Unprotected Left Main Bifurcation Lesions Research Articles

Comparing the clinical outcomes of single vs. systematic dual stenting strategies for unprotected left main bifurcation lesion: a systematic review and meta-analysis.

The optimal percutaneous coronary intervention (PCI) strategy for coronary left main (LM) bifurcation lesions remains controversial. This meta-analysis compared the medium and long-term follow-up clinical outcomes of single vs. systematic dual stenting strategies of LM bifurcation lesions. We systematically identified studies published within 5 years comparing single vs. systematic double stenting strategies for LM bifurcation lesions. The primary endpoint was medium-term (1 year) and long-term (at least 3 years) all-cause death. Secondary outcomes included major adverse cardiovascular events (MACEs), target lesion revascularization (TLR), overall occurrence of stent thrombosis (ST), cardiovascular (CV) mortality, and myocardial infarction (MI). Two randomized controlled trials and nine observational studies with 7,318 patients were included in this meta-analysis. In terms of the medium-term follow-up clinical outcomes, our pooled analysis showed that use of the systematic dual stenting strategy was associated with a lower ST risk (odds ratio [OR] = 0.43, 95% confidence interval [CI]: 0.20-0.89, P = 0.02) and cardiac death risk (OR = 0.43, 95% CI: 0.21-0.89, P = 0.02) compared to the single stenting strategy; there was no significant difference between the two strategies regarding rates of all-cause death, MACE, TLR, and MI. Patients with long-term follow-up showed comparable observed clinical outcomes between the two strategies. Most importantly, for patients with true LM bifurcation, the risk of all-cause death, ST, and CV mortality following the systematic dual stenting strategy was significantly lower than the single stenting strategy. For patients with LM bifurcation lesions, both the systematic dual stenting strategy and single stenting strategy demonstrated comparable results in terms of all-cause mortality during medium-term and long-term follow-up. However, the systematic dual stenting strategy showed a tendency towards lower incidence of ST and CV mortality compared to the single stenting strategy during medium-term follow-up. Consequently, the systematic dual stenting strategy yielded superior clinical outcomes for patients with LM bifurcation lesions.

TCTAP C-052 Rotational Atherectomy on Calcified Unprotected Left Main Bifurcation Lesion with Severe Left Ventricular Dysfunction

### Patient Initials or Identifier Number SDFL ### Relevant Clinical History and Physical Exam A 78-year-old lady was admitted to another hospital due to acute non-ST-elevation myocardial infarction 9 days ago. She underwent coronary angiography that showed calcified left main with the triple-

Culotte versus the novel nano-crush technique for unprotected complex bifurcation left main stenting: difference in procedural time, contrast volume and X-ray exposure and 3-years outcomes

To assess the procedural performance and 3-years outcomes of unprotected complex bifurcation Left Main (LM) stenting using either Culotte or the novel nano-crush techniques, consisting in the use of two ultra-thin strut stents with a 1-ring stent crushed into the LM. We analysed the records of patients with complex distal/bifurcation LM disease and contraindications and/or refusal of bypass surgery, who from 1 January 2014 to 1 November 2017, received at operators' discretion LM double stenting by means of nano-crush technique using Orsiro (Biotronik Inc, Bulack, Switzerland) or Onyx (Medtronic Inc, Galway, Ireland) stents or Culotte stenting using same stent platforms. Among 65 patients (28 females, mean age 77.2 ± 6.2years), 32 received nano-crush while 33 patients received Culotte technique. Mean angles between left anterior descending coronary artery and left circumflex was 63.6 ± 21.3°. Post-operative success was achieved in 100% of cases. Nano-crush patients showed lower contrast medium volume and X-ray exposure, shorter fluoroscopy and procedural times compared to Culotte patients group. At a mean follow-up of 27.4 ± 10.8 months, clinical-driven target lesion revascularization, myocardial infarction and cardiovascular death were 0 versus 4/33 (12.1%, p = 0.04), 1/32 (3.1%) versus 6/33 (18.1%, p = 0.03) and 2/32 (6.2%) versus 8/33 (24.2%, p = 0.04) in nano-crush versus Culotte patients, respectively. In this single center study, the nano-crush technique was associated with less use of contrast, less procedural time and less X-ray exposure compared to the culotte technique for the treatment of unprotected left main bifurcation lesions.

Optical coherence tomography assessment of in-stent restenosis after percutaneous coronary intervention with two-stent technique in unprotected left main

BackgroundOptical coherence tomography (OCT) has contributed to a better understanding of in-stent restenosis (ISR); however, studies evaluating ISR pattern after two-stent technique in unprotected left main (ULM) are lacking. We aim to evaluate the ISR pattern of proximal LAD and LCX after two-stent technique in ULM. MethodsWe performed OCT in 26 patients with isolated or combined ISR (identified by angiography as >50%) after two stent implantation in the proximal LCX and LAD. Finally, 13 LAD and 22 LCX ISR lesions underwent OCT assessments. OCT analyses were undertaken in the proximal segments of the LAD and LCX. In addition, we compared OCT findings in the flow divider (FD) and lateral wall (LW). ResultsIn both the LAD and LCX, the distance from the ostium to the minimum lumen area (MLA; LAD, 2.00mm [1.00, 3.00]; LCX, 1.00mm [0.00, 1.80] distal to ostium) was short. Uncovered struts were more common on the FD side compared with the LW in the LAD (6.25% [0.00, 20.00] vs 0.00% [0.00, 0.00], respectively, p=0.016) and LCX (11.32% [0.00, 19.44] vs 0.00% [0.00, 4.55], respectively, p<0.001). Conversely, neointimal hyperplasia (NIH) was significantly thicker on the FD side compared with the LW in the LCX (0.31mm [0.19, 0.47] vs 0.15mm [0.09, 0.31], p<0.001). ConclusionsWhile uncovered struts were more commonly found on the FD side of both arteries, NIH was significantly thicker on the FD side compared with the LW in the LCX. These unique findings might indicate inferior outcomes after two-stent techniques in ULM bifurcation lesions.

Calcification analysis by intravascular ultrasound to define a predictor of left circumflex narrowing after cross-over stenting for unprotected left main bifurcation lesions

The aim of this study was to identify predictors of significant LCx-ostium compromise after distal unprotected left main coronary artery (ULMCA) stenting on the basis of baseline intravascular ultrasound (IVUS). Provisional single-stenting is considered as the default strategy for non-true bifurcation lesions in ULMCA. However, in certain cases, left circumflex artery (LCx)-ostium stenting is necessary. A total of 77 patients underwent percutaneous coronary intervention with drug-eluting stents for non-true bifurcation lesions in ULMCA and had IVUS evaluation. Pre-procedural IVUS was performed to measure cross-sectional areas at the following segments: left main trunk, left anterior descending artery (LAD)-ostium. Post-stenting-narrowing at the circumflex ostium (PSN-LCx) was defined as the presence of more than 50% diameter stenosis at the LCx-ostium as determined by quantitative coronary angiography analysis. PSN-LCx occurred in 27 (35%) patients. The presence of calcified plaque at the culprit lesion as identified by IVUS was more frequently observed in the PSN-LCx group as compared to the non-PSN-LCx group (81.5% vs. 22.0%, p<0.001). Calcium arc in the PSN-LCx group was significantly greater than that in the non-PSN-LCx group (118.1°±69.9° vs. 36.9°±63.0°, p<0.001). On multivariable analysis, a calcium arc>60° was an independent predictor of PSN-LCx (odds ratio: 5.12, 95% confidence interval: 1.21-25.01, p=0.03). The presence of calcified plaque at the culprit lesion appears to be one of the factors involved in LCx-ostial compromise in non-true bifurcation ULMCA lesions, especially when the calcium arc is >60°.

TCT-25 Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one- versus two-stent techniques versus double-kissing crush technique

TCT-25 Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one- versus two-stent techniques versus double-kissing crush technique

Impact of bifurcation angle on mace after cross over single drug-eluting stent strategy in unprotected left main bifurcation lesion: 3-dimensional quantitative coronary angiographic analysis

Purpose: Several studies had revealed that three dimensional (3D) quantitative coronary angiography (QCA) overcomes the shortcoming of 2-dimensional QCA regarding bifurcation angle analysis. The impact of bifurcation angle (BA) in left main (LM) on clinical outcomes after single stenting treated with drug-eluting stent (DES) have never been documented. The Aim of this study was to investigate the impact of unprotected LM bifurcation angle on clinical outcomes after cross over single stent strategy using DES with 3D QCA. Methods: A total of 152 patients who underwent PCI in unprotected LM bifurcation with successful single cross over DES stenting from the LM into the left anterior descending artery (LAD) were enrolled. The distal BA (between LAD and left circumflex [LCX]: shown in Fig) were computed in end-diastole before PCI with 3D QCA software. The patients were diveded into two groups with median value of the distal BA (high-angle group; BA≥86.04°, low-angle group; BA<86.04°) and cumulative incidence of major adverse cardiac and cardiovascular event (MACE: cardiac death, myocardial infarction, any target lesion revascularization) rate were stratified between two groups. Results: Mean follow up duration was 353±51.3 days. Compared to high angle group, the low angle group had significant high incidence of MACE (p=0.0086) (Fig. 1). ![Figure][1] Figure 1 Conclusion: Pre-PCI distal bifurcation angle and proximal bifurcation angle were independent predictors of MACE after single stent strategy cross over LM to LAD using DES. [1]: pending:yes

Long-term clinical outcomes of patients with unprotected left main bifurcation lesions treated with 2-stent techniques

Background Currently available evidence suggests that outcomes are less favorable when left main (LM) bifurcation lesions are treated with 2-stent techniques compared with a single-stent technique. We aimed to evaluate the long-term outcomes of the 2-stent techniques for treating unprotected LM bifurcation lesions in Chinese patients. Methods We enrolled 301 consecutive patients treated with drug-eluting stents (DES) implantation using 2-stent techniques for unprotected LM bifurcation lesions (MEDINA 1, 1, 1, 70.5%). The 2-stent techniques included crush technique, V stenting, T stenting, and Culottes stenting. After stenting, both vessels were redilated at a high pressure before final kissing balloon (FKB). Clinical and angiographic data were analyzed. The primary endpoints were major adverse cardiac events (MACE), which included death, myocardial infarction, and target lesion revascularization. Results Immediate procedural success was obtained in all cases with a FKB success rate of 95.3%. Follow-up data were available for all patients. The overall incidence of angiographic in-stent restenosis (ISR) rate was 20.3% and most ISRs were of the focal type. During long-term follow-up (mean duration, (54±22) months), the cumulative incidence of MACE was 11.0%, with 8 (2.7%) deaths, 7 (2.3%) myocardial infarctions, and 18 (6.0%) repeated lesion revascularization. MACEs in high SYNTAX score terciles were significantly higher compared with those in low and intermediate SYNTAX score terciles (P=0.001). Conclusions Although percutaneous coronary intervention (PCI) with 2-stent technique for unprotected LM bifurcation lesions was accompanied with a slightly high incidence of ISR, the long-term clinical follow-up is acceptable. Technical modifications and stent innovations may further improve both the angiographic and clinical outcomes for patients with LM bifurcation disease treated by PCI.

Clinical Impact of Bifurcation Angle After Cross over Single Stent Strategy in Unprotected Left Main Bifurcation Lesion In 3-Dimensional QCA

The Impact of Pre And Post Dilatation on Stent Deformity After Kissing Balloon Technique in a Large Left Main Bifurcation Model. Soichiro Enomoto, Tomoaki Ito, Takenori Domei, Kisaki Amemiya, Hiroyoshi Yokoi, Masashi Iwabuchi, Masakiyo Nobuyoshi. Kokura Memorial Hospital, Kitakyusyu, Japan. Background: Treating left main (LM) bifurcation with stents is complex as LM trunks have larger vessel references than others. Kissing balloon technique (KBT) and/or post stent dilatation to LM trunks are needed in order to obtain adequate stent apposition in LM trunks. The objective of this study was to investigate the impact of pre and post left main dilatation on stent deformity during KBT. Methods: LM bifurcation vessel model with 6.0mm proximal vessel reference was used in this study. After crossover stenting (3.5mm Nobori stent, Terumo Corporation, Tokyo) to the main branch, two strategies of LM dilatation with a 6.0mm balloon were tested. Strategy in model A was LM dilatation after KBT and not before, while strategy in model B was LM dilatation before and not after KBT. Results: In model A, post LM dilatation after KBT led to decrease the effect of KBT; stent malaposition in the ostial of the side branch. On the other hand, in model B, adequate stent apposition in the ostial of the side branch was obtained by KBT without any unfavorable major distortion in the main or LM trunk. Conclusion: LM dilatation before performing KBT is better especially when KBT is performed in large LM bifurcation lesions. If LM dilatation after KBT is needed, checking of stent distortion should be done afterward.

Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique

The present study aimed to compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions. Between March 2004 and April 2007, 633 consecutive patients with ULMCA bifurcation lesions (232 in the one-stent group and 401 in the two-stent group) were prospectively enrolled. The primary endpoint was the occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), and target vessel revascularisation (TVR), at five-year follow-up. Patients in the the two-stent group were classified as DK crush (n=155) and other two-stent techniques (culotte, T-stenting, kissing stenting and classical crush, n=246). Forty-seven (16.8%) patients in the one-stent group crossed over to the two-stent group. The one-stent group was associated with an increased incidence of MI compared to the two-stent approach (10.5% vs. 5.5%, p=0.025). The crude rate of MACE at five years was 28.0% in the one-stent group and 28.4% in the two-stent group (p=0.927). DK crush was associated with a significantly decreased five-year MACE compared to the other two-stent approaches or the one-stent approach (DK crush: 14.8% vs. other two-stent approaches: 37.0%, one-stent approach: 28.0%, p<0.001). The main benefit of DK crush primarily appeared to be secondary to a reduction in TVR (7.7% vs. 30.5% vs. 18.1%, p<0.001). By Cox regression analyses, the non-DK crush two-stent technique, a high SYNTAX Score (≥33) or New Risk Stratification (NERS) score (>20), and incomplete revascularisation were shown to be independent predictors of MACE at five-year follow-up. With distal left main true bifurcations, the two-stent technique (excluding DK crush) is an independent predictor of long-term MACE. DK crush is associated with more favourable long-term clinical outcomes. Confirmation of these findings is required from randomised controlled trials.

TCT-696 Impact of Bifurcation Angle on Major Cardiac Events After Cross Over Single Stent Strategy In Unprotected Left Main Bifurcation Lesion: 3-Dimensional Quantitative Coronary Angiographic Analysis

TCT-696 Impact of Bifurcation Angle on Major Cardiac Events After Cross Over Single Stent Strategy In Unprotected Left Main Bifurcation Lesion: 3-Dimensional Quantitative Coronary Angiographic Analysis

AS-030 “Flower Petal Stenting” with Sirolimus-Eluting Stent Implantation for the Treatment of Unprotected Left Main Bifurcation Lesions: 3-Year Follow-Up Outcome

The “Flower Petal Stenting” for treatment of bifurcation lesions is a recently introduced strategy that ensures complete coverage of the side-branch ostium (JACC Intv 2010;3:58). However, there is limited data available regarding long-term outcome after this technique with sirolimus-eluting stent (SES) for the treatment of unprotected left main “true” bifurcation lesions (ULM-bifurcation).

Final kissing balloon inflation by classic crush stenting did not improve the clinical outcomes for the treatment of unprotected left main bifurcation lesions: The importance of double‐kissing crush technique

The mechanisms contributing to final kissing balloon inflation between classic crush and double-kissing (DK) crush stenting techniques for the treatment of coronary bifurcation lesions contrast. The authors compared the clinical outcomes in patients with unprotected distal left main bifurcation lesions treated by classic crush or DK crush stenting techniques. Thirty-seven patients with unprotected left main bifurcation lesions were selected (20 in classic crush, 17 in DK crush groups) from a prospective, multicenter, randomized DKCRUSH-1 BIFURCATION STUDY. Clinical and angiographic data were analyzed. Follow-up was available for all patients. There were significant differences of the bifurcation angle between the classic and the DK crush group (83.28 +/- 20.69)(0) vs. (67.71 +/- 26.35)(0), P = 0.02). Unsatisfactory kissing rate in the classic group was significantly higher (26.32% vs. 5.88%, P = 0.01). The acute gain in the side branch was greater in the DK crush stent group (1.48 +/- 0.50 mm vs. 1.36 +/- 0.55 mm, P = 0.03). The accumulative restenosis rate in the main vessel segments, side branch, and accumulative MACE were higher in the classic group than the DK crush group (13.39% vs. 5.12%, P = 0.058, 42.10% vs. 5.88%, P = 0.01, 42.10% vs. 5.82%, P = 0.001, respectively). By logistic regression, acute gain in side branch immediately after PCI, bifurcation angle and unsatisfactory kissing were three independent factors of TLR at 8-month follow-up. Classic crush stenting with final kissing balloon inflations did not improve the clinical outcomes for the treatment of left main bifurcation lesion when compared with DK crush stenting technique.

Long-term outcomes following drug-eluting stent implantation in unprotected left main bifurcation lesions

The safety and efficacy of drug-eluting stents (DES) implantation in unprotected left main (LM) bifurcation lesions has yet to be determined. The aim of the present report was to evaluate the long-term outcome following implantation of DES in unprotected LM bifurcation lesions. We identified 70 consecutive patients treated with DES in unprotected LM bifurcation lesions from April 2003 to January 2005. Of them, 42 patients were treated with sirolimus-eluting stent (SES) and 28 patients were treated with paclitaxel-eluting stent (PES). Stents to the left anterior descending and to the circumflex were implanted in 62 patients. During 1-year follow-up, 3 (4.3%) patients died of cardiac causes. One of them had myocardial infarction and adjudicated as possibly due to stent thrombosis. Angiographic follow-up was available in 80% of patients. The per lesion restenosis rate was 13.4% in the entire cohort, of which 10.7% occurred in lesions treated with SES and 16.1% in those treated with PES (P = 0.58). All restenosis was focal and occurred in the lesions treated with a stent with stent size to post-procedural reference vessel diameter ratio < 1.0 (17.6% vs 0, P = 0.04). The per patient target lesion revascularization rate at 1 year was 17.1%. One year survival free from major adverse cardiac events was 77.1%. Treatment of LM bifurcation lesions using DES is a safe and feasible way with a low one-year mortality. The need for revascularization in 17% of patients demands for improvement.

Angioplasty and stenting of an unprotected left main bifurcation lesion

A case of unprotected bifurcation left main disease treated on two occasions by angioplasty and stenting is presented. This case demonstrates the two main features of salvage angioplasty, namely medically refractory rest angina and refused bypass surgery. In addition, it presents short inflation time angioplasty for sole or main conduits and treating the left main as a bifurcation lesion. Cathet. Cardiovasc. Diagn. 41:174–178, 1997. © 1997 Wiley-Liss, Inc.