1
|
Aedma SK, Naik A, Kanmanthareddy A. Coronary Bifurcation Stenting: Review of Current Techniques and Evidence. Curr Cardiol Rev 2023; 19:e060422203185. [PMID: 35388761 PMCID: PMC10201883 DOI: 10.2174/1573403x18666220406113517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/04/2022] [Accepted: 01/21/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Coronary bifurcation stenting constitutes 20% of all PCI performed. Given the extensive prevalence of bifurcation lesions, various techniques have sought to optimally stent the bifurcation to improve revascularization while also decreasing rates of stent thrombosis and lesion recurrence. Advanced techniques, such as planned two-stent approaches, have been shown to have improved outcomes but also require fluoroscopy and procedure time, posing an economic argument as well as a patient-outcome one. OBJECTIVE Because of the many strategies posited in the literature, it becomes essential to objectively evaluate evidence from randomized controlled trials and meta-analyses to help determine the optimal stenting strategy. METHODS We reviewed the clinical evidence on the efficacy of coronary bifurcation stenting. RESULTS In this paper, we review the most recent randomized controlled trials and meta-analyses on the efficacy of various stenting techniques and advances in stenting technologies published to gauge the current state of understanding and chart where the field is heading. CONCLUSION Bifurcation stenting is a maturing problem in the field of interventional cardiology that is adapting to the needs of the patients and advances in technology.
Collapse
Affiliation(s)
- Surya Kiran Aedma
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, Illinois, 61801, USA
| | - Anant Naik
- Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois, 61820, USA
| | - Arun Kanmanthareddy
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, 68198, USA
- CHI Health Heart Institute, Omaha, Nebraska, 68124, USA
- Division of Cardiovascular Medicine, Creighton University School of Medicine, Omaha, Nebraska, 68124, USA
| |
Collapse
|
2
|
Hildick-Smith D, Arunothayaraj S, Stankovic G, Chen SL. Percutaneous coronary intervention of bifurcation lesions. EUROINTERVENTION 2022; 18:e273-e291. [PMID: 35866256 PMCID: PMC9912967 DOI: 10.4244/eij-d-21-01065] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bifurcation coronary artery disease is common as the development of atherosclerosis is facilitated by altered endothelial shear stress. Multiple anatomical and physiological factors need to be considered when treating bifurcation lesions. To achieve optimal results, various stenting techniques have been developed, each with benefits and limitations. In this state-of-the-art review we describe technically important characteristics of bifurcation lesions and summarise the evidence supporting contemporary bifurcation techniques.
Collapse
Affiliation(s)
- David Hildick-Smith
- Sussex Cardiac Centre, Royal Sussex County Hospital, Eastern Road, BN2 5BE Brighton, United Kingdom
| | - Sandeep Arunothayaraj
- Sussex Cardiac Centre, University Hospitals Sussex NHS Trust, Brighton, United Kingdom
| | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia, and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Shao-Liang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| |
Collapse
|
3
|
Clinical Implications of Bifurcation Angles in Left Main Bifurcation Intervention Using a Two-Stent Technique. J Interv Cardiol 2020; 2020:2475930. [PMID: 32733170 PMCID: PMC7374237 DOI: 10.1155/2020/2475930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 06/08/2020] [Accepted: 06/22/2020] [Indexed: 12/04/2022] Open
Abstract
Objectives The aim of this study was to assess the clinical impact of 3 bifurcation angles in left main (LM) bifurcation treated with the 2-stent technique. Background Data are limited regarding the impact of bifurcation angles after LM percutaneous coronary intervention (PCI). Methods Using patient-level 4 multicenter registries in Korea, 462 patients undergoing LM bifurcation PCI with the 2-stent technique were identified (181 crush, 167 T-stenting; 63% 1st generation drug-eluting stent (DES), 37% 2nd generation DES). Three bifurcation angles, between the LM and left anterior descending (LAD), the LM and left circumflex (LCX), and the LAD and LCX, were measured. The primary outcome was target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization (TLR). Results In patients treated with the crush technique, the best cutoff value (BCV) to predict TLF was 152° of the LM-LAD angle. In the crush group, a significantly higher TLF rate, mostly driven by TLR, was observed in the LM-LAD angle ≥152° group compared with the <152° group (35.7% vs. 14.6%; adjusted hazard ratio 3.476; 95% confidence interval 1.612–7.492). An LM-LAD angle ≥152° was an independent predictor of TLF. In the T-stenting, no bifurcation angle affected the clinical outcomes. Conclusions In LM bifurcation PCI using the 2-stent technique, wide LM-LAD angle (≥152°) was associated with a greater risk of TLF in the crush, whereas none of the bifurcation angles affected T-stenting outcomes.
Collapse
|
4
|
Feasibility of a Porcine Arteriovenous Shunt Model for Assessment of Acute Thrombogenicity in Bifurcation Stenting Technique By Optical Coherence Tomography. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:1000-1005. [PMID: 30686620 DOI: 10.1016/j.carrev.2018.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 12/28/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Double kissing (DK) crush stenting has been reported as a superior bifurcation stenting strategy compared to culotte stenting. However, the mechanism associated with the reduction of clinical events by DK crush stenting remains unclear. We therefore investigated the thrombogenicity of DK crush stenting and culotte stenting with both bare-metal stents (BMS) and drug-eluting stents (DES) and the feasibility of a novel porcine arteriovenous shunt model. METHODS High-resolution intracoronary imaging with optical coherence tomography (OCT) evaluated the bifurcation stenting models for thrombogenicity. RESULTS All porcine models retained continuous circulation without blood leakage. Thrombus was macroscopically demonstrated around the bifurcation in all settings. The volume of thrombus (mm3) with BMS using DK crush/culotte and DES using DK crush/culotte were 1.38/1.19 and 0.09/0.15, respectively. Culotte stenting had more thrombus in the proximal main branch, and DK crush stenting had more at the bifurcation. Unlike DK crush stenting, culotte stenting showed malapposition in the proximal main branch and bifurcation segments. CONCLUSION The feasibility of a porcine arteriovenous shunt model to assess thrombogenicity by OCT in bifurcation stenting technique was confirmed. OCT detected less thrombogenicity in DES when used in the bifurcation model when compared to BMS.
Collapse
|
5
|
ZHANG DONG, DOU KEFEI. Coronary Bifurcation Intervention: What Role Do Bifurcation Angles Play? J Interv Cardiol 2015; 28:236-48. [DOI: 10.1111/joic.12203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- DONG ZHANG
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute; Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing 100037 China
| | - KEFEI DOU
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute; Fuwai Hospital and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing 100037 China
| |
Collapse
|
6
|
Impact of 3-Dimensional Bifurcation Angle on 5-Year Outcome of Patients After Percutaneous Coronary Intervention for Left Main Coronary Artery Disease. JACC Cardiovasc Interv 2013; 6:1250-60. [DOI: 10.1016/j.jcin.2013.08.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2013] [Accepted: 08/14/2013] [Indexed: 11/17/2022]
|
7
|
Rubinshtein R, Lerman A, Spoon DB, Rihal CS. Anatomic features of the left main coronary artery and factors associated with its bifurcation angle: a 3-dimensional quantitative coronary angiographic study. Catheter Cardiovasc Interv 2012; 80:304-9. [PMID: 22121105 DOI: 10.1002/ccd.23425] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 08/31/2011] [Accepted: 10/07/2011] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess the anatomic characteristics of the left main coronary artery (LM), and the relation between anatomic and clinical factors and the LM bifurcation angle (BA) using a novel, three dimensional quantitative coronary angiography (3D QCA) software. BACKGROUND Percutaneous intervention of the LM is a therapeutic option in selected patients with coronary artery disease (CAD). The anatomic features of the LM and its BA are determinants of procedural success and clinical outcome. However, those features and the factors that may affect the LM BA have not been fully described. METHODS The LM anatomy was evaluated from angiograms of 203 patients (age = 66 ± 11 years, 31% female) with and without LM CAD using 3D QCA analysis (IC-PRO, Paieon, Israel). LM size as well as the proximal BA (between LM and LCX) and the distal BA (between left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX)) were measured in end-diastole. Angiographic and clinical findings were also recorded. RESULTS 133/203 patients (65%) had no LM CAD. 3D QCA analysis demonstrated significant variability in the anatomy of the normal LM, including the LM branch vessels (LAD, LCX) diameter, and the LM BA. Among the 70 patients with LM CAD, 44 had distal LM disease. Importantly, patients with distal LM CAD had narrower proximal BA and a wider distal BA. Multivariate analysis (adjusted for clinical and anatomic variables) identified female sex (P = 0.02), trifurcation anatomy (P = 0.009), age > 75 years (P = 0.0009), and LM length > 12 mm (P = 0.001) as independent associates of the proximal BA. Independent associates of the distal BA were: trifurcation anatomy (P = 0.001), LM length > 12 mm (P < 0.0001), age > 75 years (P = 0.004), and a history of coronary bypass surgery (P = 0.04). CONCLUSIONS The current study demonstrates significant variability in the anatomy of the LM. The LM BA differs between patients with and without distal LM CAD, and both anatomic and clinical factors may affect the LM BA. Our findings also emphasize the possible usefulness of 3D QCA in the assessment of the LM.
Collapse
Affiliation(s)
- Ronen Rubinshtein
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester Minnesota 55905, USA
| | | | | | | |
Collapse
|
8
|
Iakovou I, Kadota K, Papamentzelopoulos S, Pavlides G, Mitsudo K. Is there a higher risk of stent thrombosis in bifurcation lesion or is it related to the technique? EUROINTERVENTION 2012; 6 Suppl J:J107-11. [PMID: 21930473 DOI: 10.4244/eijv6supja17] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Bifurcation lesions and bifurcation stenting have been reported to be risk factors of stent thrombosis (ST). ST is a complex process that may be the culmination of device, patient, lesion and procedural factors. The strategy of provisional SB stenting is widely accepted for suitable bifurcation lesions, and is accompanied by low rates of ST. However, it is not applicable to all patients, and in these clinical scenarios (approx. 10%), there is no consensus on the best option for elective stenting with two stents regarding the incidence of ST. Excessive metal scaffolding, such as in the classical crush technique, should be avoided. Further accumulation of long-term data from larger clinical registries and randomised studies will be needed to elucidate the best technique regarding the avoidance of ST in bifurcation treatment. Dedicated bifurcation stents tailored for each type of lesion could resolve this issue, especially the excess of metal protruding in the vessel lumen or crushed onto the wall. However, they need to be tested in upcoming and ongoing trials. Stent thrombosis (ST) is the sudden occlusion of a stented coronary artery due to thrombus formation. Despite major improvements of antiplatelet therapy, thrombotic events remain the primary cause of death after percutaneous coronary interventions (PCI). The clinical consequences of ST are frequently catastrophic and include death in 20% to 48% or major myocardial infarction (MI) in 60% to 70% of the cases. In the drug-eluting stent era, ST and especially very late ST remains a concern of coronary intervention. Bifurcation lesions and bifurcation stenting have been reported to be the risk factors for ST. ST is a complex process that may be a culmination of device, patient, lesion, and procedural factors. The exact cause of the higher risk of ST in bifurcation lesions is unknown although pathologic studies have suggested that the arterial branch points are predisposed to development of atherosclerotic plaque, thrombus, and inflammation because they are foci of low shear stress.
Collapse
Affiliation(s)
- Ioannis Iakovou
- 1st Cardiology Clinic, Onassis Cardiac Surgery Centre, 356 Sygrou Avenue, Kallithea, Athens, Greece.
| | | | | | | | | |
Collapse
|
9
|
Chen SL, Mintz G, Kan J, Zhang JJ, Hu ZY, Ye F, Tian NL, Zhang JX, Xu T, Liu ZZ. Serial intravascular ultrasound analysis comparing double kissing and classical crush stenting for coronary bifurcation lesions. Catheter Cardiovasc Interv 2011; 78:729-36. [DOI: 10.1002/ccd.23110] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
10
|
Shin DH, Park KW, Koo BK, Oh IY, Seo JB, Gwon HC, Jeong MH, Seong IW, Rha SW, Yang JY, Park SJ, Yoon JH, Han KR, Park JS, Hur SH, Tahk SJ, Kim HS. Comparing two-stent strategies for bifurcation coronary lesions: which vessel should be stented first, the main vessel or the side branch? J Korean Med Sci 2011; 26:1031-40. [PMID: 21860553 PMCID: PMC3154338 DOI: 10.3346/jkms.2011.26.8.1031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 06/21/2011] [Indexed: 12/02/2022] Open
Abstract
This study compared two-stent strategies for treatment of bifurcation lesions by stenting order, 'main across side first (A-family)' vs 'side branch first (S-family). The study population was patients from 16 centers in Korea who underwent drug eluting stent implantation with two-stent strategy (A-family:109, S-family:140 patients). The endpoints were cardiac death, myocardial infarction (MI), stent thrombosis (ST), and target lesion revascularization (TLR) during 3 years. During 440.8 person-years (median 20.2 months), there was 1 cardiac death, 4 MIs (including 2 STs), and 12 TLRs. Cumulative incidence of cardiac death, MI and ST was lower in A-family (0% in A-family vs 4.9% in S-family, P = 0.045). However, TLR rates were not different between the two groups (7.1% vs 6.2%, P = 0.682). Final kissing inflation (FKI) was a predictor of the hard-endpoint (hazard ratio 0.061; 95% CI 0.007-0.547, P = 0.013), but was not a predictor of TLR. The incidence of hard-endpoint of S-family with FKI was comparable to A-family, whereas S-family without FKI showed the poorest prognosis (1.1% vs 15.9%, retrospectively; P = 0.011). In conclusion, 'A-family' seems preferable to 'S-family' if both approaches are feasible. When two-stent strategy is used, every effort should be made to perform FKI, especially in 'S-family'.
Collapse
Affiliation(s)
- Dong-Ho Shin
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Kyung Woo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Il-Young Oh
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jae-Bin Seo
- Department of Internal Medicine, Boramae Medical Center, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
| | - Myung-Ho Jeong
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - In-Whan Seong
- Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Seung Woon Rha
- Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Ju-Young Yang
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Seung-Jung Park
- Department of Internal Medicine, University of Ulsan Asan Medical Center, Seoul, Korea
| | - Jung Han Yoon
- Department of Internal Medicine, Wonju Christian Hospital, Wonju, Korea
| | - Kyoo-Rok Han
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Jong-Sun Park
- Department of Internal Medicine, Yeungnam University Medical Center, Daegu, Korea
| | - Seung-Ho Hur
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Seung-Jea Tahk
- Department of Internal Medicine, Ajou Univeristy Hospital, Suwon, Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| |
Collapse
|
11
|
Chen SL. Seeing double: the double kissing crush stenting technique for coronary bifurcation lesions. Interv Cardiol 2011. [DOI: 10.2217/ica.11.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
|
12
|
Girasis C, Schuurbiers JC, Onuma Y, Serruys PW, Wentzel JJ. Novel bifurcation phantoms for validation of quantitative coronary angiography algorithms. Catheter Cardiovasc Interv 2011; 77:790-7. [DOI: 10.1002/ccd.22704] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
13
|
Chen SL, Santoso T, Zhang JJ, Ye F, Xu YW, Fu Q, Kan J, Paiboon C, Zhou Y, Ding SQ, Kwan TW. A Randomized Clinical Study Comparing Double Kissing Crush With Provisional Stenting for Treatment of Coronary Bifurcation Lesions. J Am Coll Cardiol 2011; 57:914-20. [PMID: 21329837 DOI: 10.1016/j.jacc.2010.10.023] [Citation(s) in RCA: 214] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2010] [Revised: 09/16/2010] [Accepted: 10/05/2010] [Indexed: 12/11/2022]
Affiliation(s)
- Shao-Liang Chen
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Chen SL, Zhang JJ, Ye F, Liu ZZ, Zhu ZS, Lin S, Tian NL, Fang WY, Chen YD, Sun XW, Wei M, Shan SJ, Kan J, Qian J, Yang S, Yuan ZB, Kwan TW, Hu DY. Crush stenting with drug-eluting stents: relevance of coronary bifurcation lesion location on angiographic and clinical outcomes. Clin Cardiol 2010; 33:E32-9. [PMID: 20857513 DOI: 10.1002/clc.20544] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Accepted: 09/18/2008] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Data on the relevance of the location of coronary bifurcation lesions treated by crush stenting with outcomes were limited. HYPOTHESIS We hypothesized that the location of the bifurcation lesion correlated with clinical outcome. METHOD A total of 212 patients with 230 true bifurcation lesions treated by crush stenting with drug-eluting stents (DES) were assessed prospectively. Surveillance quantitative angiographies were indexed at 8 months after procedure. Primary endpoint was major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, and target lesion revascularization (TLR). RESULTS Patients in the distal right coronary artery (RCAd) group were characterized by higher proportions of prior myocardial infarction and very tortuous lesions. However, lesions in the RCAd group, compared to those of other groups, had the lowest late lumen loss, with resultant lowest incidence of MACE at a mean follow-up of 268±35 days. Independent predictors of MACE included unsatisfied kissing (KUS; hazard ratio [HR]: 12.14, 95% confidence interval [CI]: 4.01-12.10, P = .001) and non-RCA lesion (HR: 20.69, 95% CI: 5.05-22.38, P = .001), while those of TLR were KUS (HR: 10.21, 95% CI: 0.01-0.34, P = .002), bifurcation angle (HR: 4.728, 95% CI: 2.541-4.109, P = .001), and non-RCA lesion (HR: 16.05, 95%CI: 1.01-4.83, P = .001). CONCLUSIONS Classical crush stenting with drug-eluting stents is associated with significantly better outcomes in RCAd. Quality of kissing inflation is mandatory to improve outcome.
Collapse
|
15
|
Godino C, Al-Lamee R, La Rosa C, Morici N, Latib A, Ielasi A, Di Mario C, Sangiorgi GM, Colombo A. Coronary left main and non-left main bifurcation angles: how are the angles modified by different bifurcation stenting techniques? J Interv Cardiol 2010; 23:382-93. [PMID: 20624203 DOI: 10.1111/j.1540-8183.2010.00562.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Investigation of the correlation between bifurcation angles and outcomes is limited with discordant results. The aim of this study is to investigate left main (LM) and non-left main (N-LM) bifurcation angles and their modification after percutaneous coronary intervention (PCI). Measurement of all three angles adds to our understanding of bifurcation anatomy and the resultant effect of different stenting techniques. METHODS AND RESULTS All three bifurcation angles were described according to the European Bifurcation Club definition: the A (proximal bifurcation angle), the B (distal bifurcation angle) and the C (main branch angle). Measurements were performed in 75 LM and 140 N-LM bifurcations. In LM bifurcations baseline mean values of C, A, and B were 151 degrees +/- 28 degrees, 131 degrees +/- 32 degrees, and 78 +/- 28 degrees, respectively. In bifurcations with 2 stents the B significantly decreased by a mean of 10 degrees (P = 0.003) and A increased by 10 degrees (P = 0.006). Crush stenting significantly decreased B (A - 14 degrees ; P = 0.020) and increased A (A + 21 degrees; P = 0.005), particularly non-true bifurcations. In N-LM bifurcations mean values for C, A, and B were 156 degrees +/- 19 degrees , 144 degrees +/- 22 degrees, and 60 degrees +/- 20 degrees, respectively. Similar to LM bifurcations, the B became narrower mainly at the expense of the A, which became wider. In both types of bifurcations the greatest variation in A and B was found following 2-stent techniques performed in T-shaped (> or =70 degrees) bifurcations. CONCLUSIONS In both LM and N-LM bifurcations we found a significant difference in A and B pre- and post-PCI. This difference was driven by the 2-stent technique and was most evident with a baseline bifurcation angle > or =70 degrees. The Crush technique caused the largest angle variation post-procedure, particularly in non-true LM bifurcations.
Collapse
Affiliation(s)
- Cosmo Godino
- Interventional Cardiology Unit, San Raffaele Institute, Milan, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Chen SL, Chen JP, Mintz G, Xu B, Kan J, Ye F, Zhang J, Sun X, Xu Y, Jiang Q, Zhang A, Stone GW. Comparison Between the NERS (New Risk Stratification) Score and the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) Score in Outcome Prediction for Unprotected Left Main Stenting. JACC Cardiovasc Interv 2010; 3:632-41. [DOI: 10.1016/j.jcin.2010.04.006] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2009] [Revised: 04/09/2010] [Accepted: 04/15/2010] [Indexed: 11/15/2022]
|
17
|
Girasis C, Serruys PW, Onuma Y, Colombo A, Holmes DR, Feldman TE, Bass EJ, Leadley K, Dawkins KD, Morice MC. 3-Dimensional bifurcation angle analysis in patients with left main disease: a substudy of the SYNTAX trial (SYNergy Between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery). JACC Cardiovasc Interv 2010; 3:41-8. [PMID: 20129567 DOI: 10.1016/j.jcin.2009.10.019] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 10/21/2009] [Accepted: 10/22/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We explore the bifurcation angle (BA) parameters of the left main coronary artery (LM), the effect of percutaneous coronary intervention (PCI) on this angulation, and the impact of BA on clinical outcome. BACKGROUND The BA is emerging as a predictor of outcome after PCI of bifurcation lesions. Three-dimensional (3D) quantitative coronary angiography (QCA) overcomes the shortcomings of 2-dimensional analysis and provides reliable data. METHODS This is a substudy of the SYNTAX (SYNergy Between Percutaneous Coronary Intervention With TAXus and Cardiac Surgery) trial. The cineangiograms of the 354 patients who underwent PCI of their LM stem were analyzed with 3D QCA software (CardiOp-B, Paieon Medical, Ltd., Rosh Ha'ayin, Israel). The proximal BA (between LM and left circumflex [LCX]) and the distal BA (between left anterior descending and LCX) were computed in end-diastole and end-systole, both before and after PCI. The cumulative major adverse cardiac and cardiovascular event (MACCE) rates throughout the 12-month period after randomization were stratified across pre-PCI distal BA values and compared accordingly. RESULTS Complete analysis was feasible in 266 (75.1%) patients. Proximal and distal BA had mean pre-PCI end-diastolic values of 105.9 +/- 21.7 degrees and 95.6 +/- 23.6 degrees , respectively, and were inversely correlated (r = -0.75, p < 0.001). During systolic motion of the heart there was an enlargement of the proximal angle and a reduction of the distal angle (DeltaBA -8.2 degrees and 8.5 degrees , respectively, p < 0.001 for both). The PCI resulted in a mean decrease in the distal BA (DeltaBA 4.5 degrees , p < 0.001). The MACCE rates did not differ across distal BA values; freedom from MACCE at 12 months was 82.8%, 85.4%, and 81.1% (p = 0.74) for diastolic values (first through third tertile). CONCLUSIONS Left main BA analysis with 3D QCA is feasible. Both proximal and distal angles are affected by cardiac motion; PCI modifies the distal angle. There is no clear difference in event rates across pre-PCI distal BA values.
Collapse
Affiliation(s)
- Chrysafios Girasis
- Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
CHEN SHAOLIANG, KWAN TAKW. Twenty-Four-Month Update on Double-Kissing Crush Stenting of Bifurcation Lesions. J Interv Cardiol 2009; 22:121-7. [DOI: 10.1111/j.1540-8183.2009.00440.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
19
|
TAN HUAYCHEEM. Stent Thrombosis after Percutaneous Coronary Intervention for Bifurcation Lesions. J Interv Cardiol 2009; 22:114-6. [DOI: 10.1111/j.1540-8183.2009.00438.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
20
|
|
21
|
Abstract
Percutaneous intervention, whether coronary or noncoronary, continues to be a highly active area of medicine. This article contains an overview of the most notable developments reported in recent months. Drug-eluting stents (DESs) have provided one of the major advances in interventional cardiology as they have very effectively reduced the restenosis rate. Both randomized clinical trials and large observational studies have confirmed their safety, and their use has been extended to include highly complex conditions. Although thrombosis is one complication that can affect both conventional stents and DESs, the rate of late stent thrombosis is slightly, though significantly, higher with DESs. Primary angioplasty is the treatment of choice for patients with acute myocardial infarction if carried out under appropriate conditions, within a reasonable time period in a specialized center by experienced personnel. Use of thrombectomy devices can improve procedural outcomes and it appears that DES implantation is safe and effective, though more data are still needed. In patients with non-ST-elevation acute coronary syndrome, early treatment using an invasive approach coupled to the administration of various combinations of antiplatelet and antithrombotic drugs continues to be fundamental. Although left main coronary artery lesions are generally treated surgically, advances in percutaneous techniques and the use of DESs mean that an increasing number of patients are being treated using percutaneous coronary interventions. A number of studies have shown good results in other lesions and in high-risk patients with, for example, bifurcation lesions, chronic occlusions or diabetes. Intracoronary ultrasound is the predominant intracoronary diagnostic technique and it can be used to assist in optimizing DES implantation. In addition, measurement of the fractional flow reserve is helpful in evaluating the severity of moderate lesions whereas the high-resolution images provided by optical coherence tomography are particularly informative. Multislice computed tomography enables the presence of coronary artery disease to be ruled out and the technique is also useful as a complementary tool for interventional cardiologists. Research into regenerative techniques is promising but remains experimental at present. With regard to noncoronary interventions, new data have become available that support the use of a percutaneous approach in patients with patent foramen ovale. In addition, clinical experience with percutaneous aortic valve replacement, via either the transfemoral or transapical route, is increasing.
Collapse
|