Unprotected Left Main Bifurcation Research Articles

Long-term outcomes of percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main coronary bifurcation disease in the drug-eluting stent era

ObjectivesThere are limited data on long-term outcomes (ie, beyond 4 years) for patients with unprotected left main bifurcation disease who underwent percutaneous coronary intervention (PCI) or coronary artery bypass graft...

AS-164 Crushing versus Kissing Stenting in ‘Real World' Unprotected Left Main Bifurcation Intervention with Drug-Eluting Stents

AS-164 Crushing versus Kissing Stenting in ‘Real World' Unprotected Left Main Bifurcation Intervention with Drug-Eluting Stents

AS-174 Role of Final Kissing Balloon for Unprotected Distal Left Main Bifurcation Intervention with Single Stent Strategy

AS-174 Role of Final Kissing Balloon for Unprotected Distal Left Main Bifurcation Intervention with Single Stent Strategy

AS-030 Long-Term Results of the Dominance of 1-Stent Strategy in the Unprotected Left Main Coronary Bifurcation Lesion

Although 1-stent strategy in the bifurcation lesion is recommended, a high proportion (30-56%) of 2-stent deployment has been still performed in the left main coronary artery (LMCA) bifurcation in the recent studies. The purpose of this study is to investigate the results of the dominance of 1-stent strategy for the unprotected LMCA bifurcation lesion.

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

Background: 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) between left main (LM) and left anterior descending artery (LAD) on clinical outcomes after single stenting (LM to LAD) have never been documented. Therefore, we investigated the impact of this angle on clinical outcomes after cross over single stent strategy in this study. Methods: A total of 170 patients who underwent PCI in unprotected LM bifurcation with successful single cross over stenting from the LM into the LAD were enrolled. The proximal BA (BA between LM and LAD: shown in Fig.A) were computed in end-diastole before PCI with 3D QCA software. The patients were classified into three groups according to the tertile of the proximal BA(low BA group; n=57, middle BA group; n=57, and high BA group; n=56, shown in Fig.B)The cumulative incidence of major adverse cardiac event (...

Modified culotte stenting for treatment of unprotected left main coronary bifurcation lesions: immediate outcomes

Background and ObjectivesThe optimal stenting strategy for the treatment of unprotected left main coronary bifurcation lesions (UPLMCBLs) remains uncertain. Present study observed the technical feasibility and immediate outcomes of the...

Long‐Term Outcomes of Sirolimus‐Eluting Stents vs Paclitaxel‐Eluting Stents in Unprotected Left Main Coronary Artery Bifurcation Lesions

The treatment of unprotected left main coronary artery (uLMCA) bifurcation lesions remains challenging. We hypothesized that the type of drug-eluting stent would correlate with clinical outcomes for the treatment of uLMCA bifurcation lesions. One hundred fifteen patients who underwent stent implantation using a provisional T-stenting technique with sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) for uLMCA bifurcation lesions were enrolled. A major adverse cardiac event (MACE) was defined as a composite of cardiac death, myocardial infarction, or target lesion revascularization. Ninety-four patients were treated with SES and 21 patients with PES. Baseline characteristics were similar between the 2 groups. Angiographic follow-up was performed in 99 (86%) patients. Late loss in the LMCA to the left anterior descending coronary artery was significantly lower in the SES group than in the PES group (0.28 ± 0.54 mm vs 1.03 ± 0.45 mm, P<0.001). One case of stent thrombosis occurred in the SES group. During follow-up with a median of 712 days, the SES group had a lower MACE compared with the PES group (10.6% vs. 28.6%, P = 0.032). Cox proportional hazards models including age, sex, diabetes, acute coronary syndrome, true bifurcation, stenting strategy, and type of drug-eluting stent used (SES vs. PES) demonstrated that stent type was the only predictor of MACE (hazard ratio of PES vs SES: 3.88, 95% confidence interval: 1.29-11.67, P = 0.016). According to the results of the present study, SES may be associated with more favorable outcomes than PES for stenting of uLMCA bifurcation, which should be further studied by larger trials.

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).

Effect of Intravascular Ultrasound Findings on Long-Term Repeat Revascularization in Patients Undergoing Drug-Eluting Stent Implantation for Severe Unprotected Left Main Bifurcation Narrowing

We studied the effect of the preprocedural intravascular ultrasound findings on stent expansion and the pre- and postprocedural findings on the long-term clinical outcomes in patients undergoing drug-eluting stent implantation for unprotected left main (LM) bifurcation disease. Using a left anterior descending (LAD) pullback, we evaluated the ostial LAD artery (3 mm distal to the carina), the polygon of confluence (POC; the confluent zone of the LAD artery and left circumflex artery), and the distal LM artery (3 mm just proximal to the POC). The measurements included the minimum lumen area (MLA) and minimum stent area within each segment. In 168 LM bifurcations, the preprocedural MLA and post-stenting minimum stent area within the LM artery were located within the POC in 41% and 70%, respectively. Independent predictors for the post-stent minimum stent area within the distal portion of LM artery above the LAD carina were the preprocedural lumen area of the LAD carina (β = 0.253, 95% confidence interval [CI] 0.10 to 0.36, p = 0.001) and preprocedural MLA within the POC (β = 0.205, 95% CI 0.04 to 0.23, p = 0.008). During the 41.8 ± 18.0-month follow-up period, 26 patients experienced cardiac events. In the multivariate Cox model, female gender (adjusted hazard ratio 2.56, 95% CI 1.173 to 5.594, p = 0.018) and preprocedural MLA within the POC (adjusted hazard ratio 0.829, 95% CI 0.708 to 0.971, p = 0.020) were independent predictors for the occurrence of events at 3 years of follow-up. In conclusion, as assessed by the LAD pullback, the preprocedural MLA within the POC was a surrogate reflecting the overall severity of LM bifurcation disease, contributed to the post-stent minimum stent area within the distal segment of LM bifurcation, and was a predictor of clinical events during follow-up.

Comparison of single‐ versus two‐stent techniques in treatment of unprotected left main coronary bifurcation disease

This study sought to compare 3-year outcomes of single- versus two-stent techniques in patients with distal unprotected left main coronary artery (LMCA) disease treated with drug-eluting stents (DES). A total of 392 patients with distal unprotected LMCA disease who underwent DES implantation with single- (n = 234) or two- (n = 158) stent techniques were evaluated. The primary end point was major adverse cardiac events (MACE), defined as the composite of death, myocardial infarction (MI), and target lesion revascularization (TLR). The two-stent group was more likely to have extensive coronary artery stenosis. After adjustment with weighted Cox model using the inverse probability of treatment weighting, the 3-year risk of death was similar in the single- and two-stent groups (hazard ratio [HR], 0.77, 95% confidence interval [CI], 0.28-2.13, P = 0.62). However, the 3-year risks of MI (HR, 0.38, 95% CI, 0.19-0.78, P = 0.008), TLR (HR, 0.16, 95% CI, 0.05-0.57, P = 0.005), and MACE (HR, 0.89, 95% CI, 0.22-0.67, P = 0.0007) were significantly lower in the single-stent group. Compared with the two-stent technique, the single-stent technique showed more favorable long-term clinical outcomes in patients with distal unprotected LMCA disease who received DES

Conundrum: intervention for unprotected left main bifurcation coronary lesions

Conundrum: intervention for unprotected left main bifurcation coronary lesions

TCT-62: Intravascular Ultrasound Data Analysis in Patients Undergoing Drug Eluting Stent Implantation for Unprotected Left Main Bifurcation Disease

TCT-62: Intravascular Ultrasound Data Analysis in Patients Undergoing Drug Eluting Stent Implantation for Unprotected Left Main Bifurcation Disease

AS-193: Simultaneous Versus Sequential Kissing Stenting in Real-World Unprotected Left Main Intervention with Drug-Eluting Stents

Unprotected left main (LM) bifurcation angioplasty with drug-eluting stents (DES) is being performed by either simultaneous or sequential kissing stenting, but their safety and efficacy has not yet been reported. We evaluated the safety and efficacy of different kissing stenting strategies in true LM bifurcation intervention up to 12 months.

AS-155: Single- Versus 2-Stent Techniques in the Treatment of Unprotected Left Main Bifurcation Disease under Intravascular Ultrasound Guidance

AS-155: Single- Versus 2-Stent Techniques in the Treatment of Unprotected Left Main Bifurcation Disease under Intravascular Ultrasound Guidance

Side Balloon Stenting of the Left Main Bifurcation: A Three‐Year Angiographic Follow‐Up

None of the currently used interventional techniques yield durable results for coronary bifurcation lesions. We successfully treated a patient with unprotected left main bifurcation disease using a side balloon stent technique with a drug-eluting stent (DES). This technique produced excellent immediate and long-term results.

Re-evaluating risk factors for periprocedural complications during percutaneous coronary intervention in patients with unstable angina/non-ST-elevation myocardial infarction: who may benefit from more intensive antiplatelet therapy?

Controversy regarding the optimal antiplatelet/antithrombotic regimen indicates a need to re-evaluate the place of these agents in treating patients with unstable angina/non-ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention. Although clinical trial data suggest that glycoprotein IIb-IIIa inhibition benefits moderate-risk to high-risk patients, recent studies question the use of intensive antiplatelet therapy in lower risk patients. The resultant shift towards less intensive alternative regimens raises questions about identifying patients in whom an alternative strategy is preferable. The concept of risk stratification for coronary intervention has evolved from lesion-based categorization to include clinical factors, for example, elevated levels of cardiac troponin. Risk factors for periprocedural complications during percutaneous coronary intervention can be divided into anatomic (unprotected left main stenting, bifurcation lesions, and diffuse disease) and clinical (older age, diabetes, renal disease, left ventricular function, recent myocardial damage, and female sex) factors. These may interact additively or synergistically, increasing the likelihood of complications in patients who might otherwise have been considered at low risk. We need to reconsider, therefore, how we identify appropriate options and, hopefully, optimize clinical outcomes. This review evaluates risk factors for periprocedural complications in an effort to determine patients who may benefit most from intensive antiplatelet regimens.

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.

Which is the most appropriate stenting technique with drug‐eluting stent for unprotected left main bifurcation stenosis?

Which is the most appropriate stenting technique with drug‐eluting stent for unprotected left main bifurcation stenosis?

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.

Stenting of Unprotected Distal Left Main Coronary Artery Bifurcation Stenoses Using Modified Crush Technique with Double Kissing Balloon Inflation (Sleeve Technique): Immediate Procedure Result and Early Clinical Outcome

Sleeve technique is a modified version of the crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter. This study sought to look at the feasibility, safety, and early clinical outcome of sleeve technique in stenting of unprotected distal left main coronary artery (LMCA) bifurcation stenoses. From August 2005 to April 2006, 12 consecutive patients with symptomatic distal LMCA bifurcation stenoses of diameter narrowing > or =50%, who refused coronary artery bypass graft surgery, were treated with two-stent strategy using the sleeve technique. Eleven patients (91.7%) were male, with a mean age of 64.4 +/- 9.3 years. Intravenous abciximab was given to 10 patients (83.3%). The baseline reference vessel diameters of the main vessel and side branch were 3.32 +/- 0.44 and 3.00 +/- 0.58 mm, respectively. After intervention, the minimal luminal diameter was increased from 0.99 +/- 0.46 to 3.26 +/- 0.28 mm and 1.43 +/- 0.71 to 2.93 +/- 0.45 mm in the main vessel and side branch, respectively. The intervention procedure was successful in all patients with 100% final kissing balloon inflation rate. The average procedure time was 58.6 +/- 20.5 minutes. Two patients had a small non-Q myocardial infarction postprocedure. The resultant major adverse cardiac event rate was 16.7% at 30 days after the procedure. Sleeve technique is a safe and feasible approach in the stenting of distal LMCA bifurcation stenoses.