Kissing Palmaz-Schatz stents for coronary bifurcation stenoses

Procedural and Clinical Outcomes in Management of Bifurcational Lesions in ST Elevation Myocardial Infarction

BACKGROUND

Bifurcation percutaneous coronary intervention (PCI) remains a challenging frontier in interventional cardiology, especially in the setting of ST-elevation myocardial infarction (STEMI). We examined the procedural and clinical outcomes of this patient subset.

METHODS

We conducted a retrospective case-control study. Between February 2006 and March 2011, 129 patients with STEMI underwent bifurcation PCI at our institution. One hundred and twenty-nine (129) control STEMI patients with non-bifurcation PCI were selected from the institutional database, matched for age, gender, culprit vessel, and lesion location. Patients with cardiac arrest, cardiogenic shock, or who required mechanical ventilation were excluded. Twelve (12)-month follow-up data were collected by telephone calls and examination of the medical records.

RESULTS

The average age of patients presenting with STEMI was 61.6 ± 13.1 in the bifurcation group and 61.5 + 31.1 in the non-bifurcation group. There was no difference in lesion type, use of thrombus aspiration catheters, or glycoprotein inhibitors (GPI) among them. Also, the use of drug eluting stent (DES), total cumulative length of stent used, and diameter of the post-dilation balloon were similar. Final kissing balloon post-dilation was performed in 40.3% of bifurcation PCI cases. The incidence of procedural failure (TIMI 0 flow) was 1.5% vs. 0%; p = 0.478. At 12-months follow-up, the bifurcation PCI group had higher incidence of target lesion revascularisation (TLR) (10.9% vs. 3.9%, p = 0.050), mortality (10.1% vs. 2.3%, p = 0.020), and stent thrombosis (9.3% vs. 1.6%; p = 0.013); comprising one acute, nine subacute, and two late vs. two subacute stent thromboses.

CONCLUSIONS

During acute STEMI, bifurcation PCI has excellent acute procedural outcomes, but significantly increased incidence of TLR, stent thrombosis and mortality at 12 months.

Simultaneous kissing stents to treat unprotected left main stem coronary artery bifurcation disease; stent expansion, vessel injury, hemodynamics, tissue healing, restenosis, and repeat revascularization

Objectives

To perform detailed analysis of stent expansion, vessel wall stress, hemodynamics, re‐endothelialization, restenosis, and repeat PCI in the simultaneous kissing stents (SKS) technique of bifurcation left main stem (LMS) stenting.

Background

The SKS technique is useful to treat patients with true bifurcation disease of the LMS but remains controversial.

Methods and Results

Computational structural analysis of SKS expansion demonstrated undistorted and evenly expanded stents. Computational fluid dynamics modelling revealed largely undisturbed blood flow. 239 PCI procedures were performed on 217 patients with unprotected bifurcation LMS disease with SKS using DES (2004‐2017). We electively studied 13 stable patients from baseline to 10 years post‐SKS with repeat angiography and optical coherence tomography, and demonstrated tissue coverage of the stent struts at the carina, with no evidence of lacunae behind the stents. We studied all patients with symptomatic recurrence. Target lesion revascularization rate was 3.2% at 1 year and 4.6% at 2 years. Of all 20 patients with restenosis, the site was the LMS‐Cx stent in 7, the LMS‐LAD stent in 2 and both in 11. Two‐year recurrence rate was 7/32 (5.3%) for first, and 4/108 (3.7%) for second generation DES. Treatment with repeat kissing techniques was undertaken in 19/20, with sustained clinical results with re‐SKS.

Conclusion

The SKS technique for treating unprotected LMS bifurcation disease does not distort the stents, is associated with favorable hemodynamics, tissue coverage of the exposed struts, and a low restenosis rate when performed with contemporary stents. Re‐PCI with repeat SKS appears feasible, safe, and durable.

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.

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.

Culotte versus T-stenting in bifurcation lesions: immediate clinical and angiographic results and midterm clinical follow-up

BACKGROUND

Stenting the main vessel with provisional stenting of the side branch (SB) is the method of choice for most bifurcation lesions. There is limited data on which of the two techniques of bifurcation stenting compatible with a provisional approach, culotte or T-stenting, offers the best outcome.

METHODS

Between February 2004 and October 2005, 80 consecutive patients with bifurcation lesions requiring a second stent on the SB were treated with either culotte (n = 45) or T-stenting (n = 35). Coronary angiograms were analyzed using a quantitative angiography system dedicated to bifurcations. Propensity scores were used to adjust for baseline differences between groups.

RESULTS

Acute procedural success was 100% for both groups. Residual diameter stenosis of the SB ostium was 3.44% +/- 7.39% in the culotte group versus 12.55% +/- 11.47% in the T-stenting group (P < .0001). One patient (2.2%) in the culotte group had subacute thrombosis 2 days after the procedure. The culotte group had a lower target lesion revascularization rate compared with the T-stenting group (8.9% vs 27.3% propensity score adjusted; P = .014) and a trend toward lower major cardiac adverse events at 9 months (13.3% vs 27.3%; P = .051).

CONCLUSION

Both techniques of provisional SB stenting in bifurcation lesions achieve high procedural success with low complication rates. The culotte technique yields a better immediate angiographic result at the SB ostium, and, using drug-eluting stents, a better clinical outcome at 9 months.

Drug-eluting stents for the treatment of bifurcation lesions: a randomized comparison between paclitaxel and sirolimus stents

BACKGROUND

Drug-eluting stents have been shown to reduce restenosis in many types of lesions. The purpose of this article is to assess the efficacy of sirolimus- and paclitaxel-eluting stents in patients with bifurcation lesions.

METHODS

Between June 2003 and October 2004, 205 patients were enrolled in a prospective randomized trial; 103 patients were assigned to sirolimus stents and 102 patients to paclitaxel stents. All patients were treated by provisional T-stenting.

RESULTS

There were no differences between groups in terms of age, risk factors, clinical condition, location of the bifurcation lesion, or other technical factors. Angiographic data and immediate results were also similar in both groups. Three patients developed inhospital non-Q-wave acute myocardial infarction (2 from the sirolimus group and 1 from the paclitaxel group). Follow-up angiography was obtained in 109 patients (53%). In the sirolimus group, 5 patients developed restenosis (9%): 1 at the main vessel, 2 at the side branch, and 2 in both branches. In contrast, 16 patients from the paclitaxel group had restenosis (29%): 6 at the main vessel, 5 at the side branch, and 5 in both branches. Target lesion revascularization at 24 +/- 5 months post stenting occurred in 4 patients from the sirolimus group (4%) and in 13 from the paclitaxel group (13%) (P < .05). Late loss at the main vessel in the sirolimus group patients was 0.31 +/- 0.59 versus 0.60 +/- 0.77 mm in patients from the paclitaxel group (P < .05).

CONCLUSIONS

Patients with bifurcation lesions treated by sirolimus showed significantly lower rates of late loss, restenosis and target lesion revascularization than patients treated with paclitaxel-eluting stents.

Complex Coronary Interventions: Unprotected Left Main and Bifurcation Lesions

Percutaneous coronary intervention has moved forward with great speed since the advent of stents and now more recently the introduction of drug-eluting technologies. This has seen the modern interventional cardiologist tackle more and more complex coronary lesions, of which unprotected left main (ULM) and bifurcations still remain challenging and controversial. ULM coronary artery stenosis traditionally remains a surgical indication although there have been recent reports and studies demonstrating the feasibility of a percutaneous strategy in select patient groups. Furthermore, drug-eluting stents have shown great benefit in reducing the problem of restenosis and have also become the mainstay treatment modality for bifurcation lesions with a choice between one- or two-stent strategies determined by the extent of disease burden in the main vessel and side branch and the response of the side branch ostium following treatment of the main vessel. This article will provide a contemporary review of percutaneous intervention for these two lesion subsets and describe the relative merits of each of the different strategies in current use with a glimpse into what the future may hold.

In-hospital and nine-month outcome of treatment of coronary bifurcational lesions with sirolimus-eluting stent

Between April 2002 and May 2004, 174 consecutive patients who underwent percutaneous coronary intervention of bifurcational lesions with sirolimus-eluting stents were identified. Two strategies were used: stenting only 1 branch (group 1S, n = 57) or stenting both branches (group 2S, n = 117). The incidence of major adverse cardiac events was evaluated in the hospital and at 9-month follow-up. There were no statistically significant differences between the 2 groups with regard to the incidence of target lesion revascularization (5.4% vs 8.9%, p = 0.76), target vessel revascularization (5.4% vs 11.1%, p = 0.51), and cumulative major adverse cardiac events (18.9% vs 23.3%, p = 0.76) at 9 months.

Kissing sirolimus-eluting stents for the treatment of left main coronary artery stenosis

We present a case of kissing drug-eluting stent deployment in the left main coronary artery in a 43-year-old male with failed previous bypass grafting. We discuss the technique used for stent deployment and the rationale for using this technique in the drug-eluting stent era.

Treatment of Bifurcation Coronary Lesions:. A Review of Current Techniques and Outcome

Percutaneous treatment of coronary bifurcation lesions, pose a number of technical challenges to the interventional cardiologist. Each lesion has to be approached with its own, targeted solution in the context of the clinical picture, anatomy, and pathology. To achieve acceptable clinical outcomes a number of established techniques are available. The exact anatomy of the lesion determines the technique used. The most common approach is to stent the main vessel across the ostium of the side branch. The side branch can be additionally treated with a second stent or balloon angioplasty depending on the severity of the ostial lesion and/or evidence of active ischemia. Other techniques involve stenting the main branch up to the carina but sparing the side branches, multiple 'kissing stent' approaches ('Y','T', and 'V') or the 'culottes' technique. Follow-up data demonstrates a high (over 90%) technical success rate. Clinical outcome is variable but with conventional stents restenosis rates higher than 30% have been reported in most studies and there is no added advantage in routine stenting of both main vessel and side branch. Recent introduction of drug-eluting stents has resulted in a lower event rate and reduction of main vessel restenosis in comparison with historical controls. Side branch ostial restenosis remains a problem, which may require the development of novel 'bifurcate' stent designs to allow complete coverage with a single stent.

'Navius' kissing stents for coronary bifurcation stenosis, recreating a new metallic carina: an IVUS-assessed case report

We report a case of implantation of a new design of stent which allows creation of a double-hemispheric lumen for the treatment of a bifurcational stenosis. The unfavourable outcome following the implantation of this stent is described.

A new dedicated stent and delivery system for the treatment of bifurcation lesions: preliminary experience

We report the first clinical experience in eight patients with a new stent and delivery system specifically designed for the treatment of bifurcational lesions. The device (AST SLK-View system) consists of a premounted stent and a delivery system. The stent has a side aperture, which orients toward the ostium of the side branch. The system allows deployment of the stent while the access to both main and side branches is maintained by two wires. We evaluated this system in nine bifurcations. The location of bifurcations was left descending artery/diagonal branch in four lesions, left circumflex/obtuse marginal branch in three lesions, and postero-lateral branch/posterior descending artery in two lesions. Predilation was performed in six lesions of the main branches and in five lesions of the side branches. The stent was effectively delivered to all bifurcations except for one, in which the target lesion was located at a distal segment and the device could not be delivered. Following stent implantation in the main branch, two lesions at the side branches were treated by stent, while the other lesions were treated by balloon angioplasty without difficulty. Final kissing balloon was performed in four bifurcation lesions. No adverse event was observed during 1 month of clinical follow-up. Treatment of bifurcation lesions with this new dedicated device appears to be feasible. This new device may introduce a new approach for the treatment of coronary bifurcation lesions.

Stenting of bifurcation lesions using the Bestent: a prospective dual-center study

Treatment of bifurcation lesions remains a technical challenge. Among 13 stents previously tested in a bench study, the Bestent seemed of particular interest in this indication as it provided good access to the side branch after stent implantation in the main branch associated with a satisfactory coverage of the lesion after kissing balloon inflation. The use of Bestent implanted in the main branch or both branches for treatment of bifurcation lesions involving a side branch > or = 2.2 mm in diameter was prospectively evaluated in a dual-center prospective study with a prospective 6-month clinical follow-up. All angiographic documents were analyzed by an independent corelab (CORISIS). Between 11 September 1997 and 21 February 1998, 96 patients were consecutively included (mean age, 63.7 +/- 11.4 years; 81.3% male; 58.3% with unstable angina and 6.3% acute myocardial infarction). The lesion involved the left anterior descending-diagonal coronary bifurcation in 55% of cases, left circumflex-marginal 23%, posterior descending-postero-lateral 12%, distal left main 6%, and others 4%. The main branch (proximal reference diameter: 3.43 +/- 0.45 mm) was stented in 98% of cases and the side branch (2.72 +/- 0.38 mm) in 38% (both branches in 34% of cases). T-stenting or provisional T-stenting was used in 88% of cases and final kissing balloon inflation was performed in 78% of cases. Procedural success was obtained in 100% of cases in the main branch and 98% in both branches. Major cardiac and cerebral events (MACCE) during hospitalization occurred in 4.2% of cases, non-Q-wave myocardial infarction (MI) in 3.1%, Q-wave MI in 1.0%, repeat PTCA in 2.1%; there were no major access site complication, no emergency coronary artery bypass grafting operation, no death. At 6-month follow-up, total MACCE rate was 14.6% (Q-wave MI, 3.1%; non-Q-wave MI, 3.1%; target vessel revascularization, 9.4%; death, 2.1%). Patients with target vessel revascularization (TVR) had restenosis of both branches in 22.2% of cases, main branch in 22.2%, and side branch in 55.6%. This study shows that using a simple strategy of provisional T-stenting of the side branch in the majority of cases, the Bestent can be used for treating bifurcation lesions with a high rate of success and an acceptable rate of TVR at 6-month follow-up.

A stepwise strategy for the stent treatment of bifurcated coronary lesions

Several observational studies have shown a better late outcome in patients with coronary bifurcation lesions treated with stents in whom the side branch was not stented. Balloon dilation and provisional stenting for the side branch seem an attractive strategy to manage these challenging types of lesions. This study evaluated the results of a three-step phase strategy in the stent treatment of bifurcated coronary lesions. We treated 126 patients, 58 +/- 11 years old, with major coronary bifurcation stenosis. The therapeutic procedure was undertaken following three phases; progression through each phase was triggered by the failure of one procedure to achieve a <50% residual stenosis at the side branch: in the first step, balloon angioplasty of the side branch followed by stenting of the parent vessel; in the second, balloon redilation of the side-branch origin across the metallic structure of the stent; in the third, stenting of the side-branch origin. Immediate success was achieved in 116 patients (92%). Angiographic results in each phase were as follows: in the first step, 35 patients (28%) had procedural success, 3 patients had failure, and 88 crossed to the next step; in the second, 76 patients (86%) had procedural success, 7 patients had failure, and 5 crossed to the next step; in the third, all 5 patients had procedural success. The overall major cardiac event-free probability at 15 months was 78%. Target vessel revascularization took place in 19 patients (15%) and when stratified by phases were 13% of patients treated in the first step, 16% of patients in the second step, and 20% of patients in the third step. Patients with coronary stenosis at major bifurcations may be treated following an unitary stepwise approach. This attitude may avoid side-branch stent implantation in most patients, providing good immediate and long-term results.

Stenting of bifurcation lesions: a rational approach

The occurrence of stenosis in or next to coronary bifurcations is relatively frequent and generally underestimated. In our experience, such lesions account for 15%-18% of all percutaneous coronary intervention > (PCI). The main reasons for this are (1) the coronary arteries are like the branches of a tree with many ramifications and (2) because of axial plaque redistribution, especially after stent implantation, PCI of lesions located next to a coronary bifurcation almost inevitably cause plaque shifting in the side branches. PCI treatment of coronary bifurcation lesions remains challenging. Balloon dilatation treatment used to be associated with less than satisfactory immediate results, a high complication rate, and an unacceptable restenosis rate. The kissing balloon technique resulted in improved, though suboptimal, outcomes. Several approaches were then suggested, like rotative or directional atherectomy, but these techniques did not translate into significantly enhanced results. With the advent of second generation stents, in 1996, the authors decided to set up an observational study on coronary bifurcation stenting combined with a bench test of the various stents available. Over the last 5 years, techniques, strategies, and stent design have improved. As a result, the authors have been able to define a rational approach to coronary bifurcation stenting. This bench study analyzed the behavior of stents and allowed stents to be discarded that are not compatible with the treatment of coronary bifurcations. Most importantly, this study revealed that stent deformation due to the opening of a strut is a constant phenomenon that must be corrected by kissing balloon inflation. Moreover, it was observed that the opening of a stent strut into a side branch could permit the stenting, at least partly, of the side branch ostium. This resulted in the provocative concept of "stenting both branches with a single stent." Therefore, a simple approach is currently implemented in the majority of cases: stenting of the main branch with provisional stenting of the side branch. The technique consists of inserting a guidewire in each coronary branch. A stent is then positioned in the main branch with a wire being "jailed" in the side branch. The wires are then exchanged, starting with the main branch wire that is passed through the stent struts into the side branch. After opening the stent struts in the side branch, kissing balloon inflation is performed. A second stent is deployed in the side branch in the presence of suboptimal results only. Over the last 2 years, this technique has been associated with a 98% angiographic success rate in both branches. Two stents are used in 30%-35% of cases and final kissing balloon inflation is performed in > 95% of cases. The in-hospital major adverse cardiac events (MACE) rate is around 5% and 7-month target vessel revascularization (TVR) is 13%. Several stents specifically designed for coronary bifurcation lesions are currently being investigated. The objective is to simplify the approach for all users. In the near future, the use of drug-eluting stents should reduce the risk of restenosis.

Clinical outcomes of compromised side branch (stent jail) after coronary stenting with the NIR stent

Acute side-branch (SB) compromise or occlusion stent jail after native coronary stenting is a matter of concern. Attempts at maintaining SB patency can be a technical challenge. The purpose of this study was to determine the clinical impact of SB compromise or occlusion in patients undergoing stenting of parent vessel lesions. We evaluated in-hospital and long-term clinical outcomes (death, Q-wave myocardial infarction, and repeat revascularization rates at 6 months) in 318 consecutive patients undergoing NIR stent implantation across an SB. Based on independent angiographic analysis, 218 (68.6%) patients had no poststent SB compromise, 85 (26.7%) patients had narrowed SB (> 70% narrowing, without total occlusion), and 15 (4.7%) patients had an occluded SB after stent implantation. The baseline patient and lesion characteristics were similar between the groups. Procedural success was 100%. Patients with SB occlusion had a higher stents/lesion ratio (P < 0.006). Side-branch occlusion was associated with higher in-hospital ischemic complications (Q-wave myocardial infarction, 7%; non-Q-wave myocardial infarction, 20%; P < 0.05) compared to patients with SB compromise or normal SB. At 6-month follow-up, there was a trend for more myocardial infarctions in the group with SB occlusion during the index procedure (Q-wave myocardial infarction, 7% vs. 1% in the narrowed and 0% in normal SB; P = 0.09). However, late target lesion revascularization and mortality were similar in the three groups (P = 0.91). SB occlusion after parent vessel stenting is associated with more frequent in-hospital Q-wave and non-Q-wave myocardial infarctions. However, with the NIR stent, side-branch compromise or occlusion does not influence late (6 month) major adverse events, including death, myocardial infarction, or need for repeat revascularization.

Intravascular ultrasound assessment of culotte stent deployment for the treatment of stenoses at major coronary bifurcations

BACKGROUND: The mechanism for the disappointing late outcome following stenting of bifurcation lesions is unclear. This prospective observational study aims to evaluate culotte stent deployment and dimensions with intravascular ultrasound (IVUS). PATIENTS AND METHODS: Patients with bifurcation stenoses were treated using two stents in a culotte configuration. After optimizing the angiographic appearance of both stents, IVUS was used to evaluate both limbs of the culotte. The main outcome measures were cross-sectional area (CSA) and minimal lumen diameter (MLD) assessed by IVUS. RESULTS: Within the culotte stent, the final mean CSA in the main limb was 6.1 mm(2) (97% of reference) and in the side-limb was 5.9 mm(2) (97% of reference). However, in each case, the minimum CSA and IVUS MLD of both limbs was at the bifurcation point. For all patients, the final mean CSA at the bifurcation point of the main limb was 4.3 mm(2) (70% of main stent) and of the side-limb was 4.4 mm(2) (75% of side stent). The IVUS MLD at the bifurcation point of the main limb was 2.1 mm (78% of main stent) and of the side-limb was 2.1 mm (84% of the side stent). Importantly, this significant residual stenosis was not detectable with quantitative coronary angiography. CONCLUSIONS: IVUS evaluation of culotte stents is feasible. The minimum IVUS CSA and MLD of both limbs of the culotte stent is at the bifurcation point. Despite an optimal angiographic appearance a significant residual stenosis was noted with IVUS at each bifurcation point.

Immediate and long-term results of "T" stenting for bifurcation coronary lesions

The technique of "T" stenting, which incorporates wiring both the branches of a bifurcation lesion, dilating a balloon in the main branch during stent deployment in the side branch followed by deployment of stent in the main branch, provides excellent immediate results in terms of technical and procedural success. However, further innovations are mandated to optimize the long-term outcome, which with a restenosis rate of 63%, can be described as not encouraging.

Bifurcation lesions: two stents versus one stent--immediate and follow-up results

OBJECTIVES

The purpose of this study was to evaluate two different techniques of stent placement in bifurcation lesions.

BACKGROUND

Although stent placement with dedicated techniques has been suggested to be a useful therapeutic modality for bifurcation lesions, limited information is available if stent placement on the side branch and on the parent branch provides any advantage over a simpler strategy of stenting the parent vessel and balloon angioplasty of the side branch.

METHODS

Between March 1993 and April 1999, we treated a total of 92 patients with bifurcation lesions with two strategies: stenting both vessels (group B, n = 53) or stenting the parent vessel and balloon angioplasty of the side branch (group P, n = 39). Paired angiograms were analyzed by quantitative angiography, and clinical follow-up was obtained.

RESULTS

Stent placement on both branches resulted in a lower residual stenosis (7.4 +/- 10.9% vs. 23.4% +/- 18.7%, p < 0.001) in the side branch. Acute procedural success was similar in the two groups (group B: 87% vs. Group P: 92%). In-hospital major adverse cardiac events (MACE) occurred only in group B (13% vs. 0%, p < 0.05). At the six-month follow-up, the angiographic restenosis rate (group B: 62% vs. Group P: 48%) and the target lesion revascularization rate (38% vs. 36%, respectively) were similar in the two groups. There was no difference in the incidence of six-month total MACE (51% vs. 38%).

CONCLUSIONS

For the treatment of true bifurcation lesions, a complex strategy of stenting both vessels provided no advantage in terms of procedural success and late outcome versus a simpler strategy of stenting only the parent vessel.

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

OBJECTIVES

The aim of this study was to evaluate the immediate and long-term outcome of intracoronary stent implantation for the treatment of coronary artery bifurcation lesions.

BACKGROUND

Balloon angioplasty of true coronary bifurcation lesions is associated with a lower success and higher complication rate than most other lesion types.

METHODS

We treated 131 patients with bifurcation lesions with > or =1 stent. Patients were divided into two groups; Group (Gp) 1 included 77 patients treated with a stent in one branch and percutaneous transluminal coronary angioplasty (PTCA) (with or without atherectomy) in the side branch, and Gp 2 included 54 patients who underwent stent deployment in both branches. The Gp 2 patients were subsequently divided into two subgroups depending on the technique of stent deployment. The Gp 2a included 19 patients who underwent Y-stenting, and Gp 2b included 33 patients who underwent T-stenting.

RESULTS

There were no significant differences between the groups in terms of age, gender, frequency of prior myocardial infarction (MI) or coronary artery bypass grafting (CABG), or vessels treated. Procedural success rates were excellent (89.5 to 97.4%). After one-year follow-up, no significant differences were seen in the frequency of major adverse events (death, MI, or repeat revascularization) between Gp 1 and Gp 2. Adverse cardiac events were higher with Y-stenting compared with T-stenting (86.3% vs. 30.4%, p = 0.004).

CONCLUSIONS

Stenting of bifurcation lesions can be achieved with a high success rate. However, stenting of both branches offers no advantage over stenting one branch and performing balloon angioplasty of the other branch.

Stenting of bifurcation lesions: classification, treatments, and results

Percutaneous transluminal balloon coronary angioplasty (PTCA) of coronary bifurcations is associated with a low success rate, high rate of complications, and high incidence of target vessel revascularization (TVR). The strategy of systematic coronary stenting in bifurcation lesions involving a side branch >/= 2.2 mm in diameter was prospectively evaluated in a single-center observational study during a 35-month inclusion period. All patients meeting these criteria were consecutively included. Bifurcation lesions and treatment were predefined in the study. The study included 366 patients (12.1% of PTCA) with 373 bifurcation lesions, mean age 63.7 +/- 11.6 years, 79.2% male, 46.7% with unstable angina, and 8.3% acute MI. The left anterior descending/diagonal bifurcation was involved in 55.2% of cases, circumflex/marginal 22. 2%, PDA/PLA 10.4%, left main bifurcation in 6.8%, and others 5.4%. The main branch (2.78 +/- 0.42 mm reference diameter) was stented in 96.3% of cases and the side branch (2.44 +/- 0.43 mm) in 63.2% (the two branches were stented in 59.5% of cases). Procedural success was obtained in 96.3% in both branches and 99.4% in the main branch. At1-month follow-up, The major cardiac event rate (MACE) was 4.8% (death 1.1%, emergency CABG 0.6%, Q-wave MI 0.9%, acute or subacute closure 1.4%, repeat PTCA 1.1%, and non-Q-wave MI 2.3%). At 7-month follow-up, the total MACCE rate was 21.6%, including a TVR rate of 17.2%. Analysis of the 7-month outcome according to two study periods (period I, 1 January 1996 to 31 August 1997, 182 patients; period II, 1 September 1997 to 30 June 1998, 127 patients) showed that the TVR rate decreased from 20.6% to 13.8% (P = 0.04) and the MACE rate from 29.2% to 17.1% (P < 0.01) in period I and II, respectively. This was associated by univariate analysis with an increasing use of tubular stents deployed in the main branch (94.2% vs. 59.1%, P < 0.001) and kissing balloon inflation after coronary stenting (75.4% vs. 18.1%, P < 0.001). Bifurcation lesions are frequent. Procedural success of coronary stenting is high with a low rate of in-hospital MACE. TVR rate at follow-up is relatively low. In-hospital and follow-up results are influenced not only by the learning curve but also by the use of tubular stents in the main branch and final kissing balloon inflation.

Coronary bifurcation stenting using dedicated bifurcation stents

We report three cases of successful implantation of three different stents specially designed for bifurcation lesions, guided by intracoronary ultrasound. The BARD and AVE are true bifurcated stents for side-branch access and the NIR-Side Royal is a single modified NIR stent with an aperture to allow provisional bifurcation stenting. These designs introduce a new era in percutaneous management of coronary bifurcation lesions. Cathet. Cardiovasc. Intervent. 49:105-111, 2000.

Stenting with a true bifurcated stent: acute and mid-term follow-up results

Percutaneous therapy of coronary bifurcated lesions is associated with greater risk of acute complications and late restenosis. Numerous innovative techniques using various stent types have been proposed. We report the first clinical use of a truly bifurcated stent (Bard XT Carina). The implantation procedure, favorable medium-term angiographic and 1-year clinical follow-up of the first human use in a 43-year-old female are illustrated with angiography and intravascular ultrasound. As a single prosthesis that effectively covers the bifurcation, this stent presents appealing alternative for the treatment of coronary bifurcation lesions when compared to methods that involve multiple-stent implantation. Cathet. Cardiovasc. Intervent. 47:361-369, 1999.

Simple and complex stent strategies for bifurcated coronary arterial stenosis involving the side branch origin

Coronary lesions located in major bifurcations constitute a challenge for the use of stents. Although the occlusion of a side branch covered by a stent is infrequent, the maintenance of a patent, stenosis-free bifurcation may result in a complex procedure. Between September 1994 and April 1998, 70 patients were treated by stent implantation for coronary bifurcation stenosis. The side branch always had a diameter >2 mm. The pairs of treated arteries were: left anterior descending (LAD)/diagonal artery in 32 patients, circumflex/obtuse marginal in 26, right coronary/posterior descending artery in 5, and LAD/circumflex in 7. We applied 2 different techniques of stent implantation: (1) deployment of 1 stent in the parent vessel covering the takeoff of the side branch and subsequent angioplasty of the side branch across the metallic structure (group A, n = 47 patients), and (2) implantation of 1 stent at the ostium of the side branch and complete reconstruction of the entire bifurcation with additional implantation of 1 or 2 stents at the parent vessel (group B, n = 23 patients). There were no significant differences between groups at baseline variables. Procedural success was similar in both groups: 42 (89%) in group A versus 21 (91%) in group B. However, major cardiac events at 18 months follow-up were higher in group B (event-free probability 44% vs 75%, p <0.05). Selected patients with coronary stenosis at major bifurcations can be treated with an acceptable rate of primary and late success. Complex techniques providing radical stent reconstruction of the bifurcation seems to provide no advantages over the simpler stent jail followed by ostial side branch balloon dilation.

Placement of coronary stents in bifurcation lesions by the "culotte" technique

Coronary angioplasty of bifurcation lesions remains a technical challenge. Balloon angioplasty induces recoil and the "snow-plow" effect with a risk of side branch occlusion. The late result is associated with a high rate of reintervention. Randomized studies in nonbifurcated lesions have demonstrated better short- and midterm results after stent placement. We propose the "culotte" technique as a new technique to place intracoronary stents in bifurcation lesions: implantation of 2 similar stents in 2 steps in the main branch and in the side branch with overlapping of the 2 stents in the main branch before bifurcation. We performed this technique in 50 patients (in the left anterior diagonal branch in 33, in the left circumflex obtuse marginal branch in 12, in the right coronary artery in 4, and in the left main coronary artery in 1). The clinical success rate was 94% with 3 non-Q-wave myocardial infarctions. Late results indicated a 24% target lesion revascularization rate, which improved when a true kissing balloon inflation was used to achieve final deployment of both stents. This culotte technique is highly feasible and provides excellent short-term results. Assessment of its midterm benefit requires further study.

Rotational atherectomy for bifurcation lesions of the coronary circulation: technique and initial experience

Bifurcation lesions of the coronary circulation are difficult to treat with standard balloon technology and are associated with relatively low procedural success rates and high complication rates. We hypothesized that effective debulking of bifurcation lesions with rotational atherectomy would improve observed results. Fifteen patients underwent rotational atherectomy of such lesions. Both limbs of the bifurcation were rotablated in seven patients and one limb in eight; seven patients also underwent stent deployment. Successful angiographic results were obtained in all limbs (<30% residual stenoses). One patient had a non-Q-wave myocardial infarction. No other significant complications occurred. We conclude that rotablation of bifurcation coronary stenoses is feasible, safe, and associated with a high likelihood of angiographic success.

New technique for stent jail: another niche for the rotablator

We report the treatment of a jailed side branch using the Rotablator. Initial attempts at passing various low profile balloons in the jailed branch were unsuccessful. The Rotablator allowed access to the side branch, which was stented with a single Palmaz-Schatz stent, providing excellent angiographic and 9 months follow-up results.

Incidence and angiographic predictors of side branch occlusion following high-pressure intracoronary stenting

We evaluated the incidence, angiographic predictors, and clinical outcome of side branch occlusion (SBO) following high-pressure intracoronary stenting in 175 patients. All stent implants during a 7-month period were reviewed for the incidence of major (>1 mm) SBO. Side branches were further characterized based on side branch and index lesion morphology. Clinical events (death, myocardial infarction, and target vessel revascularization rates) were determined at 9 months. A total of 175 patients (182 lesions) had 224 major side branches covered by intracoronary stents. Of these, 43 (19%) occluded. Most SBOs (29 of 43 [67%]) occurred after poststent dilation using high-pressure inflations (15.3 +/- 3.3 atmospheres). No clinical characteristics correlated with SBO. By multivariate analysis, those side branches with >50% ostial narrowing that arose from within or just beyond the diseased portion of the parent vessel (threatened side branch morphologies) were a powerful angiographic predictor of SBO (odds ratio 40, 95% confidence interval, 14 to 130, p <0.0001). At 9-month follow-up there was no difference in combined clinical events between those patients with and without SBO. These data demonstrate that side branches with ostial stenoses in continuity with diseased parent lesions were at risk of occlusion following stenting. SBO, however, was not associated with adverse clinical outcome. These findings lend support to plaque shift ("snow plow effect") as the mechanism behind SBO following stent placement.

Angioplasty followed by coronary stenting at the anastomotic site of saphenous vein bypass graft with the native vessel: a case that needs special procedural strategy

In this report we describe a case in which a saphenous vein graft stenosis at the site of anastomosis with the left anterior descending artery (LAD) was dilated with a special Controlled Angioplasty Technology (CAT) balloon, and then stented. Balloon angioplasty and stenting at the site of anastomosis represents a technical problem because of diameter discrepancy and needs special attention in order to avoid minor or major complications.

The V-stent: a novel technique for coronary bifurcation stenting

Intracoronary stenting as a transcatheter treatment for bifurcation stenoses remains controversial. A novel technique of coronary bifurcation stenting is reported. A 15 mm Palmaz-Schatz stent is bent 180 degrees at its bridge articulation into a V- configuration and mounted on two balloon-catheters linked together by adhesive tape. This unified stent delivery system was used successfully in five cases of porcine coronary bifurcation stenting.