Effectiveness of decremental diameter balloon catheters (tapered balloon)

Impact of Reference Mismatch on Procedure Outcomes of Percutaneous Coronary Intervention

A significant mismatch between proximal and distal reference lumen diameters of the target lesion may pose challenges during percutaneous coronary intervention (PCI) and therefore influence the outcomes. We investigated total 1706 lesions underwent IVUS guided percutaneous coronary intervention, that were divided into 2 groups, including 411 lesions in Mismatch group and 1295 lesions in Non-Mismatch group. After propensity score matching, 397 lesions in each group were selected for final data set. The analysis showed that Mismatch group PCI required more frequently use of post-stenting optimization (79.6% vs 53.9%, P < .001) using higher max pressure (19.5 ± 3.9 vs 16.7 ± 3.7 atm, P < .001). Besides, Mismatch group also encountered more PCI major complications (7.8% vs 4.0%, P = .024) and lower procedure success rate (91.4% vs 95.5%, P = .022). On final angiogram, Mismatch group had smaller minimum lumen diameter (2.62 ± .45 vs 2.90 ± .57 mm, P < .001) and lower angiographic success rate (93.2% vs 96.7%, P = .023). On final IVUS, Mismatch group had higher rate of incomplete stent apposition and stent edge dissection (6.3% vs 3.0%, P = .029 and 2.5% vs .5%, P = .021, respectively). In conclusion, reference mismatch posed significant challenging during PCI that led to unfavorable procedural outcomes. These impacts may translate into long-term clinical implications that need to be addressed in future studies.

Feasibility and Outcomes of Left Main to Branch Vessel PCI with Novel Tapered Coronary Stent in a Tertiary Care Centre: A Real World Experience

OBJECTIVE

To assess the safety and efficacy of Novel tapered (BioMime™ Morph) sirolimus-eluting stent (SES) for left main PCI in a real-world scenario.

BACKGROUND

Currently no data is available on clinical usefulness of tapered ultrathin stents in left main PCI.

METHODS

This was a prospective, non-randomised, single centre study carried out between February 2018 and May 2020 at a tertiary cardiac care centre in southern India. The study included patients treated with BioMime Morph tapered stent for distal de novo LMB lesion or ostial LAD/LCX lesions with significant size disparity between reference segments based on the eligibility criteria. Primary endpoint of the study was the cumulative incidence of major adverse cardiovascular events (MACE) composed of cardiac death, myocardial infraction, and clinically driven target-lesion revascularisation at follow-up.

RESULTS

A total of 41 patients (average age of 54.83±9.81 years) were included in the study. Average SS-2 score was 23.17±5.42. Majority of the lesions (n=31; 75.61%) were of medina class (0.1.0). Provisional single stent strategy was adopted for treatment of LMB lesions. TIMI flow-3 was achieved in 40 patients (97.56%). Median clinical follow-up was 20 months (range 6-34 months) There was no periprocedural complication or MACE during follow-up.

Imaging Characteristics of Mismatch Lesions: An Angiographic and Intravascular Ultrasound Analysis of 1369 Coronary Lesions

OBJECTIVES

To evaluate the angiographic and intravascular ultrasound (IVUS) characteristics of coronary mismatch lesions.

BACKGROUND

Better understanding about the characteristics of mismatch lesions may help to achieve more accurate lesion assessment and, thereby, to improve the outcomes of percutaneous coronary intervention (PCI).

METHODS

Angiographic and IVUS data from 1369 lesions were analyzed. Mismatch lesion was defined as the difference between proximal and distal reference lumen diameters of ≥1.0 mm or ≥30% of the distal reference lumen diameter.

RESULTS

The incidence of mismatch lesions was 20.1% (275/1369). Compared to nonmismatch group, mismatch group had longer lesions (21.3 [6.4] mm vs 18.4 [6.4] mm, P < .001) with smaller minimum lumen diameter (0.87 [0.29] mm vs 1.10 [0.31] mm, P < .001) and more severe diameter stenosis (78.8% [9.2%] vs 66.3% [10.3%], P < .001). On IVUS, mismatch group had larger lumen area (18.7 [5.0] vs 15.8 [5.1] mm², P < .001) but lower plaque burden at the proximal reference segment (41.0% [9.2%] vs 45.7% [9.9%], P < .001) and smaller lumen area (4.83 [1.89] vs 7.36 [2.89] mm, P < .001) but higher plaque burden at the distal reference segment (42.9% [10.4%] vs 41.4% [10.1%], P = .023). Multivariable logistic regression analysis showed that mismatch lesions were frequently accompanied by diffuse lesions (odds ratio [OR] = 2.50; 95% confidence interval [CI]: 1.83-3.40; P < .001), bifurcation lesions (OR = 5.83; 95% CI: 4.40-7.74; P < .001), and lesions with a low TIMI flow grade (OR = 1.70; 95% CI: 1.08-2.67; P = .022) or severe diameter stenosis (OR = 3.05; 95% CI: 2.10-4.43; P < .001).

CONCLUSIONS

Mismatch lesions are quite common and characterized by greater lesion complexity compared with nonmismatch lesions. Further studies may be necessary to address the impact of this lesion type on the outcome of PCI.

Clinical Outcomes of Novel Long-Tapered Sirolimus-Eluting Coronary Stent System in Real-World Patients With Long Diffused De Novo Coronary Lesions

Background

When coronary lesions involve segments > 48 mm, the only treatment possibility is stent overlapping which is associated with higher neointimal proliferation that lead to more restenosis. Furthermore, tapering of coronary arteries is a major challenge observed with long diffuse coronary lesions. This study attempted to assess the safety and performance of world’s first commercialised long-tapered (60 mm) sirolimus-eluting coronary stent (SES) system for the treatment of long diffused de novo coronary lesions in real world scenario.

Methods

This was a retrospective, non-randomised, multicentre study which included 362 consecutive patients implanted with long-tapered BioMime™ Morph SES system for the treatment of long diffused de novo coronary lesions. Safety endpoint was major adverse cardiac events (MACE), which was defined as composite of cardiac death, myocardial infarction (MI) and ischemic-driven target lesion revascularization (ID-TLR), at 12-month follow-up.

Results

Out of 362 patients included, 170 (47.0%) were diabetic and 159 (43.9%) were hypertensive. The mean age of all patients was 61.09 ± 9.04 years. A total of 625 lesions were identified; out of which 402 lesions were intervened successfully using BioMime Morph. The cumulative incidence of MACE was 7 (2.0%) at 12-month follow-up which included four (1.1%) cardiac deaths, one (0.3%) case of MI and two (0.6%) ID-TLR. Acute stent thrombosis was reported in one (0.3%) patient.

Conclusions

The present study confirms the safety and performance of BioMime Morph, and hence, can be considered as a treatment of choice for long diffused tapered de novo coronary lesions in routine clinical practice.

A Report of Successful Procedural, Clinical, and Angiographic Outcomes with a Tapered Stent of a Patient in Naturally Tapered Coronary Vessel

In cases involving stenosis or occlusions in major parts of a long vessel, natural tapering of coronary vessels may create dilemma in deciding the optimal stent size during percutaneous coronary intervention. In this regard, tapered stents have been developed recently. Herein, we present a case of 67-year-old male patient with triple vessel disease including two tandem lesions in naturally tapered Left Anterior Descending (LAD) artery. The patient received a 3.0-2.5x60 mm Sirolimus-eluting BioMime Morph stent (Meril life Sciences, Gujarat, India) in the mid-distal LAD lesion along with conventional stent implantations in other two lesions. The procedure was successful and good coronary flow was obtained after revascularization. The patient remained asymptomatic thereafter. At one year, angiographic follow-up revealed good flow and no restenosis in the LAD vessel. We are of opinion that using tapered stents with decremented diameter may offer the advantages of excellent adaptation to vessel size, vessel tapering, and good apposition in patients with long coronary lesions in tapered vessels.

Image-based quantification of 3D morphology for bifurcations in the left coronary artery: Application to stent design

BACKGROUND

Improved strategies for stent-based treatment of coronary artery disease at bifurcations require a greater understanding of artery morphology.

OBJECTIVE

We developed a workflow to quantify morphology in the left main coronary (LMCA), left anterior descending (LAD), and left circumflex (LCX) artery bifurcations.

METHODS

Computational models of each bifurcation were created for 55 patients using computed tomography images in 3D segmentation software. Metrics including cross-sectional area, length, eccentricity, taper, curvature, planarity, branching law parameters, and bifurcation angles were assessed using open-sources software and custom applications. Geometric characterization was performed by comparison of means, correlation, and linear discriminant analysis (LDA).

RESULTS

Differences between metrics suggest dedicated or multistent approaches should be tailored for each bifurcation. For example, the side branch of the LCX (i.e., obtuse marginal; OM) was longer than that of the LMCA (i.e., LCXprox) and LAD (i.e., first diagonal; D1). Bifurcation metrics for some locations (e.g., LMCA Finet ratio) provide results and confidence intervals agreeing with prior findings, while revised metric values are presented for others (e.g., LAD and LCX). LDA revealed several metrics that differentiate between artery locations (e.g., LMCA vs. D1, LMCA vs. OM, LADprox vs. D1, and LCXprox vs. D1).

CONCLUSIONS

These results provide a foundation for elucidating common parameters from healthy coronary arteries and could be leveraged in the future for treating diseased arteries. Collectively the current results may ultimately be used for design iterations that improve outcomes following implantation of future dedicated bifurcation stents. © 2015 Wiley Periodicals, Inc.

Vulnerable carina anatomy and ostial lesions in the left anterior descending coronary artery after floating-stent treatment

INTRODUCTION AND OBJECTIVES

Percutaneous coronary intervention for ostial lesions of the left anterior descending coronary artery (LAD) remains a complex procedure. The aim of this study was to evaluate the usefulness of a method of treatment that we have termed the floating-stent approach.

METHODS

The study involved 71 patients with ostial LAD lesions who underwent implantation of a drug-eluting stent in the LAD, which totally or partially covered the ostium of the circumflex artery. No further interventions were planned. Intravascular ultrasound was performed both at baseline and after treatment in 49 patients. All were followed up clinically (16+/-12 months).

RESULTS

Angiography of the LAD demonstrated an immediate success rate of 100%. However, significant focal damage was observed in the circumflex ostium in 7 (10%) patients, three of whom needed treatment. The mean protrusion of the stent over the origin of the circumflex artery was 2.48+/-0.91 mm. The only predictor of circumflex ostial injury identified in the study was the carina having a spiky appearance on intravascular ultrasound, visible in the longitudinal view. We termed this feature the "eyebrow sign". Carina displacement was responsible for the focal damage in 13 of the 14 patient with this feature. Overall, the major cardiac adverse event rate during follow-up was 4%.

CONCLUSIONS

Use of the floating-stent technique for treating LAD ostial lesions was straightforward and gave excellent medium-term

RESULTS

Intravascular ultrasound showed that patients who had a carina with specific vulnerable anatomical features were predisposed to circumflex artery ostial injury.

Angiographic and procedural outcome after coronary angioplasty in high-risk subsets using a decremental diameter (tapered) balloon catheter. Tapered Balloon Registry Investigators

The angiographic and clinical outcomes of 115 patients (129 lesions) treated at 11 clinical centers using a decremental diameter (tapered) balloon catheter were evaluated. The presence of marked tapering of the reference vessel, lesion location involving a bifurcation or anastomosis of a saphenous vein graft, or total coronary occlusion where estimation of the distal vessel size was difficult were indications for this device. The tapered balloon was used as the initial dilatation device in 62 patients (73 narrowings), and as a secondary device in 53 patients (56 narrowings). Lesions selected for tapered balloon angioplasty were generally complex (95% had > or = 1 and 60% had > or = 2 adverse morphologic features). Vessel diameters were larger in the proximal reference segments (3.07 +/- 0.52 mm) than in distal ones (2.48 +/- 0.45 mm) (p<0.001). After tapered balloon angioplasty, the minimal lumen diameter increased from 0.85 +/- 0.34 mm to 2.13 +/- 0.50 mm (p<0.001), and the percent diameter stenosis decreased from 69 +/- 12% to 24 +/- 12% (p<0.001). Coronary dissections occurred in 20% of lesions; they were severe in 4% (National Heart, Lung, and Blood Institute grade C to F). Abrupt closure occurred in 4.3% of patients (2.6% immediate; 1.7% delayed). Procedural success was obtained in 110 patients (96%); major complications (in-hospital death, myocardial infarction, or emergency coronary bypass surgery) occurred in 3 patients (2.7%). Coronary angioplasty using the tapered balloon catheter appears to be a safe and effective technique for the treatment of complex lesion subsets, particularly those involving coronary arteries with marked segmental tapering.

Coronary dissection resulting from angioplasty with slow oscillating vs. rapid inflation and slow vs. rapid deflation

To determine if slow inflation or slow deflation (compared to standard rapid inflation/deflation) would minimize coronary arterial dissection, we randomized 162 lesions from 136 patients undergoing coronary angioplasty with polyolefin copolymer balloons to slow oscillating (1 atmosphere/20 sec) vs. rapid (over 30 sec) inflation and slow (over 15 sec) vs. rapid deflation. The incidence of any dissection was nearly identical in the four inflation/deflation groups. The incidence of severe dissection, however, was significantly higher for the slow inflation/slow deflation group compared to the other three groups (38% vs. 15%, P = .024). For angioplasty performed with polyolefin copolymer balloons, slow deflation combined with slow oscillating inflation is associated with more frequent severe dissections.