scholarly journals Randomised comparison of provisional side branch stenting versus a two-stent strategy for treatment of true coronary bifurcation lesions involving a large side branch: the Nordic-Baltic Bifurcation Study IV

Open Heart ◽  
2020 ◽  
Vol 7 (1) ◽  
pp. e000947 ◽  
Author(s):  
Indulis Kumsars ◽  
Niels Ramsing Holm ◽  
Matti Niemelä ◽  
Andrejs Erglis ◽  
Kari Kervinen ◽  
...  
Keyword(s):  
Primary Endpoint ◽  
Side Branch ◽  
Lesion Length ◽  
Complex Treatment ◽  
Cardiac Events ◽  
Main Vessel ◽  
Bifurcation Lesions ◽  
Versus Complex ◽  
Large Side

BackgroundIt is still uncertain whether coronary bifurcations with lesions involving a large side branch (SB) should be treated by stenting the main vessel and provisional stenting of the SB (simple) or by routine two-stent techniques (complex). We aimed to compare clinical outcome after treatment of lesions in large bifurcations by simple or complex stent implantation.MethodsThe study was a randomised, superiority trial. Enrolment required a SB≥2.75 mm, ≥50% diameter stenosis in both vessels, and allowed SB lesion length up to 15 mm. The primary endpoint was a composite of cardiac death, non-procedural myocardial infarction and target lesion revascularisation at 6 months. Two-year clinical follow-up was included in this primary reporting due to lower than expected event rates.ResultsA total of 450 patients were assigned to simple stenting (n=221) or complex stenting (n=229) in 14 Nordic and Baltic centres. Two-year follow-up was available in 218 (98.6%) and 228 (99.5%) patients, respectively. The primary endpoint of major adverse cardiac events (MACE) at 6 months was 5.5% vs 2.2% (risk differences 3.2%, 95% CI −0.2 to 6.8, p=0.07) and at 2 years 12.9% vs 8.4% (HR 0.63, 95% CI 0.35 to 1.13, p=0.12) after simple versus complex treatment. In the subgroup treated by newer generation drug-eluting stents, MACE was 12.0% vs 5.6% (HR 0.45, 95% CI 0.17 to 1.17, p=0.10) after simple versus complex treatment.ConclusionIn the treatment of bifurcation lesions involving a large SB with ostial stenosis, routine two-stent techniques did not improve outcome significantly compared with treatment by the simpler main vessel stenting technique after 2 years.Trial registration numberNCT01496638.

Side branch long lesion with main vessel vulnerable plaques by optical coherence tomography predict target-vessel myocardial infarction after provisional stenting in patients with coronary bifurcation

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
S.L Chen
Keyword(s):  
Side Branch ◽  
Lesion Group ◽  
Lesion Length ◽  
Coronary Bifurcation ◽  
Coronary Bifurcation Lesions ◽  
Vulnerable Plaques ◽  
Main Vessel ◽  
Bifurcation Lesions ◽  
Provisional Stenting ◽  
One Year

Abstract Background Provisional side branch (SB) stenting is correlated with target-vessel myocardial infarction (TVMI) in patients with coronary bifurcation lesions. However, the underlying mechanisms remain unknown. Objectives We aimed to determine the correlation of SB lesion length with vulnerable plaques using optical coherence tomography (OCT) and TVMI in patients with coronary bifurcation lesions treated by a provisional approach. Methods A total of 405 patients with 405 bifurcation lesions who underwent pre-PCI OCT imaging of both main vessel (MV) and SB was prospectively enrolled. Patients were defined as Long-SB lesion (SB lesion length ≥10 mm) and Short-SB lesion (SB lesion length <10 mm) groups according to quantitative coronary analysis and were also stratified by the presence of vulnerable plaques based on OCT findings. The primary endpoint was the occurrence of TVMI after provisional stenting at one-year follow-up. Results 178 (43.9%) patients had long SB lesions. Vulnerable plaques predominantly localized in the main vessel (MV) and more frequently in the Long-SB lesion group (42.7%) compared to 24.2% in the Short-SB lesion group (p<0.001). At one-year follow-up after provisional stenting, there were 31 (8.1%) TVMIs, with 11.8% in the Long-SB lesion group and 4.4% in the Short-SB lesion group (p=0.009), leading to significant difference in target lesion failure between two groups (15.2% vs. 6.6%, p=0.007). The rate of cardiac death, revascularization, and stent thrombosis was comparable between study groups. By multivariate regression analysis, long SB lesion length (p=0.011), presence of vulnerable plaques in the polygon of confluence (p=0.001), and true coronary bifurcation lesions (p=0.004) were three independent factors of TVMI. Conclusions Long-SB lesion length with MV vulnerable plaques predict increased TVMI after provisional stenting in patients with true coronary bifurcation lesions. Further study is warranted to identify the better stenting techniques for coronary bifurcation lesions with long lesion in the SB Kaplan-Meier survival curve Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): NSFC

scholarly journals A Short Term Clinical Outcome of Provisional versus Routine Kissing Balloon Technique after Main Vessel Crossover Stenting for Coronary Bifurcation Lesions

2020 ◽  
pp. 83-93
Author(s):  
Mohamed Ahmed Khalil ◽  
Fatehia Ahmed Elsheshtawy ◽  
Medhat Mohamed Ashmawy ◽  
Samiah Mahmoud Sharaf El-Din ◽  
Ayman Mohamed Elsaeed
Keyword(s):  
Clinical Outcome ◽  
Side Branch ◽  
Balloon Inflation ◽  
Short Term ◽  
Coronary Bifurcation Lesions ◽  
Main Vessel ◽  
Kissing Balloon Technique ◽  
Balloon Technique ◽  
Bifurcation Lesions

Background: Kissing Balloon Inflation (KBI) technique was the first technique for percutaneous intervention in bifurcation lesions. It's the standard strategy in the two-stent procedure. Its benefit in one-stent approach remains uncertain. Several trials comparing KBI strategy with the No-KBI strategy in one-stent technique did not show any advantages in the clinical outcome. Clinical outcome and the follow up of ischemic symptoms is a useful method to compare the effectiveness of both strategies. Aims: To study the short-term clinical outcome (3and 6 months) of provisional versus routine kissing‑balloon technique after main vessel stenting for coronary bifurcation lesions. Patients and Methods: The study included sixty consecutive patients. They were randomized to receive different side branch (SB) intervention strategies: group I (provisional final kissing balloon inflation group - PFKBI) (FKBI only when SB Flow less than TIMI 3) and group II (routine final kissing balloon inflation group – RFKBI). Results: 1- Dissection of side branch and conversion to two stent strategy was significantly higher in PFKBI group (14,3%) than in RFKBI group (0) 2-The amount of dye, total procedure time and time of admission was significantly higher in RFKBI group. 3-Chest pain immediately after the procedure was significantly higher in PFKBI group while at 3 and 6 months follow up no significant difference between both groups was noticed. 4- MACE, target lesion revascularization (TLR) and stent thrombosis were similar between both groups at 3 and 6 months. Conclusions: Main vessel stenting with and without final kissing balloon dilatation was associated with favorable and similar 3 and 6-month clinical outcomes.

scholarly journals Where is the stent? CTA assists angiography: A case of jailed LAD

2021 ◽  
Vol 2 (5) ◽  
Author(s):  
Ilana Golub ◽  
◽  
Suraj Dahal ◽  
Suvasini Lakshmanan ◽  
Matthew J Budoff ◽  
...  
Keyword(s):  
Side Branch ◽  
Coronary Bifurcation Lesions ◽  
Imaging Tool ◽  
Main Vessel ◽  
Procedural Complication ◽  
History Of ◽  
Bifurcation Lesions ◽  
Anatomical Information ◽  
Septal Perforator

Stent malpositioning in the septal perforator is a serious procedural complication and especially prominent after main vessel stenting in coronary bifurcation lesions. This case report demonstrates Computed Tomography Angiography’s (CTA) role as a backup imaging tool, in cases where follow-up Coronary Angiogram (CAG) cannot be immediately completed. CTA also functions as a preferred imaging tool to follow up after stenting and assess for stent malpositioning. A 72-year-old female with history of hypertension and hyperlipidemia presented with dyspnea and was found to have STEMI. About a week after her three PCI’s to the Left Anterior Descending (LAD) artery, she returned to the hospital with recurrent dyspnea and V-Tach. Instead of completing a repeat catheterization, a noninvasive CTA was thought to be the next test. CTA imaging indicates that the failed stenting of the side-branch resulted in a jailed main vessel, which may induce ischemia and ventricular tachycardia (V-Tach). After the malpositioned stent finding on CTA, the patient was then referred to the Cath Lab for angiogram. CTA thus provided detailed anatomical information about the stent’s placement, which will greatly assist further management by the interventional cardiologist.

Side branch FFR after provisional stenting: simplified approach based on OCT frame count

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
A Kini ◽  
N Okamoto ◽  
N Barman ◽  
Y Vengrenyuk ◽  
K Yasumura ◽  
...  
Keyword(s):  
Coronary Artery ◽  
Functional Significance ◽  
Area Under The Curve ◽  
Side Branch ◽  
Funding Source ◽  
Fractional Flow ◽  
Simplified Approach ◽  
Main Vessel ◽  
Bifurcation Lesions ◽  
Provisional Stenting

Abstract Background/Introduction Treatment of bifurcation coronary artery lesions remains a major challenge in interventional cardiology. Side branch (SB) stenoses are frequently observed after stent implantation in bifurcation lesions, although angiographically narrowed SBs may not be functionally significant. Fractional flow reserve (FFR), a pressure-derived index of the hemodynamic significance of a coronary artery stenosis, may be useful in determining whether additional intervention is required in jailed SBs. Angiography and intravascular ultrasound (IVUS) derived parameters have showed poor diagnostic accuracy in predicting the functional significance of jailed SBs. Purpose The aim of the present study was to use high resolution optical coherence tomography (OCT) imaging to predict functionally significant SB stenoses after provisional stenting defined as SB FFR ≤0.80. Methods Seventy-one patients with 71 calcified bifurcation lesions with angiographically intermediate SB stenoses undergoing provisional stenting were enrolled in the prospective study. OCT pullbacks were performed before and after stent placement, and SB FFR was measured after main vessel stenting. SB ostium area (SBOA) was assessed using three-dimensional OCT cut-plane analysis off-line. In addition, we developed a simplified approach to SB ostium assessment based on SB ostium frame count using two-dimensional OCT pullback not requiring off-line 3D reconstruction. For the analysis, consecutive frames were counted between the most distal and most proximal take-off of the SB frames. Results Similar to previous studies, quantitative coronary angiography findings were not associated with the functional significance of SBs after main vessel stenting. In contrast, SBOA assessed by 3D-OCT after provisional stenting strongly correlated with post-procedure SB FFR. The optimal cut-off value for the SBOA area to predict a SB FFR ≤0.80 was 0.76 mm2 (sensitivity 82%, specificity 89% and area under the curve of 0.92 (95% CI: 0.84–0.99). A simplified approach to SB ostium assessment using OCT frame count yielded a sensitivity of 82%, specificity 89% and area under the curve 0.92 (95% CI: 0.84 to 0.99) with a cut-off of 4.5 frames allowing detection of functionally significant SB stenoses during the procedure in real time. Figure 1 shows a receiver-operating characteristic curve for SB FFR ≤0.8 and a representative case with SB FFR = 0.66 after provisional stenting and SB ostium frame count equal 3 (Frame 1 to 3) Conclusion(s) Assessment of SB using either 3D OCT off-line reconstruction or a simplified approach based on OCT frame count can detect SB branches with FFR ≤0.80 with high sensitivity and specificity. The developed approaches may represent a useful tool to assess provisional stent outcomes. Figure 1 Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific; St. Jude Medical

Effect of paclitaxel-coated balloon angioplasty on side branch lesion and cardiovascular outcomes in patients with de novo true coronary bifurcation lesions undergoing percutaneous coronary intervention

2021 ◽  
Author(s):  
Youmei Li ◽  
Qi Mao ◽  
Huanyun Liu ◽  
Denglu Zhou ◽  
Jianhua Zhao
Keyword(s):  
Percutaneous Coronary Intervention ◽  
De Novo ◽  
Coronary Intervention ◽  
Side Branch ◽  
Cardiovascular Outcomes ◽  
Major Adverse Cardiovascular Events ◽  
Coronary Bifurcation ◽  
Percutaneous Coronary ◽  
Bifurcation Lesions

Abstract Purpose To compare the effects of paclitaxal-coated balloon (PCB) versus conventional balloon (CB) on side branch (SB) lesion and cardiovascular outcomes in patients with de novo true bifurcation lesions. Methods In total, 219 patients with de novo true bifurcation lesions were enrolled and divided into PCB group (102 cases) and CB group (117 cases) according to angioplasty strategy in SB. Drug-eluting stent (DES) was implanted in main vessel (MV) for each subject. All subjects underwent a 12-month follow-up for late lumen loss (LLL), restenosis and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI). MACEs included cardiac death, nonfatal myocardial infarction and angina pectoris. Results There were no differences in diameter, minimum lumen diameter (MLD) and stenosis for bifurcation lesions between the two groups before and immediately after PCI (P > 0.05). After 12-month follow-up, no differences occurred in MV-MLD and MV-LLL between the two groups (P > 0.05); SB-MLD in PCB group was higher than that in CB group (1.97 ± 0.36 mm vs. 1.80 ± 0.43 mm, P = 0.007); SB-LLL in PCB group was lower than that in CB group (0.11 ± 0.18 mm vs. 0.19 ± 0.25 mm, P = 0.024). Multivariate COX analyses indicated that PCB group had lower MACE risk than CB group (HR = 0.480, 95%CI 0.244–0.941, P = 0.033). Conclusion PCB could decrease SB-LLL and MACE risk in patients with de novo true coronary bifurcation lesion 12 months after single-DES intervention.

scholarly journals Coronary Bifurcation Lesion–Management

2020 ◽  
Vol 5 (02) ◽  
pp. 137-154
Author(s):  
Maddury Jyotsna
Keyword(s):  
Management Strategy ◽  
Cardiac Events ◽  
Coronary Bifurcation ◽  
Bifurcation Lesion ◽  
Adverse Cardiac Events ◽  
Drug Eluting ◽  
Bifurcation Lesions ◽  
Coronary Bifurcation Lesion ◽  
Modern Era

AbstractCoronary bifurcation lesion management is challenging even in this modern era of drug-eluting stents (DES). A debate always exists as to what mode of treatment is better–one-stent or two-stent strategy. As in hospital and major adverse cardiac events (MACE) are more in the follow-up, what improvements in management strategy are required in relation to bifurcation lesions? We have more questions than answers for this type of lesion. In this article, we try to analyze these issues.

P5753Jailed pressure wire to assess the side branch result for bifurcation lesions treated by provisional stenting strategy: iFR as a new index

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
M Romero ◽  
F Hidalgo ◽  
S Ojeda ◽  
J Segura ◽  
J Suarez De Lezo ◽  
...  
Keyword(s):  
Side Branch ◽  
Diagonal Branch ◽  
Coronary Syndrome ◽  
Bifurcation Lesion ◽  
Pressure Wire ◽  
Bifurcation Lesions ◽  
Microscopic Damage ◽  
The Wire ◽  
Provisional Stenting

Abstract Purpose To analyze the feasibility and efficacy of the jailed pressure wire technique for bifurcation lesions treated by provisional stenting strategy and to assess the physiological side branch (SB) result using instantaneous wave free ratio (iFR). Methods Between June 2017 and December 2018, 50 patients who presented a bifurcation lesion considered appropriate for provisional stenting strategy were included in the study. Pressure wire was passed to side branch before treatment. Main vessel (MV) and side branch (SB) was predilated at the operator criteria. iFR determination was obtained in the SB baseline and after MV stenting (leaving the pressure wire jailed). Afterwards, the wire was removed to MV ostium to discard the possibility of drift. SB postdilation was performed if SB iFR was less than 0,89 (according to vessel thresholds established in clinical trials), evaluating the result by a new iFR determination. Results The mean age was 64±10 years. Sixteen patients (32%) had diabetes. Clinical presentation was stable angina in 26 patients (52%), non-STEMI in 19 patients (38%) and STEMI (non culprit lesion) in 5 patients (10%). The most frequent bifurcation type according to Medina classifications was 1,1,0 (21 patients, 42%). Seventeen patients (34%) had a true bifurcation lesion. The MV and SB reference diameter was 3,0±0,5 mm and 2,25±0,5 mm respectively. Most of the bifurcations were located at the left anterior descending artery/diagonal branch (27 bifurcations, 54%). Ten patients (20%) presented a distal left main bifurcation. Baseline SB iFR was 0,78±0,2. Under continuous SB iFR monitoring MV stenting was performed by trapping the pressure wire. After MV stenting, the SB iFR changed to 0,90±0,1. We confirmed the presence of drift in 5 patients (10%). In these cases, recalibration of the wire and SB rewiring was performed in 4 cases. In the remaining patient, rewiring was not possible even using specific coronary wires. According to SB IFR, postdilation was necessary in 14 patients (28%). Final SB iFR was 0,94±0,03. A second stent was not necessary in any patient because final SB iFR was higher than 0.89 in all cases. We observed discordance between angiographic and physiological result in 17 cases (34%). All the wires could be removed. Forty wires (80%) were microscopically analyzed. Some grade of microscopic damage was found in 32 wires (80%), all of them distal to the pressure sensor. However, only one of these wires (2%) presented severe damage, and no case of fracture was observed. After a mean follow up time of 10±6 months only one patient (2%) presented a major cardiac adverse event (acute coronary syndrome due to voluntary cessation of dual antiplatelet therapy). Conclusions The use of jailed pressure wire to monitor SB results for bifurcations treated by provisional stenting seems to be safe. The iFR index seems to provide new physiological information about the significance of the SB stenosis.

scholarly journals One-Year Follow-Up Results From the Observational, Multicenter, Prospective, and Controlled Registry: The WALTZ All-Comers Study

2019 ◽  
Vol 13 ◽  
pp. 117954681985405 ◽  
Author(s):  
Alfredo E Rodriguez ◽  
Miguel Larribau ◽  
Carlos Fernandez-Pereira ◽  
Jorge Iravedra ◽  
Omar Santaera ◽  
...  
Keyword(s):  
Primary Endpoint ◽  
Cardiac Death ◽  
Risk Scores ◽  
Exclusion Criterion ◽  
Cobalt Chromium ◽  
Left Main ◽  
Cardiac Events ◽  
Vessel Disease ◽  
Coronary Stent Implantation

The aim of this study was to evaluate 1-year follow-up results in an all “comers” population treated with a new cobalt chromium bare-metal stent (BMS) design. Since August 2016 to March 2017, 201 (9.7% of screening population) consecutive patients undergoing coronary stent implantation in 11 centers in Argentina were prospectively included in our registry. The inclusion criteria were multiple-vessel disease and/or unprotected left main disease, acute coronary syndromes (ACS) with at least one severe (⩾70%) stenosis in any of major epicardial vessel. In-stent restenosis, protected left main stenosis, or impossibility to receive dual-antiplatelet therapy was an exclusion criterion. Major adverse cardiac events (MACE) were the primary endpoint and included cardiac death, myocardial infarction (MI), and target lesion revascularization (TLR); also, all components of the primary endpoint were separately analyzed. Completeness of revascularization was analyzed as post hoc data using residual SYNTAX or ERACI risk scores. Demographic characteristics showed that 6.5% of patients were very elderly, 22.5% have diabetes, 47% have multiple-vessel disease, 67% have ACS, and 32% have ST elevation MI. At a mean of 376 ± 18.1 days of follow-up, MACE was observed in 10.4% of patients: death + MI + cardiovascular accident (CVA) in 3% (6 of 201) and cardiac death + MI + CVA in 1.5% (3 of 201). Residual ERACI score ⩽5 was associated with 98% of event-free survival ( P < .04). In conclusion, this prospective, multicenter, and observational all-comers registry with this novel BMS design showed a low incidence of adverse events at 1 year mainly due to coronary restenosis.

scholarly journals The Proximal Optimisation Technique for Intervention of Coronary Bifurcations

2017 ◽  
Vol 12 (02) ◽  
pp. 110 ◽  
Author(s):  
Angela Hoye ◽  
Keyword(s):  
Clinical Data ◽  
Stent Implantation ◽  
Optimal Strategy ◽  
Balloon Dilation ◽  
Side Branch ◽  
Review Article ◽  
Main Vessel ◽  
Bifurcation Lesions ◽  
Optimisation Technique

The proximal optimisation technique (POT) has been proposed as a strategy to improve the results of stent scaffolding of bifurcation lesions. It is a straightforward technique whereby a short, appropriately-sized balloon is inflated in the main vessel just proximal to the carina. The technique has several advantages: it reduces the risk of side branch compromise related to shifting of the carina, it improves stent apposition in the proximal main vessel, and it facilitates side branch access after main vessel stent implantation. When treating bifurcations, final kissing balloon dilation (KBD) has traditionally been used routinely to optimise angiographic results. However, recent clinical data have questioned this philosophy and bench models have demonstrated several shortcomings of KBD. Instead, the optimal strategy may centre on performing POT, followed by side branch dilation, and completed with a final (re)-POT. The following review article describes how to perform POT and presents the evidence to support its� routine use.

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