Immediate and long-term outcome of intracoronary stent implantation for true bifurcation lesions

Early and long-term outlook of percutaneous coronary intervention for bifurcation lesions in young patients

BACKGROUND

Coronary artery disease is most common in older patients, but may occur in younger subjects. The outlook of young patients after percutaneous coronary intervention (PCI) of challenging lesion subsets such as coronary bifurcations, is not established. We thus aimed to appraise the early and long-term results of PCI for bifurcations in young patients.

METHODS

A multicenter, retrospective study was conducted enrolling consecutive patients undergoing bifurcation PCI between 2002 and 2006 in 22 Italian centers. Patients were divided in 2 groups: age ≤ 45 years, and age > 45 years. The primary end-point was long-term rate of major adverse cardiac events (MACE).

RESULTS

4,314 patients were included: 195 (4.5%) in the younger group, and 4119 (95.5%) in the older group. 30-day outcomes did not show significant differences in MACE rates, with 1.0% in the ≤ 45 years group and 2.1% in the >45 years group (p=0.439), with death in 0.5% and 1.2% (p=0.388). At long-term follow-up (24.4 ± 15.1 months), younger patients showed similar rates of MACE, (12.8% vs. 16.6%, p=0.161), myocardial infarction (3.1% vs. 3.7%, p=0.633), target lesion revascularization (11.3% vs. 12.5%, p=0.627), or stent thrombosis (1.5% vs. 2.8%, p=0.294), despite an increased risk of death in older patients (1.0% vs. 5.0%, p=0.012). Even at extensive multivariable analysis, younger patients still faced a similar risk of MACE (HR=0.78 [0.48-1.27], p=0.318).

CONCLUSIONS

Despite their low age, young patients undergoing PCI for bifurcation face a significant risk of early and late non-fatal adverse events. Thus, they should not be denied careful medical management and follow-up.

Atheroma and coronary bifurcations: before and after stenting

First generation drug-eluting stents (DES) have significantly improved the treatment options for patients with symptomatic coronary artery disease by decreasing rates of restenosis after percutaneous coronary revascularisation procedures. However, early enthusiasm was tempered by reports of late stent thrombosis, primarily in "off-label" use. In particular, the treatment of atherosclerotic plaques at coronary bifurcations has been challenging for interventional cardiologists regardless of the stent choice due to the underlying nature of the atherosclerotic disease and the use of multiple stents. In this article we illustrate the location and severity of plaque and investigate the healing following both bare metal stents (BMS) and drug-eluting stents (DES) at bifurcations using post-mortem specimens. The presented data will demonstrate that neointimal growth following stent implantation correlate to flow conditions, as there is less underlying atherosclerotic disease at high shear regions and subsequently less neointimal growth is observed in these regions versus low shear regions. The occurrence of late stent thrombosis in DES is also shown to be associated with greater presence of uncovered stent struts at the high shear region, which is likely due to local flow mechanics.

Effect of statins on coronary bifurcation atherosclerosis: an intravascular ultrasound virtual histology study

This study is aimed at assessing by intravascular ultrasound virtual histology (VH-IVUS) the effect of statins on coronary bifurcation atherosclerosis in non-culprit vessels. In this non-randomized study, in 48 patients, 51 bifurcation atherosclerotic sites in non-culprit vessels without significant angiographic stenosis, underwent baseline and 12 months follow-up VH-IVUS. Patients received treatment with either simvastatin (20 mg daily, n = 24) or rosuvastatin (10 mg daily, n = 24) for the same period. VH-IVUS analysis of bifurcation lesions included the 5-mm proximal, bifurcation only (side-branch point) and 5-mm distal subsegments. Overall plaque and external elastic membrane volume decreased after 1 year (115.7 ± 35.5 to 106.1 ± 29.3 mm³, P < 0.001; and 241.0 ± 57.0 to 232.4 ± 54.2 mm³, P = 0.005, respectively). Similarly, overall dense calcium volume significantly increased (7.1 ± 5.3 to 11.0 ± 8.5 mm³, P < 0.010), while fibrous and fibrofatty volumes significantly decreased (36.9 ± 19.2 to 24.1 ± 11.7 mm³, P < 0.001; and 5.1 ± 3.8 to 2.3 ± 2.0 mm³, P < 0.001, respectively), and necrotic core volume did not change significantly (17.0 ± 11.1 to 19.8 ± 13.5 mm³, P = 0.053). There were no significant differences in compositional analysis between the simvastatin and rosuvastatin treatment groups. However, within groups, necrotic core volume significantly increased in the simvastatin treatment group (19.7 ± 13.9 to 24.3 ± 16.1 mm³, P = 0.029) but not in the rosuvastatin treatment group. (14.3 ± 6.7 to 15.6 ± 8.7 mm³, P = 0.423). The independent clinical predictors for reduction of necrotic core volume by multiple stepwise logistic regression analysis were the percent change of HDL-cholesterol level (P = 0.041, odds ratio: 1.052, 95% confidence interval (CI): 1.002 to 1.104) and the percent change of hsCRP level (P = 0.021, odds ratio: 0.989, 95% CI: 0.980 to 0.998). After 1 year, overall dense calcium volume significantly increased whilst fibrous and fibrofatty volumes significantly decreased; no significant change in the content of necrotic core was observed. Although changes in the volumes of all plaque components were not significantly different between the simvastatin and rosuvastatin treatment groups, halting of necrotic core progression was apparent in the rosuvastatin group.

Stenting of complex lesions: an overview

Contemporary management of coronary artery disease relies increasingly on percutaneous techniques combined with medical therapy. Although percutaneous coronary intervention (PCI) can be performed successfully in most lesions, several difficult lesion subsets continue to present unique technical challenges. These complex lesions may be classified according to anatomic criteria, including extensive calcification, thrombus, and chronic occlusions, or by location, such as bifurcations, saphenous vein grafts and unprotected left main. PCI of these lesions often requires novel devices, such as drug-eluting stents, hydrophilic guidewires, distal protection balloons or filters, thrombectomy catheters, rotational atherectomy, and cutting balloons. An integrated approach that combines these devices with specialized techniques and adjunctive pharmacologic agents has greatly improved PCI success rates for these complex lesions.

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

BACKGROUND

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).

METHODS AND RESULTS

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.

CONCLUSION

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

Effects of disturbed flow on vascular endothelium: pathophysiological basis and clinical perspectives

Vascular endothelial cells (ECs) are exposed to hemodynamic forces, which modulate EC functions and vascular biology/pathobiology in health and disease. The flow patterns and hemodynamic forces are not uniform in the vascular system. In straight parts of the arterial tree, blood flow is generally laminar and wall shear stress is high and directed; in branches and curvatures, blood flow is disturbed with nonuniform and irregular distribution of low wall shear stress. Sustained laminar flow with high shear stress upregulates expressions of EC genes and proteins that are protective against atherosclerosis, whereas disturbed flow with associated reciprocating, low shear stress generally upregulates the EC genes and proteins that promote atherogenesis. These findings have led to the concept that the disturbed flow pattern in branch points and curvatures causes the preferential localization of atherosclerotic lesions. Disturbed flow also results in postsurgical neointimal hyperplasia and contributes to pathophysiology of clinical conditions such as in-stent restenosis, vein bypass graft failure, and transplant vasculopathy, as well as aortic valve calcification. In the venous system, disturbed flow resulting from reflux, outflow obstruction, and/or stasis leads to venous inflammation and thrombosis, and hence the development of chronic venous diseases. Understanding of the effects of disturbed flow on ECs can provide mechanistic insights into the role of complex flow patterns in pathogenesis of vascular diseases and can help to elucidate the phenotypic and functional differences between quiescent (nonatherogenic/nonthrombogenic) and activated (atherogenic/thrombogenic) ECs. This review summarizes the current knowledge on the role of disturbed flow in EC physiology and pathophysiology, as well as its clinical implications. Such information can contribute to our understanding of the etiology of lesion development in vascular niches with disturbed flow and help to generate new approaches for therapeutic interventions.

Anatomic and Functional Evaluation of Bifurcation Lesions Undergoing Percutaneous Coronary Intervention

Background— We sought to investigate the mechanism of geometric changes after main branch (MB) stent implantation and to identify the predictors of functionally significant “jailed” side branch (SB) lesions.

Methods and Results— Seventy-seven patients with bifurcation lesions were prospectively enrolled from 8 centers. MB intravascular ultrasound was performed before and after MB stent implantation, and fractional flow reserve was measured in the jailed SB. The vessel volume index of both the proximal and distal MB was increased after stent implantation. The plaque volume index decreased in the proximal MB (9.1�3.0 to 8.4�2.4 mm 3 /mm, P =0.001), implicating plaque shift, but not in the distal MB (5.4�1.8 to 5.3�1.7 mm 3 /mm, P =0.227), implicating carina shifting to account for the change in vessel size (N=56). The mean SB fractional flow reserve was 0.71�0.20 (N=68) and 43% of the lesions were functionally significant. Binary logistic-regression analysis revealed that preintervention % diameter stenosis of the SB (odds ratio=1.05; 95% CI, 1.01 to 1.09) and the MB minimum lumen diameter located distal to the SB ostium (odds ratio=3.86; 95% CI, 1.03 to 14.43) were independent predictors of functionally significant SB jailing. In patients with ≥75% stenosis and Thrombolysis In Myocardial Infarction grade 3 flow in the SB, no difference in poststent angiographic and intravascular ultrasound parameters was found between SB lesions with and without functional significance.

Conclusions— Both plaque shift from the MB and carina shift contribute to the creation/aggravation of an SB ostial lesion after MB stent implantation. Anatomic evaluation does not reliably predict the functional significance of a jailed SB stenosis.

Clinical Trial Registration: http://www.clinicaltrials.gov. Unique Identifier: NCT00553670.

Clinical safety and efficacy of a novel thin-strut cobalt-chromium coronary stent system: results of the real world Coroflex Blue Registry

OBJECTIVES

The aim of this registry was to evaluate the clinical efficacy and safety of the Coroflex Blue cobalt-chromium stent in real-world practice.

BACKGROUND

The development of cobalt-chromium bare-metal stents (BMS) with thinner struts has lead to better deliverability and lower target-lesion revascularization rates compared with stainless steel BMS.

METHODS

The Coroflex Blue Registry was an international, prospective, multicenter registry enrolling patients with symptomatic ischemic heart disease attributable to single de novo or restenotic nonstented lesions of a single vessel amenable for percutaneous stenting. The primary end point was clinically driven target-lesion revascularisation (TLR) 6 months after enrolment, secondary endpoints were technical/procedural success, in-hospital outcome, definite stent thrombosis and major adverse cardiac events (death, myocardial infarction, or TLR) after 6 months.

RESULTS

The registry included 2,315 patients (mean age 64.3 +/- 11.1 years, 19.8% diabetes, 37.3% acute myocardial infarction). Although a complex lesion cohort with 60.3% Typ B(2)/C-lesions, the technical success rate was 99.1% and the procedural success rate 98.5%. The incidence of TLR after 6 months was 5.5% and the cumulative 6-month acute/subacute stent thrombosis rate was 1.6%. After 6 months cumulative event-free survival was 90.8% in all patients and 87% in patients with acute PCI for acute myocardial infarction.

CONCLUSIONS

This registry demonstrates the safety and efficacy of the Coroflex Blue cobalt-chromium stent platform in real-world practice. In the era of drug-eluting stents (DES), these results raise the serious question if the use of DES for primary prevention of restenosis and TLR is really justified.

Long-term outcome of percutaneous catheter intervention for de novo coronary bifurcation lesions with drug-eluting stents or bare-metal stents

BACKGROUND

The purpose of this study was to assess the long-term risks and benefits of drug-eluting stents (DESs) compared with bare-metal stents (BMSs) for treatment of coronary bifurcation lesions.

METHODS

Our registry comprised 1,038 patients treated for coronary bifurcation lesion according to the provisional T-stenting strategy who were followed up for 3 years.

RESULTS

Target lesion revascularization rates were 24.3% for BMSs (n = 337), 15.6% for sirolimus-eluting stents (SESs, n = 422), and 17.3% for paclitaxel-eluting stents (PESs, n = 279) (P = .003 BMSs vs DESs, P = .54 SESs vs PESs). The respective incidences were 11.4%, 9.5%, and 14.8% (P = .65, P = .13) for death and myocardial infarction and 9.9%, 6.5%, and 10.6% (P = .72, P = .19) for death. Propensity score adjusted hazard ratios (95% CI) for DESs versus BMSs were 0.49 (0.35-0.68, P < .001) for target lesion revascularization, 0.94 (0.64-1.40, P = .078) for death and myocardial infarction, and 0.85 (0.55-1.32, P = .47) for death. We did not find any significant differences between SESs and PESs, except for an increased risk of death after PESs compared with SESs (but not BMSs) in the subgroup receiving a side-branch stent (adjusted hazard ratio 2.45, 95% CI 1.05-5.73, P = .035).

CONCLUSIONS

Compared with BMSs, both PESs and SESs substantially reduced the long-term need for repeated revascularization but did not increase the risk of death and myocardial infarction.

Interventional Therapy of Bifurcation Lesions

Background— Treatment of bifurcations is a complex problem. The clinical value of treating side branches is an unsolved problem in the field of interventional cardiology.

Methods and Results— We initiated a prospective randomized controlled trial. One hundred and ten patients with bifurcations were randomly assigned to 2 arms: Stenting of the main branch (MB, Taxus-stent, paclitaxel-eluting stents) and mandatory side branch (SB) percutaneous coronary intervention (PCI; kissing balloons) with provisional SB stenting (therapy A), or stenting of the MB (paclitaxel-eluting stents) with provisional SB-PCI only when the SB had a thrombolysis in myocardial infarction flow <2 (therapy B). The primary end point was target lesion revascularization. The mean ages were 66.8 years (A) versus 65.1 years (B, P =0.4), 71.4% (A) versus 77.8% were men ( P =0.4), patients with diabetes were present in 25.0% versus 25.9% ( P =0.9). The MB was left anterior descending artery in 80.4% versus 81.5% (A versus B, P =0.9). The SB-PCI and kissing balloon-PCI were performed according to the study protocol in 82.1%/73.2% versus 16.7%/13.0% ( P <0.05 for both), while changing of the intended therapy was necessary in 17.9% versus 16.7% (A versus B, P =0.9). A final thrombolysis in myocardial infarction flow 3 (MB) was reached in all patients (groups A and B), final thrombolysis in myocardial infarction flow 3 (SB) was observed in 96.4% versus 88.9% (A versus B, P =0.3). Radiation time (min) and contrast medium (mL) were 14.2/210 (group A) versus 7.8/151.6 (group B; P for both <0.05). Six month – follow up: major adverse cardiac events was 23.2% (A) versus 24.1% (B, P =0.9), target lesion revascularization was 17.9% (A) versus 14.8% (B, P =0.7), and late lumen loss (MB) was 0.2 mm (A) versus 0.3 mm (B, P =0.5). In group B, no PCI of the SB was done during follow up.

Conclusion— A simple strategy using paclitaxel-eluting stents with only provisional SB-PCI may be of equal value to a more complex strategy with mandatory SB-PCI.

Clinical Trial Registration— URL: http://www.controlled.trials.com. Unique identifier: ISRCTN22637771.

Percutaneous therapy of bifurcation lesions with drug‐eluting stent implantation: the Culotte technique revisited

INTRODUCTION

The most effective strategy for bifurcation stenting is currently undefined. The Culotte technique was developed as a method that ensures complete bifurcation lesion coverage. However, it went out of favour due to a high rate of restenosis when utilizing bare metal stents. Drug-eluting stents reduce the rate of restenosis and need for repeat lesion revascularization compared with bare metal stents; we re-evaluated this technique with drug-eluting stent implantation.

METHODS

Between April 2002 and October 2003, 207 patients were treated for at least one bifurcation lesion with drug-eluting stent implantation to both the main vessel and side branch. Of these, 23 were treated with the Culotte technique (11.1%) for 24 lesions. Sirolimus-eluting stents were used in 8.3%, and paclitaxel-eluting stents in the remaining 92.7%.

RESULTS

Clinical follow-up was obtained in 100%. One patient had a myocardial infarction at 14 days (maximum rise in creatine kinase 872 IU/L) related to thrombosis occurring in another lesion, and underwent repeat revascularization. There were no episodes of stent thrombosis in the Culotte lesions. At eight months follow-up, there were no deaths and no further myocardial infarction. One patient required target lesion revascularization (TLR), and a second underwent target vessel revascularization. The cumulative rates of survival-free of TLR and major adverse cardiac events were 94.7% and 84.6% respectively. Angiographic follow-up was obtained in 16 patients (69.6%) at a mean period of 8.3+/-4.3 months. The late lumen loss for the main vessel and side branch were 0.48+/-0.56 mm and 0.53+/-0.33 mm respectively, with binary restenosis rates of 18.8% and 12.5%.

CONCLUSIONS

In this small study of bifurcation stenting utilizing the Culotte technique with drug-eluting stent implantation, there was a low rate of major adverse events and need for target lesion revascularization at eight months, when compared with historical data of bifurcation stenting with bare metal stents. Further re-evaluation of this technique utilizing drug-eluting stents, is warranted in the setting of larger randomized studies.

Evaluation of a strategy for treating bifurcated lesions by single or double stenting based on the Medina classification

INTRODUCTION AND OBJECTIVES

The Medina bifurcated lesion classification has been widely adopted because of its simplicity. However, no data are available on its use in helping select the best stenting technique for bifurcations.

METHODS

Consecutive patients with bifurcated lesions (side branch >or=2.25 mm) were prospectively assessed using the Medina classification. The treatment strategy studied involved implanting two stents in lesions with a Medina classification of 1,1,1 (M3 group) and one stent in only the main vessel in lesions with other Medina classifications (OM group). Clinical endpoints were a major adverse cardiac event (MACE) and target lesion revascularization (TLR) during hospitalization and at 12-month follow-up.

RESULTS

The study included 120 patients: 25 in the M3 group and 95 in the OM group. There was no difference in baseline characteristics between the groups. The treatment strategy was successfully implemented in 97% of the OM group and 68% of the M3 group (P< .001). No death or TLR was recorded during hospitalization, though three myocardial infarctions occurred postoperatively (2.1% in the OM group vs 4.0% in the M3 group; P=.6). At 12 months, there was no difference in clinical outcome between the two groups (MACE: 12.6% in the OM group vs 8% in the M3 group; P=.4; TLR: 13.7% in the OM group vs 8% in the M3 group; P=.5). Multivariate analysis showed that bare metal stent implantation (only in patients receiving a single stent) was the only independent predictor of TLR.

CONCLUSIONS

The planned treatment strategy of implanting a single stent in patients with bifurcated lesions not classified as Medina 1,1,1 lesions was associated with a very low rate of second stent implantation. Moreover, bare metal stent use was a predictor of TLR, suggesting that drug-eluting stents should be used routinely to treat bifurcated lesions regardless of their angiographic complexity.

[Clinical and angiographic outcomes after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique]

The most common approach in the treatment of bifurcation lesions is stenting only the main branch (MB) with provisional T-stenting of the side branch (SB). However, some bifurcation lesions may have extensive disease within a large SB requiring stenting of this vessel. The "crush" technique, which has been proposed as an alternative approach to other strategies to treat complex bifurcations, is a relatively simple technique that ensures complete coverage of the SB ostium. Previous series have reported its safety and feasibility, but limited data are available about the long-term outcomes. We report our experience on 21 consecutive patients (pts) treated with the "crush" technique with drug-eluting stents (DES) between November 2005 and March 2007. Clinical follow-up was 18+/-7 months for 19 pts (90%), and angiographic follow-up was completed in 66% of pts (N=14), at a mean time of 8.5+/-4 months. Mean pt age was 70+/-11 years; 33% (N=7) had diabetes mellitus, and mean preoperative logistic EUROSCORE predicted 11% mortality rate. The left anterior descending artery/diagonal and the distal left main were the most frequent bifurcation locations (52 and 43% of cases respectively), with a type 1,1,1 of the Medina classification of bifurcation lesions in 62% of pts, and an angulation MB-SB below 50 degrees in 66% of cases. Final kissing balloon dilation was performed in 90% of pts (N=20). Stent diameter and length were similar between MB and SB. The procedure was successfull in 100% of cases in the MB and 95% of cases in the SB. Procedure-related CK elevation above 2 ULN was seen in two pts (9.5%), without ECG modification. One pt had subacute stent thrombosis 5 days after his procedure. At the end of follow-up, target vessel revascularization (TVR) was required in four pts (19%), and target lesion revascularisation (TLR) in three pts (14%) whom had focal restenosis in the SB ostium (one pt) and in the MB and SB ostia (one pt). Sudden death occurred in one pt 14 months after his procedure. In conclusion, when an effective strategy for stenting both branches is planned, the "crush" technique with final kissing balloon can be safely used by experienced operators to treat complex bifurcation lesions with DES. The safety profile and TLR rate in our small series of "crush" stenting were similar to that of other studies reported thus far.

In vitro, time-resolved PIV comparison of the effect of stent design on wall shear stress

The effect of stent design on wall shear stress (WSS) and oscillatory shear index (OSI) was studied in vitro using time-resolved digital particle image velocimetry (DPIV). Four drug-eluting stents [XIENCE V (Abbott Vascular), TAXUS Liberté (Boston Scientific), Endeavor (Medtronic), and Cypher (J&J Cordis)] and a bare-metal stent [VISION (Abbott Vascular)] were implanted into compliant vessel models, and the flow was measured in physiologically accurate coronary conditions featuring reversal and realistic offsets between pressure and flowrate. DPIV measurements were made at three locations under two different flow rates (resting: Re = 160, f = 70 bpm and exercise: Re = 300, f = 120 bpm). It was observed that design substantially affected the WSS experienced at the vessel walls. Averaged values between struts ranged from 2.05 dynes/cm(2) (Cypher) to 8.52 dynes/cm(2) (XIENCE V) in resting conditions, and from 3.72 dynes/cm(2) (Cypher) to 14.66 dynes/cm(2) (VISION) for the exercise state. Within the stent, the WSS dropped and the OSI increased immediately distal to each strut. In addition, an inverse correlation between average WSS and OSI existed. Comparisons with recently published results from animal studies show strong correlation between the measured WSS and observed endothelial cell coverage. These results suggest the importance of stent design on the WSS experienced by endothelial cells in coronary arteries.

Impact of Bifurcation Technique on 2-Year Clinical Outcomes in 773 Patients With Distal Unprotected Left Main Coronary Artery Stenosis Treated With Drug-Eluting Stents

Background— Distal unprotected left main coronary artery (ULMCA) stenosis represents a technical challenge for interventional cardiologists. In this study, we compared 2-year clinical outcomes of different stenting strategies in patients with distal ULMCA stenosis treated with drug-eluting stents.

Methods and Results— The survey promoted by the Italian Society of Invasive Cardiology on ULMCA stenosis was an observational study on patients with ULMCA stenosis treated with percutaneous coronary intervention. In this study, we selected patients with distal ULMCA stenosis treated with drug-eluting stents. Seven hundred seventy-three patients were eligible for this study: 456 were treated with 1 stent (group 1) and 317 with 2 stents (group 2). The primary end point of the study was the incidence of major adverse cardiac events (MACEs), defined as the occurrence of mortality, myocardial infarction, and target lesion revascularization. During a 2-year follow-up, risk-adjusted survival free from MACE was significantly higher in patients in group 1 than in patients in group 2. The propensity-adjusted hazard ratio for the risk of 2-year MACE in patients in group 1 versus group 2 was 0.53 (95% CI, 0.37 to 0.76). The propensity-adjusted hazard ratio for the risk of 2-year cardiac mortality and myocardial infarction in patients in group 1 versus group 2 was 0.38 (95% CI, 0.17 to 0.85).

Conclusions— Compared with the 2-stent technique, the 1-stent technique is associated with a better 2-year MACE-free survival. The stenting strategy is a prognostic factor that should be taken into account when deciding the optimal revascularization treatment.

Comparative study of simple versus complex stenting of coronary artery bifurcation lesions in daily practice in Chinese patients

BACKGROUND

Recently, several randomized and controlled trials have demonstrated great advantages of a drug-eluting stent (DES) with respect to significant reduction in restenosis and recurrence of symptoms, and improvement in clinical outcomes after percutaneous coronary intervention (PCI). Little is known about the comparative effects of the 1-DES plus the kissing balloon technique with the 2-DES for bifurcation angioplasty in a Chinese population.

METHODS

From April 2004 to June 2006, 566 consecutive Chinese patients underwent DES implantation for true bifurcation lesions, including 346 1-DES with the kissing balloon technique (300 male, 57.7 +/- 11.5 y old) and 220 2-DES (183 male, 58.1 +/- 10.7 y old) were analyzed. Clinical and angiographic follow-up was performed after 7 mo.

RESULTS

The major adverse cardiac event (MACE) rates were higher in the 2-DES group than in the 1-DES group (5.5% versus 2.0%; p = 0.032), which was mainly contributed to by acute myocardial infarction (AMI) (4.5% versus 1.4%; p = 0.032), rather than death and target lesion revascularization (TLR) (0% versus 0.5%; p = 0.389, 1.4% versus 2.7%; p = 0.352). Stent thrombosis rates were higher in the 2-DES group than in the 1-DES group (0.6% versus 2.7%; p = 0.042), except for 1 late-stent thrombosis in the 2-DES group, and all of them were subacute stent thrombosis (2 in the 1-DES group and 5 in the 2-DES group). The 7 mo angiographic follow-up rate was 36.4%. In the main branch there was no difference in restenosis rate in the 1-DES group compared with the 2-DES group (9.8% versus 11.9%; p = 0.652), but in the side branch the restenosis rate was higher in the 1-DES group (33.6% versus 15.5%; p = 0.004). However, there was no difference in in-segment late loss between the 2 groups, either in the main or side branch.

CONCLUSION

Compared with the 2-DES strategy, if a final kissing balloon could be achieved, the 1-DES strategy may be more efficient and safe.

Intravascular ultrasound (IVUS) guided fixation of an accidentally crushed coronary stent

Stent deployment during coronary intervention has become more and more common recently. Inappropriate stent deployment may lead to unexpected high mortality and morbidity rates. A 62 year-old man with unstable angina presented with a bifurcation lesion after diagnostic coronary angiography. A drug-eluting stent was successfully deployed across the bifurcation lesion. However, after wire exchange and rewiring followed by high pressure balloon postdilatation, the stent was accidentally crushed under IVUS guidance. We used a looping wire technique and successfully redilated the crushed instent portion. This case suggests interventionists should not always change the wire before stent well deployment and should bear in mind the value of IVUS in managing such a complication.

Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions

AIMS

We investigated whether routine T-stenting reduces restenosis of the side branch as compared with provisional T-stenting in patients with de novo coronary bifurcation lesions.

METHODS AND RESULTS

Our randomized study assigned 101 patients with a coronary bifurcation lesion to routine T-stenting with sirolimus-eluting stents (SES) in both branches and 101 patients to provisional T-stenting with SES placement in the main branch followed by kissing-balloon angioplasty and provisional SES placement in the side branch only for inadequate results. Primary endpoint was per cent diameter stenosis of the side branch at 9 month angiographic follow-up. Angiographic follow-up in 192 (95%) patients revealed a per cent stenosis of the side branch of 23.0 +/- 20.2% after provisional T-stenting (19% with side-branch stent) and of 27.7 +/- 24.8% (P = 0.15) after routine T-stenting (98.2% with side-branch stent). The corresponding binary restenosis rates were 9.4 and 12.5% (P = 0.32), prompting re-intervention in 5.0 and 7.9% (P = 0.39), respectively. In the main branch, binary restenosis rates were 7.3% after provisional and 3.1% after routine T-stenting (P = 0.17). The overall 1 year incidence of target lesion re-intervention was 10.9% after provisional and 8.9% after routine T-stenting (P = 0.64).

CONCLUSIONS

Routine T-stenting with SES did not improve the angiographic outcome of percutaneous coronary intervention of coronary bifurcation lesions as compared with stenting of the main branch followed by kissing-balloon angioplasty and provisional side-branch stenting.

Sirolimus-eluting and paclitaxel-eluting stents for the treatment of coronary bifurcations

BACKGROUND

The aim of the study was to compare the outcomes of sirolimus-eluting (SES) and paclitaxel-eluting (PES) stent implantation in coronary bifurcations treated with either a 1-stent or 2-stent strategy.

METHODS

The study used a retrospective cohort analysis of consecutive de novo bifurcations, excluding left main, treated with SES or PES between April 2003 and June 2005.

RESULTS

We identified 170 bifurcations in 161 patients treated with SES and 119 bifurcations in 112 patients treated with PES. During a median follow-up of 1,061 days (interquartile range 814-1,314), 43 patients (26.7%) in the SES group and 28 (25.0%) in the PES group had a major adverse cardiac event (P = .78). The angiographic restenosis rate per bifurcation was 20.9% and 25.9%, respectively (P = .41). There was no difference overall in the occurrence of target lesion revascularization (TLR) per bifurcation, 22 with SES (12.9%) and 18 with PES (15.1%), P = .61. The TLR rate was similar for SES and PES in bifurcations treated with 1 stent (6.7% vs 11.4%, P = .40) and in bifurcations treated with both branch stenting (20.0% vs 20.4%, P =1.0).

CONCLUSIONS

In this cohort, the long-term clinical outcomes appear similar overall between SES and PES in the treatment of coronary bifurcations irrespective of whether a 1-stent or 2-stent strategy was used.