Besides, SB residual stenosis and number of patients with &amp;gt;50% SB residual stenosis remained significantly higher in re-POT group both in general and true bifurcation subgroup analysis (20.3±19.8% vs 16.5±16.4%, p=0.02; 11.9% vs 5.7%, p=0.01 and 24.1±23.2% vs 18.8±18.7%, p=0.03; 17.6% vs 6.6%, p=0.005; respectively). Combined clinical adverse outcomes were similar between groups. (Figure 1) SB dissection (10.2% vs 20.1%, p=0.001) and need for SB stenting (12.6% vs 19%, p=0.04) were reached statistically significance in KBI group after adjustment. (Figure 2) Conclusions Re-POT may be a simple and safe technique with a shorter procedure time and lower incidence of adverse events in non-complex CBL treated with single-stent strategy. Funding Acknowledgement Type of funding sources: None. Adverse clinical outcomes; weighted

Effect of Balloon Embedded Bifurcating Stenting with Single Stent Strategy for Side Branch Protection

Background: Intervention 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 National Institute of Cardiovascular Diseases and Hospital (NICVD), Dhaka, Bangladesh with a technique which can be incorporated into bifurcation stenting to reduce or almost eliminate the incidence of side branch occlusion or catastrophe. Methods: A prospective, observational, non-blinded study in patients from a single tertiary referral cardiac center National Institute of Cardiovascular Diseases &amp; Hospital (NICVD), Dhaka, Bangladesh. Patients with an indication for percutaneous coronary intervention (PCI) of a denovo bifurcation lesion were screened. The study included 51 patients who underwent coronary angiogram in our institution and had bifurcation lesions suitable for single stent strategy between March 2017 to September 2018. Results: 51 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 success was achieved in all the patients but procedural success was achieved in 88.2% of the patients. TIMI 3 flow of main branch (MB) was achieved 96.08% and side branch (SB) was achieved 88.2%. Incidence of dissection was 5.9%, acute occlusion of SB was 2.0% and MACE was 3.9%. Mean fluoroscopy time and contrast volume was similar to that of conventional bifurcation stenting. The jailed SB balloon and wire could be successfully removed in all patients. Conclusion: The present study suggests that balloon embedded bifurcation stenting with a semi inflated balloon to protect the SB is feasible, with minimal procedural adverse events and successful in minimizing or almost eliminating the incidence of acute side branch occlusion or dissection as well as MACE. Bangladesh Heart Journal 2021; 36(1): 17-23

TCTAP C-095 OCT Guided PCI of Left Main Coronary Artery with Single Stent Strategy

TCTAP C-095 OCT Guided PCI of Left Main Coronary Artery with Single Stent Strategy

Inflation Pressure in Side Branch during Modified Jailed Balloon Technique Does Not Affect Side Branch Outcomes.

Objectives This study aimed to investigate the optimal jailed balloon inflation in the side branch during the modified jailed balloon technique for bifurcated lesions. Background The modified jailed balloon technique is one of the effective techniques to minimize the emergence of side branch (SB) compromise by preventing plaque or carina shifting during a single stent strategy in the main vessel with provisional SB treatment. However, there are no detailed studies on the method of optimal jailed balloon inflation. Methods We analyzed 51 consecutive patients who underwent percutaneous coronary intervention (PCI) for bifurcated lesions with a modified jailed balloon technique between September 2018 and December 2020. These 51 patients were divided into two groups according to the magnitude of inflation pressure of the jailed balloon: a higher pressure (HP) group and lower pressure (LP) group. Results No significant differences in procedural outcomes were observed between the two groups. The findings of SB compromise were relatively common with our procedure (30.0% in the HP group; 33.3% in the LP group). The patterns of SB compromise such as dissection or stenosis increase were observed at similar frequencies between them. In particular, SB dissection was noted in the SB lesion with some plaque burden, irrespective of the magnitude of the jailed balloon inflation pressure. Univariate analysis showed that calcification in the main vessel and SB lesion length was significantly associated with SB compromise. Finally, all PCI procedures were successfully completed without any provisional stent deployment in SB. Conclusions We speculate that lesion characteristics rather than the PCI procedural factors may be critical determinants to cause SB compromise.

Efficacy of Combination Atherectomy of Orbital Atherectomy System and Rotational Atherectomy for Severely Calcified Nodule

Provisional single drug-eluting stent (DES) strategy remains the standard of care in simple bifurcation lesions which comprise the vast majority of coronary bifurcations. Nevertheless, the presence of complex bifurcations which are defined based on the 1) Side Branch (SB) lesion length of >10 mm and 2) SB ostial diameter stenosis of >70% are approached with a 2-DES strategy upfront. The bifurcation angle will further define the most appropriate technique, with T-stenting more suitable in angulations close to 90°, Culotte and the family of Crush techniques more appropriate for acute angles of <75°. The Crush techniques which are composed of the classic Crush, mini-Crush and double kissing Crush (DK-Crush) share the core principle of protruding the SB DES within the Main Branch (MB) to minimize the risk of ostial SB restenosis, which remains the most prevalent etiology of stent failure during 2-stent approach in bifurcations. Proximal Side Optimization (PSO) is an additional technical consideration to further optimize the protruding SB struts enabling 1) optimal SB strut accommodation to the larger MB vessel diameter, 2) strut enlargement that will further facilitate effortless rewiring for kissing balloon inflation (KBI) avoiding unfavorable guide wire advancement in the peri-ostial SB area.

Clinical Profile and Approach to Osteal LAD Lesion During Primary Angioplasty in Myocardial Infarction (PAMI)

Isolated Coronary Artery Stenoses (CAS) involving the ostium of the Left Anterior Descending (LAD) artery is very challenging, especially in a setting of primary Angioplasty in Myocardial Infarction (PAMI). Intimal atherosclerosis in the Left Main Coronary Artery (LMCA) bifurcation is primarily in area of low shear stress which is the lateral wall, close to the LAD and Left Circumflex (LCx). Thus, carina is usually free of disease, which can explain why single-stent strategy can be successful. However, precise stent placement is often difficult due to unwanted stent movement within vessel or its proximity to side branches. A decision must be made at the outset, to decide on the approach to be employed, to treat osteal LAD lesions. Limited data is available on patients undergoing primary PCI of osteal LAD lesions. Here, we present our experience and problems encountered during the management of osteal LAD lesions in the setting of PAMI.

A Randomized Trial Evaluating Online 3-Dimensional Optical Frequency Domain Imaging-Guided Percutaneous Coronary Intervention in Bifurcation Lesions.

Clinical implications of online 3-dimensional optical frequency domain imaging (3D-OFDI)-guided stenting for bifurcation lesions have not been investigated in the randomized controlled trials. The purpose of this study was to determine whether online 3D-OFDI-guided stenting is superior to angiography-guided percutaneous coronary intervention (PCI) in terms of incomplete stent apposition at the bifurcation segment. The OPTIMUM trial (Online 3-Dimensional Optical Frequency Domain Imaging to Optimize Bifurcation Stenting Using UltiMaster Stent) was a randomized, multicenter clinical trial. Eligible patients had an angiographically significant stenosis in the bifurcation lesion treated with a provisional single stent strategy using the Ultimaster sirolimus eluting stent. Patients were randomly allocated to either online 3D-OFDI-guided or angiography-guided PCI. Patients randomized to 3D-OFDI guidance underwent online 3D-OFDI assessment after rewiring into the jailed side branch after stenting and proximal optimization technique, while in the angiography guidance arm, rewiring was performed using conventional fluoroscopic/angiographic guidance. The primary end point of this trial was the postprocedural average percentage of malapposed struts per lesion assessed by OFDI in the confluence zone of the main and side branches. Between June 8, 2017 and September 26, 2018, 110 patients with 111 bifurcation lesions were randomized at 4 Japanese centers. Of these, 56 patients with 57 lesions were treated with 3D-OFDI-guided PCI, whereas 54 patients with 54 lesions were treated with angiography-guided PCI. In the 3D-OFDI guidance arm, the feasibility of online 3D-OFDI was 98.2%. The average percentage of incomplete stent apposition per lesion at bifurcation was lower in the 3D-OFDI guidance arm than that in the angiography guidance arm (19.5±15.8% versus 27.5±14.2%, P=0.008). The superiority of the 3D-OFDI guidance arm was also confirmed in the strut level analysis (odds ratio: 0.54 [95% CI, 0.36-0.81]; P=0.003). Online 3D-OFDI-guided bifurcation PCI was superior to angiography-guided bifurcation PCI in terms of acute incomplete stent apposition at bifurcation. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02972489.

One stent versus two stents for distal LM PCI: insights from the experience of a high volume center

Abstract Introduction Distal left main (LM) PCIremains a challenge. One of the most debated issues is whether to use a single vs 2 stent provisional strategy. While most studies and guidelines favour a single stent strategy, the recent DK-CRUSH V trial has shown better results with a 2 stent strategy. Objective To evaluate the performance of a single vs dual stent strategy for LM PCI in a real-world population setting. Methods Single-center procedural prospective registry of patients (pts) submitted to LM PCI from 2015–2018, with retrospective event analysis. Demographic, clinical data and procedure characteristics were analysed. Results were obtained with χ2 test, T student test, Kaplan-Meier survival analysis, logistic and Cox regression. Results 100 pts (73 men; 69±11 years) were included. Co-morbidities were very frequent (85 had hypertension, 54 had diabetes, 71 had dyslipidemia and 39 were past smokers). 32 had reduced LVEF (&amp;lt;40%) and 45 previous CABG. The decision to proceed to PCI vs surgery was undertaken individually by the local HeartTeam. Most of the procedures (57) were in an acute coronary syndrome setting (11 in STEMI, 7 with cardiogenic shock). The anatomical distribution of the lesions was: distal in 69 pts (61 involved the LAD and or Cx ostium), mid shaft in 7 pts, ostial in 18 pts and diffuse in 6 pts. Protected left main PCI encompassed 41% of the procedures. The complication rate was 7%. During a mean follow-up of 866±400 days, there were 4 peri-procedural deaths, 1-year mortality rate of 10% and 22 pts died overall. In pts submitted to distal LM PCI, a single stent was used in 49 pts (66%) versus a 2 stent approach in 23 pts (31%). The only significant difference between these groups were diabetes (66% in the single stent vs 32% in the 2 stent group, p=0.006) and protected LM (51% in the single stent vs 26.1% in the two stent group, p=0.046). While a 2 stent strategy was associated with higher mortality by Kaplan Meyer analysis (LogRank = 11.07, p=0.001), it was not an independent predictor of mortality in Cox regression. Cox univariate analysis identified LVEF &amp;lt;40% (OR 2.2, CI 1.01–4.9, p=0.047) and complications (OR 3.1, CI 1.4 – 6.9, p=0.004) as the only predictors of death. In multivariate analysis, only the latter was an independent predictor of mortality (OR 2.6, IC 1.1–5.9, p=0.028). The use of a 2 stent strategy was significantly associated with complications (χ2=5.1 p=0.024)) and was the only independent predictor of it (OR 3.8, IC 1.1–12.8, p=0.03). This was true even in the subgroup of protected LM PCI. Conclusion In a real-world setting of challenging LM PCI cases, a single stent strategy for distal LM PCI performed better. The use of 2 stents was an independent predictor of complications, strongly associated with increased risk of death. While a LM PCI must be undertaken on an individual basis, a single stent provisional strategy, whenever feasible, seems to be the best option. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Hospita Santa Maria

Four-year outcomes of unprotected left main lesion treated with one-stent versus two-stent technique

Introduction – Most reports on left main bifurcation lesions have demonstrated that treatment with a singlestent strategy is superior to a two-stent strategy but have excluded patients with acute coronary syndromes (ACS). Aims – The aim of the current study was to compare the four year outcomes of patients with unprotected left main coronary artery disease (ULMCAD) treated by percutaneous coronary intervention (PCI) with a one-stent or two-stent strategies in a population including those presenting as ACS. Methods – A total of 135 patients with ULMCAD treated by PCI were included, of which 75 (55.6%) had a one-stent strategy (Group A) and 60 (44.4%) had a two-stent strategy (Group B). Results – Fewer patients in Group A had a TIMI III flow at the end of the procedure (89.4% vs 100%, p=0.03) and complete revascularization (65.3% vs 88.3%, p=0.002). We found a higher early mortality in Group A without reaching statistical significance (13.4% vs 3.3%, p=0.1). Mortality rate at 4-year follow up was higher with Group A after multivariable analysis (adjusted HR 0.36, CI 0.15-0.85, p=0.02). We found no significant differences between the groups in terms of major adverse cardiac event (MACE) (adjusted HR 0.85, CI 0.34-1.48, p=0.7) or target lesion revascularization (TLR) (adjusted HR 1.37, CI 0.42-4.47, p=0.6) at 4-year follow up. Conclusions – Among unselected patients with ULMCAD PCI, with or without ACS, the early mortality rate is similar between one and two-stent strategy. Although, 4 year TLR and MACE rates were similar between the two groups, the 4-year all-cause mortality rate was lower in the two-stent strategy group.

Proximal side optimization in crush stenting. A step-by-step technical approach

In simple bifurcation lesions provisional single stent strategy remains the standard of care. While complex bifurcations, defined based on the 1) Side Branch (SB) lesion length of &gt; 10 mm and 2) SB ostial diameter stenosis of &gt;70% are approached with a 2-DES strategy upfront. The Crush techniques which are composed of the classic Crush, mini-Crush and double kissing Crush (DK-Crush) share the core principle of protruding the SB DES within the Main Branch (MB) to minimize the risk of ostial SB restenosis, which remains the most prevalent etiology of stent failure during 2-stent approach in bifurcations. Proximal SB optimization (PSO) is an additional technical consideration to further optimize the protruding SB struts enabling 1) optimal SB strut accommodation to the larger MB vessel diameter, 2) strut enlargement that will further facilitate effortless rewiring for kissing balloon inflation (KBI) avoiding unfavorable guide wire advancement in the peri-ostial SB area.