Lesion morphology and coronary angioplasty: current experience and analysis

Double Kissing Mini-Culotte Stenting in Unprotected Distal Left Main Bifurcation Under Optical Coherence Tomography Guidance: Immediate and Short-Term Outcomes

Culotte stenting is an effective strategy for left main coronary artery bifurcation lesions. Increased side branch ostial restenosis is the main drawback of culotte stenting. This is due to a napkin ring or potential gap produced at the ostium of the side branch. A bench study by Toth et al11 has shown that additional sequential kissing balloon dilation before main vessel stenting can prevent this deformity. We report immediate and short-term results of double kissing (DK) mini-culotte stenting with a 1-year angiographic follow-up. Between March 2020 and December 2022, 45 patients with distal left main (LM) disease underwent DK mini-culotte stenting at our center under optical coherence tomography guidance. Of 45 patients (male: 35 (77.77%); mean age: 63.67 ± 4.94 years), chronic coronary artery syndrome was present in 26 (57.8%) and unstable angina in the remainder. All lesions were Medina (1,1,1), (0,1,1), or (1,0,1), with a median Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score of 28 (interquartile range 23 to 29). All procedures were technically successful with no adverse clinical events (death, myocardial infarction, or stent thrombosis). Under optical coherence tomography guidance, adequate minimal stent area of 13.28 ± 0.77 mm2, 8.25 ± 0.29 mm2, and 7.54 ± 0.45 mm2 was achieved in LM, left anterior descending, and left circumflex, respectively. Adequate stent expansion of >80% was achieved in all cases. At the end of 1 year, the incidence of major adverse cardiovascular events was 2.2%. Furthermore, restenosis of the side branch developed in 1 patient (2.2%), which was managed conservatively. DK mini-culotte stenting in the distal LM bifurcation has shown promising results and is effective in preventing side branch stent deformation and its sequelae of in-stent restenosis.

Drug-Coated Balloon in Acute Coronary Syndromes: Ready for the Prime Time?

PURPOSE OF REVIEW

Acute coronary syndromes (ACS) are a major global health concern. Percutaneous coronary intervention (PCI) with new-generation drug-eluting stents (DES) has been endorsed as safe and effective in the management of culprit and non-culprit lesions of ACS. However, permanent metallic implants may have drawbacks, including the need for prolonged dual antiplatelet therapy (DAPT) and the risk of long-term stent-related complications. An alternative approach using drug-coated balloons (DCBs) is gaining growing interest, having the potential of delivering therapy directly to vulnerable plaques, avoiding the need for permanent metallic implants, and potentially allowing for better long-term medical treatment. Despite limited evidence, DCB is being explored in several patients' subgroups. This review aims to discuss the existing evidence regarding DCB in ACS management.

RECENT FINDINGS

DCB appears to be a promising strategy in the management of ACS, showing comparable angiographic and clinical results as compared to new-generation DES in relatively small clinical trials or large prospective registries. The advantage of avoiding permanent implants is particularly appealing in this setting, where DCB has the potential of delivering anti-atherogenic local therapy directly to vulnerable plaques still amenable to atherogenic regression. This review seeks to underline the theoretical background of DCB use and reports the available evidence in its support in the specific setting of ACS. In the context of ACS, the use of DCB is highly attractive, offering a dedicated anti-atherogenic local therapy, capable of addressing a broad range of vulnerable plaques and patients.

Endovascular Drug Delivery

Drug-eluting stents (DES) and balloons revolutionize atherosclerosis treatment by targeting hyperplastic tissue responses through effective local drug delivery strategies. This review examines approved and emerging endovascular devices, discussing drug release mechanisms and their impacts on arterial drug distribution. It emphasizes the crucial role of drug delivery in modern cardiovascular care and highlights how device technologies influence vascular behavior based on lesion morphology. The future holds promise for lesion-specific treatments, particularly in the superficial femoral artery, with recent CE-marked devices showing encouraging results. Exciting strategies and new patents focus on local drug delivery to prevent restenosis, shaping the future of interventional outcomes. In summary, as we navigate the ever-evolving landscape of cardiovascular intervention, it becomes increasingly evident that the future lies in tailoring treatments to the specific characteristics of each lesion. By leveraging cutting-edge technologies and harnessing the potential of localized drug delivery, we stand poised to usher in a new era of precision medicine in vascular intervention.

OCT or Angiography Guidance for PCI in Complex Bifurcation Lesions

BACKGROUND

Imaging-guided percutaneous coronary intervention (PCI) is associated with better clinical outcomes than angiography-guided PCI. Whether routine optical coherence tomography (OCT) guidance in PCI of lesions involving coronary-artery branch points (bifurcations) improves clinical outcomes as compared with angiographic guidance is uncertain.

METHODS

We conducted a multicenter, randomized, open-label trial at 38 centers in Europe. Patients with a clinical indication for PCI and a complex bifurcation lesion identified by means of coronary angiography were randomly assigned in a 1:1 ratio to OCT-guided PCI or angiography-guided PCI. The primary end point was a composite of major adverse cardiac events (MACE), defined as death from a cardiac cause, target-lesion myocardial infarction, or ischemia-driven target-lesion revascularization at a median follow-up of 2 years.

RESULTS

We assigned 1201 patients to OCT-guided PCI (600 patients) or angiography-guided PCI (601 patients). A total of 111 patients (18.5%) in the OCT-guided PCI group and 116 (19.3%) in the angiography-guided PCI group had a bifurcation lesion involving the left main coronary artery. At 2 years, a primary end-point event had occurred in 59 patients (10.1%) in the OCT-guided PCI group and in 83 patients (14.1%) in the angiography-guided PCI group (hazard ratio, 0.70; 95% confidence interval, 0.50 to 0.98; P = 0.035). Procedure-related complications occurred in 41 patients (6.8%) in the OCT-guided PCI group and 34 patients (5.7%) in the angiography-guided PCI group.

CONCLUSIONS

Among patients with complex coronary-artery bifurcation lesions, OCT-guided PCI was associated with a lower incidence of MACE at 2 years than angiography-guided PCI. (Funded by Abbott Vascular and others; OCTOBER ClinicalTrials.gov number, NCT03171311.).

Sex-based treatment and outcomes for coronary bifurcation stenting: A report from the e-ULTIMASTER registry

BACKGROUND

Percutaneous coronary intervention (PCI) for bifurcation lesions can be technically challenging and is associated with higher risk. There is little data on sex-based differences in strategy and outcomes in bifurcation PCI.

AIMS

We sought to assess whether differences exist between women and men in the treatment and outcomes of bifurcation PCI.

METHODS

We collected data on 4006 patients undergoing bifurcation PCI, from the e-ULTIMASTER study, a prospective, multicentre study enrolling patients from 2014 to 2018. We divided the bifurcation cohort according to sex, with 1-year follow-up of outcomes (target lesion failure [TLF], target vessel failure [TVF], and patient-oriented composite endpoint [POCE]).

FINDINGS

Women were older (69.2 ± 10.9 years vs. 64.4 ± 11.0 years), with a greater burden of cardiovascular comorbidities. For true and non-true bifurcation lesions, women and men were equally likely to undergo a single stent approach (true: 63.2% vs. 63.6%, p = 0.79, non-true: 95.4% vs. 94.3%, p = 0.32), with similar rates of final kissing balloon (FKB) (37.2% vs. 35.5%, p = 0.36) and proximal optimization (POT) (34.4% vs. 34.2%, p = 0.93) in cases where two stents were used. Lastly, after propensity score matching, there was no difference between women and men in the incidence of the composite endpoints of TLF (5.5% vs. 5.2%, RR 1.05 [95% CI 0.77-1.44], p = 0.75), TVF (6.2% vs. 6.3%, RR 0.99 [95% CI 0.74-1.32], p = 0.96), and POCE (9.9% vs. 9.5%, RR 1.05 [95% CI 0.83-1.31], p = 0.70).

CONCLUSION

In this contemporary, real-world study of bifurcation PCI, we report no difference in stent strategy between women and men, with similar outcomes at 1-year.

STEMI patients receiving percutaneous coronary intervention for a culprit lesion with coronary artery bifurcation-efficacy and safety of the jailed semi-inflated balloon

Background

We aimed to evaluate the efficacy and safety of the 'jailed semi-inflated balloon technique' (JSIBT) for side branch (SB) protection in STEMI patients with a culprit lesion involving a coronary artery bifurcation while undergoing emergent percutaneous coronary intervention (PCI).

Methods

We treated between Jan, 2011 and Jun, 2020, a total of 264 STEMI patients with a culprit lesion that involved a coronary artery bifurcation using primary PCI. In 30 patients, SB was protected by JSIBT (the JSIBT group). In 234 patients, SB was either protected or not protected by a placed wire (the non-JSIBT group).

Results

In both groups, after PCI procedure, TIMI flows of main vessel (MV) and SB were increased significantly compared with their measurements before the procedure. TIMI flows of post-procedural MV were similar between the two groups. In the JSIBT group, TIMI flows of SB both peri-procedure and post-procedure measurements were significantly greater than the non-JSIBT group. Despite a higher incidence of SB dissection in the JSIBT group, no inter-group difference was found in their total SB complications (like SB dissection, SB occlusion, wire entrapment or balloon rupture/entrapment). While JSIBT was an independent predictor for the SB TIMI 3 flow measured at the end of primary PCI, it was not an independent predictor for SB complications.

Conclusion

The use of JSIBT as a method of SB protection during primary PCI not only provided better SB protection, but it also had a similar rate of SB complications compared with those with or without prior application of SB wire. This technique may be an effective method of protecting SB for STEMI patients involving coronary artery bifurcation and underwent emergent PCI.

Utility of the ACC/AHA Lesion Classification to Predict Outcomes After Contemporary DES Treatment: Individual Patient Data Pooled Analysis From 7 Randomized Trials

Background Use of the modified American College of Cardiology (ACC)/American Heart Association (AHA) lesion classification as a prognostic tool to predict short- and long-term clinical outcomes after percutaneous coronary intervention in the modern drug-eluting stent era is uncertain. Methods and Results Patient-level data from 7 prospective, randomized trials were pooled. Clinical outcomes of patients undergoing single lesion percutaneous coronary intervention with second-generation drug-eluting stent were analyzed according to modified ACC/AHA lesion class. The primary end point was target lesion failure (TLF: composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization). Clinical outcomes to 5 years were compared between patients treated for noncomplex (class A/B1) versus complex (class B2/C) lesions. Eight thousand five hundred sixteen patients (age 63.1±10.8 years, 70.5% male) were analyzed. Lesions were classified as A, B1, B2, and C in 7.9%, 28.5%, 33.7%, and 30.0% of cases, respectively. Target lesion failure was higher in patients undergoing percutaneous coronary intervention of complex versus noncomplex lesions at 30 days (2.0% versus 1.1%, P=0.004), at 1 year (4.6% versus 3.0%, P=0.0005), and at 5 years (12.4% versus 9.2%, P=0.0001). By multivariable analysis, treatment of ACC/AHA class B2/C lesions was significantly associated with higher rate of 5-year target lesion failure (adjusted hazard ratio, 1.39 [95% CI, 1.17-1.64], P=0.0001) driven by significantly higher rates of target vessel myocardial infarction and ischemia-driven target lesion revascularization. Conclusions In this pooled large-scale analysis, treating complex compared with noncomplex lesions according to the modified ACC/AHA classification with second-generation drug-eluting stent was associated with worse 5-year clinical outcomes. This historical classification system may be useful in the contemporary era for predicting early and late outcomes following percutaneous coronary intervention.

Elevated levels of sIL-2R, TNF-α and hs-CRP are independent risk factors for post percutaneous coronary intervention coronary slow flow in patients with non-ST segment elevation acute coronary syndrome

To evaluate the association between circulating levels of inflammatory cytokines and the occurrence of post-percutaneous coronary intervention (PCI) coronary slow flow (CSF) in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS). CSF after PCI commonly occurs and implies poor outcomes, while the determinants of post-PCI CSF in patients with NSTE-ACS remain controversial. In this multicenter case control study, 176 patients diagnosed with NSTE-ACS and with post-PCI CSF occurred composed of CSF group, while 352 matched NSTE-ACS patients composed control group. Corrected thrombolysis in myocardial infarction frame count (cTFC), circulating levels of inflammatory cytokines and PCI related parameters were analyzed using Logistic regression models. Among 528 patients with median age of 67 (59-76) and male proportion of 65.5%, 176 (35.0%) patients had occurrence of post-PCI CSF defined as cTFC ≥ 24. Patients with CSF presented more intense inflammatory activity revealed by higher levels of white blood cell, high-sensitivity C-reactive protein (hs-CRP), interleukin-1ß (IL-1ß), soluble IL-2 receptor (sIL-2R), IL-6, IL-8, IL-10 and tumor necrosis factor-α (TNF-α), while PCI related parameters were comparable. Correlation analysis showed cTFC was positively correlated with those inflammatory cytokines. Logistic regression model indicates that hs-CRP (odds ratio (OR) = 3.038, 95% confidence interval (CI) 1.545-5.975), sIL-2R (OR = 2.103, 95% CI 1.959-4.026) and TNF-α (OR = 3.708, 95% CI 1.426-9.641) were valuable predictors for CSF occurrence. Elevated circulating levels of inflammatory cytokine including hs-CRP, sIL-2R and TNF-α rather than PCI related parameters could predict post-PCI CSF in patients with NSTE-ACS.

Protective ballooning technique for prevention of side branch occlusion in coronary nonleft main true bifurcation lesions: A single-center study

OBJECTIVES

We aimed to evaluate the efficacy of a protective ballooning technique in preventing side branch (SB) occlusion and to assess the long-term clinical outcomes for coronary nonleft main true bifurcation lesions.

BACKGROUND

SB occlusion is a major complication associated with percutaneous coronary intervention (PCI) for coronary bifurcation lesions.

METHODS

Patients were consecutively enrolled and randomly assigned to protective ballooning technique or jailed wire technique group. Periprocedural and long-term clinical outcomes were compared.

RESULTS

Patients in the protective ballooning technique (n = 173) and jailed wire technique (n = 167) groups were followed up for 12 months. SB occlusion occurred in one patient (0.6%) and nine patients (5.4%) in each group, respectively. The proportion of thrombolysis in myocardial infarction (TIMI) flow grade 3 of the SB was higher in the protective ballooning technique group (98.8% vs. 95.2%, p < 0.05). SB rewiring was necessary in one patient in the protective ballooning technique group (0.6%) with provisional stenting, significantly lower than that in the jailed wire technique group (seven patients, 4.2%; p = 0.03). Periprocedural myocardial infarction occurred in three (1.73%) and six (3.59%) patients in the protective ballooning technique and jailed wire technique groups without significant difference, respectively. Major adverse cardiovascular events at 12 months were similar in both groups.

CONCLUSIONS

Protective ballooning technique is effective for the prevention of SB occlusion in nonleft main true bifurcation lesions and had favorable long-term outcomes at the 12-month follow-up.

Rationale, Design, and Implications of Bifurcation Coronary Stenting: Insight from the Indian Bifurcation Stenting (IBIS) Registry

Background

Bifurcation coronary stenting (BCS) has unique therapeutic challenges. Several BCS strategies are prescribed for treatment, with conflicting data, and which is the best strategy for optimal short- and long-term outcomes remains a matter of debate. There is no systematic data from an Indian perspective in regard to patterns of BCS and its outcomes.

Methods and analysis

The Indian Bifurcation Stenting (IBIS) registry is a prospective, nationwide, endpoint-driven, investigator-initiated, multi-center, observational registry to compare the different bifurcation stent strategies, the effect of adjuvant techniques, and bifurcation anatomical differences in predicting short- and long-term clinical outcomes of bifurcation coronary interventions in India. A total of 1,000 patients from 20 clinical sites across the country will be enrolled in this study from September 2020 to August 2023. The primary endpoint will be the composite endpoint of major adverse cardiac events including cardiac death, target lesion myocardial infarction (MI), and ischemia-driven target lesion revascularization at the end of two years. The secondary endpoints include all causes of death, MI, target vessel revascularization, in-stent restenosis, stroke, and predefined procedural parameters. The safety endpoint is the occurrence of definite or probable stent thrombosis.

Conclusion

The aim of this prospective observational registry is to assess the practice patterns and clinical outcomes of patients undergoing coronary bifurcation lesion angioplasty in India. This will be extremely useful to provide an evidence-based insight as well as guidance to bifurcation angioplasty in India.

Vascular Lesion-Specific Drug Delivery Systems: JACC State-of-the-Art Review

Drug delivery is central to modern cardiovascular care, where drug-eluting stents, bioresorbable scaffolds, and drug-coated balloons all aim to restore perfusion while inhibiting exuberant healing. The promise and enthusiasm of these devices has in some cases exceeded demonstration of efficacy and even understanding of driving mechanisms. The authors review the means of drug delivery in each device, outlining how the technologies affect vascular behavior. They focus on how drug retention and response are governed by lesion morphology: lipid displacing drug-specific binding sites, calcium inhibiting diffusion, blocking thrombi or promoting luminal washout, and vascular healing steering hyperplastic developments. In this regard, the authors outline the fundamental impact of vascular structure on drug delivery and review the development of contemporary and future devices for coronary and peripheral intervention. They look toward a future where incorporating information on lesion distribution is central to therapeutic success and envision a transition toward lesion-specific treatment for improved interventional outcomes.

Contemporary Management of Isolated Ostial Side Branch Disease: An Evidence-based Approach to Medina 001 Bifurcations

The optimal management of bifurcation lesions has received significant interest in recent years and remains a matter of debate among the interventional cardiology community. Bifurcation lesions are encountered in approximately 21% of percutaneous coronary intervention procedures and are associated with an increased risk of major adverse cardiac events. The Medina classification has been developed in an attempt to standardise the terminology when describing bifurcation lesions. The focus of this article is on the management of the Medina 0,0,1 lesion (‘Medina 001’), an uncommon lesion encountered in <5% of all bifurcations. Technical considerations, management options and interventional techniques relating to the Medina 001 lesion are discussed. In addition, current published data supporting the various proposed interventional treatment strategies are examined in an attempt to delineate an evidence-based approach to this uncommon lesion.

Prognostic significance of the Medina classification in bifurcation lesion percutaneous coronary intervention with second-generation drug-eluting stents

The Medina classification is the most widespread method to describe bifurcation lesions. However, little is known regarding its prognostic impact. Therefore, the aim of this study is to assess the prognostic significance of the Medina classification following percutaneous coronary intervention (PCI). From a prospective registry of 738 consecutive patients undergoing PCI for bifurcation lesions, 505 were treated with second-generation drug-eluting stents (DES). Of these, 407 (80.6%) presented with "true bifurcation" (TB) lesions (Medina class 1.0.1, 1.1.1, 0.1.1) and 98 (19.4%) in all other categories ("non-true bifurcation" = NTB). We compared rates of death and major adverse cardiac events (MACE: cardiac death, myocardial infarction, or target vessel revascularization) at 12 months and 3 years. Patients with TB had lower rates of previous bypass surgery (7.4% vs. 11.2%, p = 0.043). TB lesions were more likely to be calcified (33.9% vs. 28.6%, p = 0.003) and ulcerated (8.8% vs. 4.1%, p < 0.01). At 12 months, mortality was numerically higher for TB PCI (4.1% vs. 2.1%, p = 0.052) and MACE rates were higher (19.2% vs. 10.2%, p < 0.001). At 3 years, both all-cause death (10.1% vs. 5.1%, p = 0.002) and rates of MACE (37.2% vs. 17.6%, p < 0.001) were higher for TB PCI. After performing regression analysis, TB remained an independent predictor for poor outcomes (OR-2.28 at 12 months, CI 1.45-9.50, p = 0.007, OR-3.75 at 3 years, CI 1.52-6.77, p = 0.001 for MACE). In conclusion, TB lesions, according to the Medina classification, portend worse prognosis for patients undergoing bifurcation PCI. This may guide prognostication and decision-making in treatment.

An Upfront Two-Stent Strategy for True Coronary Bifurcation Lesions with A Large Side Branch in Acute Coronary Syndrome: A Two-Year Follow-Up Study

Background and Objectives: Little is known about the upfront two-stent strategy (U2SS) for true coronary bifurcation lesions (CBLs) in acute coronary syndrome (ACS). We aimed to present our two-year follow-up results on the U2SS by using different two-stent techniques for the true CBL with a large side branch (SB) in ACS patients, including unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), and to identify independent predictors of the presence of major adverse cardiac events (MACEs) after intervention. Materials and Methods: The study included 201 consecutive ACS patients with true CBLs who underwent percutaneous coronary intervention (PCI) using U2SS from October 2015 to March 2018. Clinical outcomes at follow-up were assessed. MACE was defined as a composite of cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR). Results: 31.3% of the patients had an UA, 46.3% had an NSTEMI, and 22.4% had an STEMI. CBL was most frequently located in the left anterior descending (LAD)/diagonal artery (59.2%). In total, 71.1% of the patients had a Medina classification (1,1,1). Overall, 62.2% of cases were treated with mini-crush stenting. Clopidogrel was given in 23.9% of the patients; 71.1% of the patients received everolimus eluting stent (EES); and 11.9% received a sirolimus eluting stent (SES). Final kissing balloon inflation was carried out in all patients, with an unsatisfactory rate of 5%. A proximal optimization technique sequence was successfully carried out in all patients. The MACE incidence was 16.9% with a median follow-up period of 2.1 years. There were seven cardiac deaths (3.5%). The TLR rate was 13.4% (n = 27), with PCI treatment in 16 patients, and coronary artery bypass grafting treatment in 11 patients. After multivariate penalized logistic regression analysis (Firth logistic regression), clopidogrel use (odds ratio (OR): 2.19; 95% confidence interval (CI): 0.41–2.51; p = 0.007) and SES use (OR: 1.86; 95% CI: 0.31–2.64; p = 0.014) were independent predictors of the presence of MACE. Conclusion: U2SS is feasible and safe for the true CBLs with large and diseased SB in ACS patients, and is related to a relatively low incidence of MACE. Clopidogrel use and SES use may predict the MACE development in ACS patients treated using U2SS.

Acute Angiographic and Intermediate-Term Clinical Results of Patients with Non-Left Main Coronary Bifurcation Lesions Treated with BVS by Jailed Semi-Inflated Balloon Technique and Provisional Side-Branch Stenting Strategy

Background

To evaluate the acute angiographic and intermediate-term clinical results of patients with non-left main (LM) coronary artery bifurcation disease (CABD) treated with BVS, as compared with those treated with DES, using the jailed semi-inflated balloon technique (JSIBT) for side branch (SB) protection and provisional stenting.

Methods and Results

Sixty-eight patients with non-LM CABD who had undergone provisional one-stent implantation with SB protection by JSIBT between January 2015 and December 2017 were retrospectively enrolled. Among them, 20 patients received Absorb BVS implantation and 48 patients received DES implantation. Patients in the BVS group were younger and had higher BMI, total cholesterol, low-density lipoprotein cholesterol, and hemoglobin but had lower serum creatinine and lower prevalence of prior PCI and MI. No SB balloon rupture/entrapment occurred in either group. The incidence of SB dissection/occlusion and SB in need of rewiring or stenting was rare in both groups and showed no significant difference between them. Postinterventional TIMI flow significantly increased in both groups. The intermediate-term clinical outcomes were good in terms of incidence of target lesion failure, target lesion revascularization, target vessel revascularization, myocardial infarction, and all-cause death in both groups.

Conclusion

The use of JSIBT for treating CABD with modern BVS can provide SB protection as similar as those with DES, even with higher incidence of acute SB dissection/occlusion. The immediate angiographic results and acute and intermediate-term clinical outcomes were also similar in both groups. Our study results demonstrate that JSIBT might be a safe and alternative SB protection tool for BVS in patients with complex CABD.

Clinical outcomes of coronary artery bifurcation disease patients underwent Culotte two-stent technique: a single center experience

Background

Percutaneous coronary intervention for coronary artery bifurcation disease (CABD) remains challenging. In patients of CABD with situations that two-stent strategy is needed, the culotte technique is a widely used method and also as the majority at out institution. We sought to take a look of the clinical outcomes of our culotte stenting patients.

Methods

This retrospective study analyzed 238 consecutive CABD patients who underwent culotte two-stent technique at a tertiary medical center between July 2008 and November 2015.

Results

Culotte technique was used in 238 lesions in 238 patients. Of these patients, all DES were implanted for culotte two-stent technique. Most of these patients were elderly, male gender, ACS on admission and multiple vessel disease. The bifurcation lesions were mostly located at left coronary artery (51.3%), categorized as true bifurcation lesion (92%) and calculated less than 70 degree of bifurcation angle (74.4%). During a medium 3.27-year follow up, the angle of bifurcation lesion ≥70° and body mass index were positively independent predictors for target lesion failure (TLF), diabetes mellitus was an independent predictor of target vessel revascularization, and statin therapy for hyperlipidemia, hemoglobin and EF were negatively independent factors associated to total mortality. The rates of in-hospital and total mortalities were 4.2 and 17.6%.

Conclusion

In this cohort of CABD patients with most left main and left anterior descending artery lesions treated by culotte stenting, the procedural success rate was high and the intermediate clinical outcomes were acceptable. (Reviewer #1, Comment #1) Bifurcation angle (≥ 70°) is an inherently independent predictor of TLF and other two-stent strategy replaced needed to be considered in this situation.

Short-term stent coverage of second-generation zotarolimus-eluting durable polymer stents: Onyx one-month optical coherence tomography study

Introduction

To date the early strut coverage with the second-generation durable-polymer ONYX zotarolimus-eluting stent (O-ZES) is unknown.

Aim

Optical coherence tomography (OCT) assessed the strut coverage of O-ZES at thirty-day follow-up.

Material and methods

OCT was performed after implantation and at 1-month follow-up in 15 patients treated with O-ZES.

Results

Mean patient age was 67 ±7 years (73% males). The clinical presentation consisted of acute coronary syndromes (n = 13) and stable coronary disease (n = 2). Four (26%) patients had diabetes. OCT analysis was performed at baseline and 1-month follow-up in all stents. 378 cross-sections with 3582 struts were assessed at baseline and 3661 at follow-up. At follow-up, 88% struts were covered by tissue with a median thickness 37.91 μm (IQR: 22.32–64.15). Median in-stent area obstruction by neointima was 2.64% (IQR: 1.70–4.84). From the total stent covered area, 92.3% showed complete strut coverage. Homogeneous tissue was observed in 74% of cases. There were no differences in minimal lumen area (5.07 ±1.08 mm² vs. 4.81 ±0.94 mm², p = 0.125) or minimal stent area (4.95 ±1.22 mm² vs. 4.92 ±0.99 mm²) at baseline and at follow-up. There were no differences in the rate of strut malapposition (4.3% vs. 5.7%, p = 0.417). For all stents, malapposition volume was 47.9 mm³ at baseline and 51.7 mm³ at follow-up, giving the late acquired stent malapposition volume of 3.8 mm³.

Conclusions

The second-generation durable polymer O-ZES showed favorable vessel healing at 30-day OCT follow-up.

Balloon-stent kissing technique versus jailed wire technique for interventional treatment of coronary bifurcation lesions: Comparison of short- and long-term clinical outcomes

Side-branch occlusion is a serious complication of provisional one-stent strategies used to treat coronary bifurcation lesions. The aim of the study was to compare the short- and long-term clinical outcomes between the balloon-stent kissing technique (BSKT) and jailed wire technique (JWT) in patients with non-left coronary bifurcation lesions.This prospective, double-blinded, randomized controlled study enrolled 89 consecutive patients (aged 18-85 years) with 90 true bifurcation lesions (hemadostenosis ≥70%; bifurcation angle <90°; Medina classification 1.1.1, 1.0.1, or 0.1.1) who underwent percutaneous coronary intervention (PCI) at the Zhongshan Hospital Affiliated to Dalian University (China) between January 2013 and May 2016. The patients were randomly divided into the BSKT (44 patients, 45 lesions) and JWT (45 patients, 45 lesions) groups. The intervention was conducted according to technical requirements using a single-stent strategy. Operative success rate, occurrence of complications, postoperative quantitative coronary angiography, and incidence of perioperative and long-term major adverse cardiovascular events (MACEs) were compared between groups.The intervention success rate was 100% in both groups. After main-branch stenting, the BSKT was associated with significantly lower rates of side-branch occlusion (0% vs 15.6%, P < .05) and side-branch post-processing (8.9% vs 26.7%, P < .05) than the JWT. The BSKT was associated with significantly lower degrees of postoperative proximal main-branch residual stenosis (6.1 ± 5.1% vs 9.6 ± 8.6%, P < .05) and side-branch ostial stenosis (51.6 ± 20.6% vs 70.3 ± 20.8%, P < .05) than the JWT. The incidence of perioperative MACEs was significantly lower in the BSKT group than in the JWT group (0% vs 13.3%, P < .05). Patients were followed for a mean duration of 19.0 ± 6.1 months. The occurrence rates of long-term MACEs, angina of Canadian Cardiovascular Society grade ≥2, and severe heart failure were not significantly different between groups.The BSKT is a safe and effective technique that may have advantages over the JWT with regard to protection of the side-branch during PCI for bifurcation lesions.

Effects of Ticagrelor versus Clopidogrel in Patients with Coronary Bifurcation Lesions Undergoing Percutaneous Coronary Intervention

Background

Percutaneous treatment of coronary bifurcation lesions can potentially lead to higher risk of ischemic events than the nonbifurcation ones, thus calling for further optimization of dual antiplatelet therapy (DAPT). This study aimed to compare the clinical outcomes from ticagrelor and clopidogrel in bifurcation lesions patients undergoing percutaneous coronary intervention (PCI).

Methods

We performed a retrospective cohort study in patients with coronary bifurcation lesions. A total of 553 patients discharged on ticagrelor or clopidogrel combined with aspirin were recruited for 1-year follow-up. The incidences of primary endpoint (major adverse cardiovascular event [MACE]: a composite of cardiac death, myocardial infarction [MI] or stroke), secondary endpoints (the individual component of the primary endpoint or definite/probable stent thrombosis), and major bleeding (Bleeding Academic Research Consortium [BARC]≥3 bleeding events) were evaluated. To minimize the selection bias, a propensity score-matched population analysis was also conducted.

Results

The risks of both primary endpoint (8.15% and 12.01% for the ticagrelor and clopidogrel groups, respectively; adjusted hazards ratio [HR]: 0.488, 95% confidence interval [CI]: 0.277-0.861, P=0.013) and MI (4.44% and 8.48% for the ticagrelor and clopidogrel groups, respectively; adjusted HR: 0.341, 95% CI: 0.162-0.719, P=0.005) were significantly reduced in the ticagrelor group as compared with those of the clopidogrel counterpart, whereas the risk of major bleeding was comparable (2.96% and 2.47% for the ticagrelor and clopidogrel groups, respectively; adjusted HR: 0.972, 95% CI: 0.321-2.941, P=0.960). Propensity score-matched analysis confirmed such findings.

Conclusions

For patients with bifurcation lesions after PCI, ticagrelor treatment shows lower MACE and MI rates than the clopidogrel one, along with comparable major bleeding.

Serum Copeptin Levels Predict Clinical Outcomes After Successful Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction

BACKGROUND

Serum copeptin has been demonstrated to be useful in early risk stratification and prognostication of patients with acute myocardial infarction (AMI). However, the prognostic value of copeptin after percutaneous coronary intervention (PCI) for clinical outcomes remains uncertain. We investigated the prognostic role of serum copeptin levels immediately after successful PCI as a prognostic marker for major adverse cardiac events (MACE; comprising death, repeat PCI, recurrent MI, or coronary artery bypass grafting) in patients with AMI.

METHODS

A retrospective study was performed in 149 patients with AMI who successfully received PCI. Serum copeptin levels were analyzed in blood samples collected immediately after PCI. The association between copeptin levels and MACE during the follow-up period was evaluated.

RESULTS

MACE occurred in 34 (22.8%) patients during a median follow-up of 30.1 months. MACE patients had higher copeptin levels than non-MACE patients did. Multiple logistic regression analysis showed that the increase in serum copeptin levels was associated with increased MACE incidence (odds ratio=1.6, P=0.005).

CONCLUSIONS

A high level of serum copeptin measured immediately after PCI was associated with MACE in patients with AMI during long-term follow-up. Serum copeptin levels can serve as a prognostic marker in patients with AMI after successful PCI.

Treatment Strategy for STEMI With Bifurcation Culprit Lesion Undergoing Primary PCI: The COBIS II Registry

INTRODUCTION AND OBJECTIVES

There are limited data on the preferred treatment strategy in ST-segment elevation myocardial infarction (STEMI) patients with bifurcation lesions. This study aimed to compare clinical outcomes between 1-stent and 2-stent strategies in STEMI patients with bifurcation lesions undergoing primary percutaneous coronary intervention (PCI).

METHODS

The COronary BIfurcation Stenting II is a retrospective multicenter registry of 2897 consecutive patients with bifurcation lesions undergoing PCI with drug-eluting stents from January 2003 through December 2009. Among the registered population, 367 (12.7%) patients had STEMI; of these, a 1-stent strategy was used in 304 patients and a 2-stent strategy in 63 patients; 77.1% of the patients received primary PCI with a first-generation drug-eluting stent. The inverse-probability-of-treatment-weighting method was used to adjust for confounding factors. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis.

RESULTS

The median length of follow-up was 38 months. Postprocedural side branch diameter stenosis differed significantly between the 2 groups (1-stent vs 2-stent, 42.7% vs 9.7%; P < .001). After the performance of inverse-probability-of-treatment-weighting methods, the rate of MACE was significantly higher in the 2-stent group than in the 1-stent group (HR, 1.85; 95%CI, 1.19-2.87; P = .006), mainly driven by target lesion revascularization and stent thrombosis.

CONCLUSIONS

In STEMI patients with bifurcation culprit lesions undergoing primary PCI, the 2-stent strategy had significantly higher rates of MACE than the 1-stent strategy, despite successful treatment of the side branch. However, this result should be interpreted with caution because this study does not reflect current practice.

Is side branch lesion length an independent predictor of acute side branch occlusion in provisional strategy? Analysis of 524 consecutive bifurcation lesions

OBJECTIVES

To detect the impact of side branch (SB) lesion length on acute SB occlusion after main vessel (MV) stenting.

METHODS

Five hundred sixteen consecutive patients with 524 bifurcation lesions undergoing one-stent techniques were studied. Multivariate logistic regression analysis was performed to identify independent predictors of acute SB occlusion. The lesions were also further divided into two groups according to the median SB lesion length. The incidences of SB occlusion and lesion characteristics in the two subgroups were compared.

RESULTS

The SB lesion length was not significantly different between lesions with and without SB occlusion. In the SB occlusion group, the distance between the position of the minimal lumen diameter and SB ostium was significantly shorter than that in the non-SB occlusion group (1.76 ± 1.04 mm vs. 2.72 ± 2.65 mm; P = 0.0003). Multivariate logistic regression analysis showed that high BA before stenting, plaque accumulation located on the same side as the SB, the Thrombolysis In Myocardial Infarction (TIMI) flow grade of the SB before stenting, and the DS of the SB before MV stenting were independently predictive of SB occlusion.

CONCLUSIONS

SB lesion length cannot be regarded as an independent predictor of acute SB occlusion after MV stenting.

Evaluation and efficacy of long length Pronova XR Bioabsorbable Polymer stent in the treatment of long coronary lesions

Aim

The study aims an observational registry of the long and extra-long length (>33 mm) Pronova XR stents in patients with long coronary lesions (>30 mm) in a prospective real world study.

Methods and results

Current study was conducted at Ruby Hall Clinic Pune, between July 2012 and July 2013 including 30 patients who underwent PTCA using long and extra-long Pronova XR stents. Among the stents used, one stent - 33 mm, 2 stents - 38 mm, 5 stents - 43 mm and 25 stents were of 48 mm in length. In particular average stent length for the study was 46.03 mm and the average stent diameter was 3.09 ± 0.41 mm.

For this study coronary angioplasty was performed using femoral approach and standard practice. Lesions were predilated using undersized balloons and study stent was deployed at pressure 7–26 atm. (12.8 ± 3.2 atm.) The successful delivery of stent at the intended lesion with visual residual stenosis less than 50% was defined as Procedural success. Follow up studies were conducted for all the patients at 30 days, 3 months and 6 months intervals. The predefined QCA parameters were calculated using Sanders Data System QCA plus software (Palo Alto, CA, USA).

No procedural complication was observed during the whole study. 100% successful stent placement was achieved in all patients. Six months clinical follow-up was available for all patients. No adverse events (Acute closure, angina, REPCI, MI, death, sub acute stent thrombosis) or hospitalization was reported for any of the patients except one. The Quantative Coronary Core Lab analysis post 6 months showed well-flowing stent with average late lumen loss 0.10 mm ±0.26.

Conclusion

In patients with long coronary lesions and very long length stent implantation series, Pronova XR showed excellent in 6 months results. This is for the first time reported that use of long length Pronova XR stents has shown so low restenosis rate and absent of mortality in six month period. These results offer a new opportunity to single long length stenting.

Comparative Study between Perfusion Changes and Positive Findings on Coronary Flow Reserve

BACKGROUND

Functional assessment of coronary artery obstruction is used in cardiology practice to correlate anatomic obstructions with flow decrease. Among such assessments, the study of the coronary fractional flow reserve (FFR) has become the most widely used.

OBJECTIVE

To evaluate the correlation between FFR and findings of ischemia obtained by noninvasive methods including stress echocardiography and nuclear medicine and the presence of critical coronary artery obstruction.

METHODS

Retrospective study of cases treated with systematized and standardized procedures for coronary disease between March 2011 and August 2014. We included 96 patients with 107 critical coronary obstructions (> 50% in the coronary trunk and/or ≥ 70% in other segments) estimated by quantitative coronary angiography (QCA) and intracoronary ultrasound (ICUS). All cases presented ischemia in one of the noninvasive studies.

RESULTS

All 96 patients presented ischemia (100%) in one of the functional tests. On FFR study with adenosine 140 g/kg/min, 52% of the cases had values ≤ 0.80. On correlation analysis for FFR ≤ 0.80, the evaluation of sensitivity, specificity, positive and negative predictive values, accuracy, and ROC curve in relation to the stenosis degree and length, and presence of ischemia, no significant values or strong correlation were observed.

CONCLUSION

Coronary FFR using a cut-off value of 0.80 showed no correlation with noninvasive ischemia tests in patients with severe coronary artery obstructions on QCA and ICUS.

Impact of lesion characteristics on the prediction of optimal poststent fractional flow reserve

BACKGROUND

Poststent fractional flow reserve (FFR) is a useful indicator of optimal percutaneous coronary intervention, and higher poststent FFR is associated with favorable long-term clinical outcome. However, little is known about the factors influencing poststent FFR. The purpose of this study was to determine the impact of lesion characteristics on poststent FFR.

METHODS

For patients who had scheduled stent implantation for stable angina, FFR measurements at maximum hyperemia were performed before and after coronary stent implantation. As one of lesion characteristics, the FFR pressure drop pattern was evaluated and classified as either an abrupt or a gradual pattern according to the pullback curve of FFR.

RESULTS

A total of 205 lesions with physiological significant stenosis were evaluated. Fractional flow reserve value increased from 0.67±0.10 to 0.87±0.07 after stent implantation. Optimal poststent FFR was achieved in 75 lesions (36.6%). Logistic regression analysis demonstrated that optimal poststent FFR was positively correlated with an abrupt pressure drop pattern (hazard ratio [HR] 2.11, 95% CI 1.06-4.15, P=.03) and prestent FFR (HR 1.04, 95% CI 1.03-2.04, P=.03; per 0.1 increase), and negatively correlated with lesion localization to the left anterior descending artery (HR 0.18, 95% CI 0.09-0.36, P<.0001). The c statistic for predicting optimal poststent FFR was 0.763 (95% CI 0.702-0.819).

CONCLUSION

Abrupt pressure drop patterns, prestent FFR, and lesion localization to the left anterior descending artery were independent predictors of optimal poststent FFR.

Predictors for Side Branch Failure During Provisional Strategy of Coronary Intervention for Bifurcation Lesions (from the Korean Bifurcation Registry)

The most favored strategy for bifurcation lesion is stenting main vessel with provisional side branch (SB) stenting. This study was performed to elucidate predictors for SB failure during this provisional strategy. The study population was patients from 16 centers in Korea who underwent drug-eluting stent implantation for bifurcation lesions with provisional strategy (1,219 patients and 1,236 lesions). On multivariate analysis, the independent predictors for SB jailing after main vessel stenting were SB calcification, large SB reference diameter, severe stenosis of SB, and not taking clopidogrel. Regarding SB compromise, however, the independent predictors were true bifurcation lesion and small SB reference diameter, whereas possible predictors were parent vessel thrombus and parent vessel total occlusion. In addition, SB predilation helps us to get favorable SB outcome. The diameter of SB ostium after main vessel stenting became similar between severe SB lesions treated with predilation and mild SB lesions not treated with predilation. In conclusion, SB calcification, less clopidogrel use, large SB reference diameter, and high SB diameter stenosis are independent predictors for SB jailing, and true bifurcation and small SB reference diameter are independent predictors for SB compromise after main vessel stenting.

Intraindividual Comparison of Everolimus-Eluting Bioresorbable Vascular Scaffolds Versus Drug-Eluting Metallic Stents

BACKGROUND

The performance of everolimus-eluting bioresorbable vascular scaffold (BVS) versus drug-eluting metallic stent (DES) in the same individual receiving multilesion percutaneous coronary intervention (PCI) remains poorly studied. This report investigates the intraindividual performance of BVS and DES in patients receiving multilesion PCI and follow-up angiography.

METHODS AND RESULTS

Data of patients undergoing BVS implantation for de novo lesions from 2012 to 2014 at 2 centers in Munich, Germany, were prospectively collected. Individuals receiving multilesion PCI with BVS and DES and follow-up angiography at 6 to 8 months were studied. Primary end point was in-device late lumen loss. Secondary end points were binary restenosis, target lesion revascularization, and definite stent/scaffold thrombosis. A total of 90 PCI patients with 239 lesions received BVS (n=112) and DES (n=127). Follow-up angiography after a median of 6.6 months (5.8-7.1) showed a higher degree of late lumen loss in lesions treated with BVS versus DES (0.30±0.59 versus 0.22±0.48 mm; P=0.035). However, the adjustment for baseline angiographic imbalances discarded an influence of stent type on late lumen loss (P=0.82). At the same time point, binary restenosis was comparable between BVS and DES (7.8% versus 8.9%; P=0.90). After a median of 13.2 months (9.2-17.6), target lesion revascularization (9.8% versus 10.2%; P=0.97) and definite stent/scaffold thrombosis (2.7% versus 1.6%; P=0.48) did not differ between BVS and DES.

CONCLUSIONS

In patients receiving multilesion PCI, BVS displays acceptable intraindividual performance compared with DES. Larger trials, extended follow-up, and continuous device iteration remain essential to improve BVS technology.

"DK Crush" Technique for a Tightly Stenosed Conjoined SVG Lesion in a Patient with Acute Coronary Syndrome and Cardiogenic Shock

Coronary artery bifurcation disease of saphenous venous graft (SVG) is extremely rare. SVG disease remains a challenging lesion to treat because of increased morbidity and mortality with repeated coronary artery bypass graft surgery (CABG), high rates of periprocedural complications, and in-stent restenosis or occlusion requiring repeat revascularization with percutaneous coronary intervention. Herein, we present the first reported case of using the "DK crush" technique to treat an inverted Y-shaped SVG bifurcation disease in a patient with a prior CABG and new-onset acute coronary syndrome. Arising from our treatment, favorable immediate and mid-term angiographic and clinical outcomes were obtained.

KEY WORDS

Coronary artery bypass surgery (CABG); "DK crush" technique; Saphenous venous graft (SVG).

New Stenting Technique to Achieve Favorable Jailing Configuration on Side Branch Ostium: Bent Stent Technique

According to data from stent-enhanced three-dimensional optical coherence tomography, incomplete stent apposition after side branch dilation in coronary bifurcation stenting can be reduced by the free carina type (no links bridged from a carina) and by distal cell rewiring. This is the first report to describe a bent stent technique that was devised to achieve the free carina type (no links bridged from a carina), as a favorable jailing configuration.

The value of imaging in subclinical coronary artery disease

Although the treatment of acute coronary syndromes (ACS) has advanced considerably, the ability to detect, predict, and prevent complications of atherosclerotic plaques, considered the main cause of ACS, remains elusive. Several imaging tools have therefore been developed to characterize morphological determinants of plaque vulnerability, defined as the propensity or probability of plaques to complicate with coronary thrombosis, able to predict patients at risk. By utilizing both intravascular and noninvasive imaging tools, indeed prospective longitudinal studies have recently provided considerable knowledge, increasing our understanding of determinants of plaque formation, progression, and instabilization. In the present review we aim at 1) critically analyzing the incremental utility of imaging tools over currently available "traditional" methods of risk stratification; 2) documenting the capacity of such modalities to monitor atherosclerosis progression and regression according to lifestyle modifications and targeted therapy; and 3) evaluating the potential clinical relevance of advanced imaging, testing whether detection of such lesions may guide therapeutic decisions and changes in treatment strategy. The current understanding of modes of progression of atherosclerotic vascular disease and the appropriate use of available diagnostic tools may already now gauge the selection of patients to be enrolled in primary and secondary prevention studies. Appropriate trials should now, however, evaluate the cost-effectiveness of an aggressive search of vulnerable plaques, favoring implementation of such diagnostic tools in daily practice.

Angiographic and clinical outcomes of patients treated with everolimus-eluting bioresorbable stents in routine clinical practice: Results of the ISAR-ABSORB registry

OBJECTIVES

We aimed to analyze angiographic and clinical results of patients undergoing BRS implantation in a real-world setting.

BACKGROUND

Angiographic and clinical outcome data from patients undergoing implantation of drug-eluting bioresorbable stents (BRS) in routine clinical practice is scant.

METHODS

Consecutive patients undergoing implantation of everolimus-eluting BRS at two high-volume centers in Munich, Germany were enrolled. Data were collected prospectively. All patients were scheduled for angiographic surveillance 6-8 months after stent implantation. Quantitative coronary angiographic analysis was performed in a core laboratory. Clinical follow-up was performed to 12 months and events were adjudicated by independent assessors.

RESULTS

A total of 419 patients were studied. Mean age was 66.6 ± 10.9 years, 31.5% had diabetes mellitus, 76.1% had multivessel disease, and 39.0% presented with acute coronary syndrome; 49.0% of lesions were AHA/ACC type B2/C, 13.1% had treatment of bifurcation lesions. Mean reference vessel diameter was 2.89 ± 0.46 mm. At angiographic follow-up in-stent late loss was 0.26 ± 0.51 mm, in-segment diameter stenosis was 27.5 ± 16.1, and binary angiographic restenosis was 7.5%. At 12 months, the rate of death, myocardial infarction, or target lesion revascularization was 13.1%. Definite stent thrombosis occurred in 2.6%.

CONCLUSIONS

The use of everolimus-eluting BRS in routine clinical practice is associated with high antirestenotic efficacy in patients undergoing angiographic surveillance. Overall clinical outcomes at 12 months are satisfactory though stent thrombosis rates are not insignificant. Further study with longer term follow-up and larger numbers of treated patients is required before we can be sure of the role of these devices in clinical practice.

Comparison of Angiographic Outcomes of Side Branch Ostium at Bifurcation Coronary Lesion between Two-stent and One-stent Techniques

Although the favored strategy for coronary bifurcation intervention is stenting main vessel with provisional side branch (SB) stenting, we occasionally use two-stent strategy. The objective of this study was to investigate the angiographic outcome of SB ostium in two-stent group, compared with one-stent group. We analyzed 199 patients with bifurcation lesion who underwent percutaneous coronary intervention (PCI) with drug-eluting stent and follow up angiography. The patients were divided into one-stent group (167 lesions, 158 patients) and two-stent group (41 lesions, 41 patients). Prior to intervention, SB ostium minimal luminal diameter (MLD) was smaller in two-stent group than in one-stent group (1.08±0.55 mm vs. 1.39±0.60 mm; P=0.01). But, immediately after PCI, SB MLD of two-stent group became greater than that of one-stent group (2.41±0.40 mm vs. 1.18±0.68 mm; P<0.01). Six to nine months after PCI, this angiographic superiority in SB MLD of two-stent group persisted (1.56±0.71 mm vs. 1.13±0.53 mm; P<0.01), although there was larger late loss in two-stent group (0.85±0.74 mm vs. 0.05±0.57 mm; P<0.01). In terms of target lesion revascularization and target vessel revascularization rates, one-stent group showed better results than two-stent group. We could attain wider long term SB ostium after two-stent strategy than after one-stent strategy.

Structural Damage to Jailed Guidewire During the Treatment of Coronary Bifurcations: Microscopic Evaluation

INTRODUCTION AND OBJECTIVES

The use of the jailed guidewire technique is highly useful when treating bifurcation lesions by provisional stenting. However, at the time of withdrawal, the guidewire can suffer damage and even fracture. The aim of this study was to evaluate structural damage in both polymer-coated and nonpolymer-coated jailed guidewires.

METHODS

Between January 2011 and December 2012, an observational study was conducted using stereoscopic microscopy to evaluate 135 jailed guidewires (45 nonpolymer-coated and 90 polymer-coated) previously used in the percutaneous treatment of bifurcation lesions. Damage after withdrawal was classified as mild, moderate, or severe.

RESULTS

Age and sex distributions were similar in both groups of patients treated with polymer-coated and nonpolymer-coated guidewires. However, operators selected polymer-coated guidewires more frequently when treating more complex bifurcations and in diabetic patients. Some type of microscopic damage was observed in 25 of the guidewires analyzed (18%). Paradoxically, damage was more common in nonpolymer-coated guidewires (53.0% vs 1.1%; P<.001). None of the guidewires suffered complete fracture.

CONCLUSIONS

Coronary guidewires that are jailed during the treatment of bifurcations using provisional stenting often suffer nonsevere microscopic damage. Although polymer-coated guidewires were used in more complex bifurcation lesions, paradoxically, they were damaged less frequently.

Impact of postdischarge statin withdrawal on long-term outcomes in patients with acute myocardial infarction

Many patients discontinue statin after acute myocardial infarction (AMI) despite its necessity. However, limited data are available describing the clinical impact of statin withdrawal after AMI. This study enrolled 3,807 patients in the Korean multicenter registry who survived for 1 year after AMI. All patients were prescribed statin at discharge and were divided into 2 groups on the basis of statin withdrawal history; 603 patients had a history of statin discontinuation and 3,204 patients continued statin therapy. The primary outcome was mortality from any cause. We also analyzed the incidence of cardiac death, nonfatal myocardial infarction, any revascularization, and stroke. The duration of follow-up was 4 years after AMI. Statin withdrawal was associated with higher mortality than continued statin treatment (hazard ratio 3.45, 95% confidence interval 2.81 to 4.24, p <0.001), primarily as the result of increased cardiac mortality (hazard ratio 4.65, 95% confidence interval 3.14 to 6.87, p <0.001). However, the incidences of nonfatal myocardial infarction, any revascularization, and stroke were not different between the groups. Analysis by propensity score matching did not affect the results. In conclusion, many patients experienced statin withdrawal after AMI, which significantly increased long-term mortality in the present study. Careful education and monitoring are needed to reduce adverse cardiac outcomes in patients after AMI.

Prognostic value of angiographic lesion complexity in patients with acute coronary syndromes undergoing percutaneous coronary intervention (from the acute catheterization and urgent intervention triage strategy trial)

Although lesion complexity is predictive of outcomes after balloon angioplasty, it is unclear whether complex lesions continue to portend a worse prognosis in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) with contemporary interventional therapies. We sought to assess the impact of angiographic lesion complexity, defined by the modified American College of Cardiology/American Heart Association classification, on clinical outcomes after PCI in patients with ACS and to determine whether an interaction exists between lesion complexity and antithrombin regimen outcomes after PCI. Among the 3,661 patients who underwent PCI in the Acute Catheterization and Urgent Intervention Triage strategy study, patients with type C lesions (n = 1,654 [45%]) had higher 30-day rates of mortality (1.2% vs 0.6%, p = 0.049), myocardial infarction (9.2% vs 6.3%, p = 0.0006), and unplanned revascularization (4.3% vs 3.1%, p = 0.04) compared with those without type C lesions. In multivariate analysis, type C lesions were independently associated with myocardial infarction (odds ratio [95% confidence interval] = 1.37 [1.04 to 1.80], p = 0.02) and composite ischemia (odds ratio [95% confidence interval] = 1.49 [1.17 to 1.88], p = 0.001) at 30 days. Bivalirudin monotherapy compared with heparin plus a glycoprotein IIb/IIIa inhibitor reduced major bleeding complications with similar rates of composite ischemic events, regardless of the presence of type C lesions. There were no interactions between antithrombotic regimens and lesion complexity in terms of composite ischemia and major bleeding (p [interaction] = 0.91 and 0.80, respectively). In conclusion, patients with ACS with type C lesion characteristics undergoing PCI have an adverse short-term prognosis. Treatment with bivalirudin monotherapy reduces major hemorrhagic complications irrespective of lesion complexity with comparable suppression of adverse ischemic events as heparin plus glycoprotein IIb/IIIa inhibitor.

A new stenting technique for bifurcation lesions a nine-patient case series

AIMS

This study describes and reports preliminary outcomes using kissing T-stenting and small protrusion (K-TAP), a novel modification of traditional T-stenting and small protrusion (TAP).

METHODS AND RESULTS

Nine patients who were treated with K-TAP between May 2008 and February 2012 at two hospitals were retrospectively included in this study. The primary endpoints were angiographic success, procedural success, and the composite 30-day and long-term occurrences of major adverse cardiac events (MACEs), which consisted of death, coronary artery bypass graft surgery, repeated percutaneous coronary intervention of the target vessel, and non-Q-wave and Q-wave myocardial infarctions. Data were obtained from the review of institutional databases, folder auditing, a telephone survey of the patients, and the review of angiograms. Angiographic success and procedural success were achieved in all patients. The mean fluoroscopy time for the total procedure was 24.1 min (range 20-28). No complications occurred during the procedures. The MACE rate during the mean follow-up period of 102 weeks (range 22-196 weeks) was 0%.

CONCLUSIONS

K-TAP, a new coronary bifurcation stenting method, has favorable angiographic and procedural success rates and a low early post-procedure MACE rate. Further studies are needed to evaluate the clinical efficacy of the K-TAP method.