Angiographic adverse events, creatine kinase-MB elevation, and ischemic end points complicating percutaneous coronary intervention (a REPLACE-2 substudy)

Current Challenges in Coronary Bifurcation Interventions

Coronary bifurcation lesions account for a significant proportion of all percutaneous coronary interventions (PCIs). Interventional treatment of coronary bifurcations is related to significant technical challenges, high complication rates, and worse angiographic and long-term clinical outcomes. This review covers the specific features and structure of coronary bifurcation and explores the main challenges in the interventional treatment of these lesions. This review evaluates various methodologies designed to address these lesions, considering factors such as plaque distribution and bifurcation geometry. It also emphasizes the limitations associated with current techniques. A novel combined optimization approach applied in the interventional treatment of coronary bifurcation may offer superior procedural and long-term outcomes. This combined technique could potentially address the drawbacks of each method, providing a more effective solution for optimizing stent placement in bifurcation lesions. Refining and evaluating these combined techniques is essential for improving clinical outcomes in patients with bifurcation lesions.

Coronary perforation incidence, outcomes and temporal trends (COPIT): a systematic review and meta-analysis

Coronary perforation is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We studied incidence, outcomes and temporal trends following PCI-related coronary artery perforation (CAP).

METHODS

Prospective systematic review and meta-analysis including meta-regression using MEDLINE and EMBASE to November 2020. We included 'all-comer' PCI cohorts including large PCI registries and randomised controlled trials and excluding registries or trials limited to PCI in high-risk populations such as chronic total occlusion PCI or cohorts treated only with atheroablative devices. Regression analysis and corresponding correlation coefficients were performed comparing perforation incidence, mortality rate, tamponade rate and the rate of Ellis III perforations against the midpoint (year) of data collection to determine if a significant temporal relationship was present.

RESULTS

3997 studies were screened for inclusion. 67 studies met eligibility criteria with a total of 5 568 191 PCIs included over a 38-year period (1982-2020). The overall pooled incidence of perforation was 0.39% (95% CI 0.34% to 0.45%) and remained similar throughout the study period. Around 1 in 5 coronary perforations led to tamponade (21.1%). Ellis III perforations are increasing in frequency and account for 43% of all perforations. Perforation mortality has trended lower over the years (7.5%; 95% CI 6.7% to 8.4%). Perforation risk factors derived using meta-regression were female sex, hypertension, chronic kidney disease and previous coronary bypass grafting. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%.

CONCLUSION

Coronary perforation complicates approximately 1 in 250 PCIs. Ellis III perforations are increasing in incidence although it is unclear whether this is due to reporting bias. Despite this, the overall perforation mortality rate (7.5%) has trended lower in recent years. Limitations of our findings include bias that may be introduced through analysis of multidesign studies and registries without pre-specified standardised perforation reporting CMore research into coronary perforation management including the optimal use of covered stents seems warranted.

PROSPERO REGISTRATION NUMBER

CRD42020207881.

Antiplatelet agents for chronic kidney disease

BACKGROUND

Antiplatelet agents are widely used to prevent cardiovascular events. The risks and benefits of antiplatelet agents may be different in people with chronic kidney disease (CKD) for whom occlusive atherosclerotic events are less prevalent, and bleeding hazards might be increased. This is an update of a review first published in 2013.

OBJECTIVES

To evaluate the benefits and harms of antiplatelet agents in people with any form of CKD, including those with CKD not receiving renal replacement therapy, patients receiving any form of dialysis, and kidney transplant recipients.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 13 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We selected randomised controlled trials of any antiplatelet agents versus placebo or no treatment, or direct head-to-head antiplatelet agent studies in people with CKD. Studies were included if they enrolled participants with CKD, or included people in broader at-risk populations in which data for subgroups with CKD could be disaggregated.

DATA COLLECTION AND ANALYSIS

Four authors independently extracted data from primary study reports and any available supplementary information for study population, interventions, outcomes, and risks of bias. Risk ratios (RR) and 95% confidence intervals (CI) were calculated from numbers of events and numbers of participants at risk which were extracted from each included study. The reported RRs were extracted where crude event rates were not provided. Data were pooled using the random-effects model. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We included 113 studies, enrolling 51,959 participants; 90 studies (40,597 CKD participants) compared an antiplatelet agent with placebo or no treatment, and 29 studies (11,805 CKD participants) directly compared one antiplatelet agent with another. Fifty-six new studies were added to this 2021 update. Seven studies originally excluded from the 2013 review were included, although they had a follow-up lower than two months. Random sequence generation and allocation concealment were at low risk of bias in 16 and 22 studies, respectively. Sixty-four studies reported low-risk methods for blinding of participants and investigators; outcome assessment was blinded in 41 studies. Forty-one studies were at low risk of attrition bias, 50 studies were at low risk of selective reporting bias, and 57 studies were at low risk of other potential sources of bias. Compared to placebo or no treatment, antiplatelet agents probably reduces myocardial infarction (18 studies, 15,289 participants: RR 0.88, 95% CI 0.79 to 0.99, I² = 0%; moderate certainty). Antiplatelet agents has uncertain effects on fatal or nonfatal stroke (12 studies, 10.382 participants: RR 1.01, 95% CI 0.64 to 1.59, I² = 37%; very low certainty) and may have little or no effect on death from any cause (35 studies, 18,241 participants: RR 0.94, 95 % CI 0.84 to 1.06, I² = 14%; low certainty). Antiplatelet therapy probably increases major bleeding in people with CKD and those treated with haemodialysis (HD) (29 studies, 16,194 participants: RR 1.35, 95% CI 1.10 to 1.65, I² = 12%; moderate certainty). In addition, antiplatelet therapy may increase minor bleeding in people with CKD and those treated with HD (21 studies, 13,218 participants: RR 1.55, 95% CI 1.27 to 1.90, I² = 58%; low certainty). Antiplatelet treatment may reduce early dialysis vascular access thrombosis (8 studies, 1525 participants) RR 0.52, 95% CI 0.38 to 0.70; low certainty). Antiplatelet agents may reduce doubling of serum creatinine in CKD (3 studies, 217 participants: RR 0.39, 95% CI 0.17 to 0.86, I² = 8%; low certainty). The treatment effects of antiplatelet agents on stroke, cardiovascular death, kidney failure, kidney transplant graft loss, transplant rejection, creatinine clearance, proteinuria, dialysis access failure, loss of primary unassisted patency, failure to attain suitability for dialysis, need of intervention and cardiovascular hospitalisation were uncertain. Limited data were available for direct head-to-head comparisons of antiplatelet drugs, including prasugrel, ticagrelor, different doses of clopidogrel, abciximab, defibrotide, sarpogrelate and beraprost.

AUTHORS' CONCLUSIONS

Antiplatelet agents probably reduced myocardial infarction and increased major bleeding, but do not appear to reduce all-cause and cardiovascular death among people with CKD and those treated with dialysis. The treatment effects of antiplatelet agents compared with each other are uncertain.

Red Cell Distribution Width as a Marker of Periprocedural Myocardial Infarction in Patients with Elective Percutaneous Coronary Intervention

We aimed to investigate whether red cell distribution width (RDW) was associated with periprocedural myocardial infarction (PMI) in patients undergoing elective percutaneous coronary intervention (PCI). Among 1723 consecutive patients undergoing elective PCI, a total of 230 (13.3%) met the diagnostic criteria of PMI. The high RDW (≥ 12.6%) group tended to have PMI (15.4% vs. 11.2%, P = 0.010). RDW was an independent predictor of PMI whether as a categorical variable (adjusted odds ratio = 1.442, 95% confidence interval = 1.088 to 1.911, P = 0.011) or a continuous variable (adjusted odds ratio = 1.236, 95% confidence interval = 1.079 to 1.415, P = 0.002). High RDW was also significantly associated with increased risk of major adverse cardiovascular events (MACE) during follow-up. However, anemia was not independently associated with PMI or MACE in the current study. In conclusion, RDW showed strong and independent association with PMI in patients undergoing elective PCI.

Usefulness of intracoronary administration of fasudil, a selective Rho-kinase inhibitor, for PCI-related refractory myocardial ischemia

BACKGROUND

Intra-procedural myocardial ischemia as an iatrogenic complication still remains a critical issue in contemporary interventional cardiology. The aim of this study was to examine the usefulness of fasudil, a selective Rho-kinase inhibitor, for percutaneous coronary intervention (PCI)-related myocardial ischemia.

METHODS

Among 448 PCI sessions performed between October 2015 and December 2017, we retrospectively examined 36 patients (69.0 ± 9.1 [SD] yrs., M/F 26/10) who underwent intracoronary administration of fasudil during a procedure to resolve myocardial ischemia that was resistant to intracoronary nitrate administration.

RESULTS

The refractory myocardial ischemia was caused by distal embolization (69%), enhanced vasoconstriction at distal site of chronic total occlusion (11%), coronary spasm (11%), and coronary dissection (8%), most of which occurred immediately after balloon or stent dilatation. Intracoronary fasudil significantly improved corrected TIMI frame count (from 37 [30-56] to 24 [12-36]) and TIMI flow grade (from 2 [1-2.5] to 3 [2-3]) (both P < 0.001). Finally, 86% of all subjects successfully obtained TIMI flow grade 3 at the end of the procedure. Intracoronary fasudil tended to be more effective in patients with an attenuated plaque detected by intravascular ultrasound. Importantly, among the 19 elective cases, fasudil successfully prevented 17 patients from developing post-procedure myocardial infarction. Although fasudil-induced transient hypotension requiring a vasopressor was noted in 22% of the subjects, no other adverse effects were noted.

CONCLUSIONS

These results indicate that fasudil is a useful and safe therapeutic option for PCI-related myocardial ischemia refractory intracoronary nitrate.

Impact of Strut Width in Periprocedural Myocardial Infarction: A Propensity-Matched Comparison Between Bioresorbable Scaffolds and the First-Generation Sirolimus-Eluting Stent

OBJECTIVES

This study aimed to assess the clinical impact of strut width (evaluated by abluminal strut surface area [ASSA]) on periprocedural myocardial infarction (PMI) and clinical outcomes in patients treated with bioresorbable scaffolds (BRS) versus first-generation sirolimus-eluting stents (SES).

BACKGROUND

To date, there are no reports on the impact of ASSA on PMI and clinical outcomes.

METHODS

We compared the impact of ASSA on outcomes and PMI in propensity-matched patients treated with BRS and SES. The primary outcome was the incidence of major adverse cardiac events (MACE), defined as the combination of all-cause mortality, follow-up myocardial infarction, and target vessel revascularization, at 30-days and 1-year follow-ups. The secondary endpoint was the incidence of PMI.

RESULTS

After propensity-matched analysis, 499 patients (147 BRS patients vs. 352 SES patients) were evaluated. Mean ASSA was higher in patients treated with BRS versus SES (BRS: 132.3 ± 76.7 mm(2) vs. SES: 67.6 ± 48.4 mm(2), p < 0.001). MACE was not significantly different between groups (30-days MACE: BRS: 0% vs. SES: 1.4%, p = 0.16, and 1-year MACE: BRS: 15.7% vs. SES: 11.4%, p = 0.67). The incidence of PMI was significantly higher in the BRS group (BRS: 13.1% vs. SES: 7.5%, p = 0.05). Multivariable analyses indicated that treatment of left anterior descending artery and ASSA were independent predictors of PMI.

CONCLUSIONS

BRS implantation, compared with SES implantation, was associated with a higher incidence of PMI. MACE at 30 days and 1 year were not significantly different. Left anterior descending artery percutaneous coronary intervention and ASSA were independent predictors of PMI.

Study of the possible medical and medication explanatory factors of angiographic outcomes in patients with acute ST elevation myocardial infarction undergoing primary percutaneous intervention

Background:

Myocardial blush grade (MBG), thrombolysis in myocardial infarction (TIMI) and corrected TIMI frame count (cTFC) are indices of successful angiographic reperfusion. This study sought to determine the predictors of angiographically successful reperfusion including demographic, clinical and angiographic factors in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI).

Materials and Methods:

A cross-sectional study of patients with a confirmed diagnosis of STEMI undergoing pPCI was designed. Eligible patients referring to a university heart center were enrolled in the study from March 2012 to December 2012. Successful epicardial reperfusion was defned as TIMI flow grade 3 or cTFC<= 28 frames and successful myocardial reperfusion as MBG 2 or 3.

Results:

The study population consisted of 100 patients, including 74 males and 26 females, with mean ± standard deviation age of 58.27 ± 11.60 years. Achieving open microvasculature (MBG 2/3) was positively associated with a history of nitrate intake (P = 0.03) and history of calcium channel blocker (CCB) intake (P = 0.005). Hyperglycemia was inversely associated with achieving a final cTFC ≤ 28 frames (r = −0.32, P = 0.001).

Conclusions:

Our findings suggest that patients with a history of nitrate and CCB intake had a higher likelihood of successful PCI. In addition, patients with a higher blood glucose level on admission may have a reduced rate of reperfusion success. Future studies with a larger sample size are recommended to investigate the significant relationships observed in this study.

Incidence of periprocedural myocardial infarction and cardiac biomarker testing after percutaneous coronary intervention in Japan: results from a multicenter registry

Periprocedural myocardial infarction (pMI) is an important complication associated with percutaneous coronary intervention (PCI). However, data on the frequency of biomarker testing and the incidence of pMI remain unclear. Using the multicenter Japan Cardiovascular Database, we identified 2182 patients who underwent PCI without preprocedural cardiac biomarker elevation (silent ischemia, stable angina, or unstable angina without biomarker elevation) from September 2008 to August 2011. Of these, 550 patients (25.2 %) underwent cardiac biomarker testing within 6-24 h after PCI. The incidence of pMI was 2.7 % among all identified patients and 7.5 % among those who underwent cardiac marker testing. Of note, cardiac biomarker testing was performed more frequently than no testing in patients with a higher risk profile such as unstable angina (32.7 vs 24.7 %, P < 0.001), higher symptom scaling (28.2 vs 22.5 %, P = 0.008), urgent or emergent procedures (19.3 vs 15.0 %, P = 0.022 or 4.2 vs 1.0 %, P < 0.001, respectively), and type C lesion (31.3 vs 25.2 %, P = 0.006). Presentation with silent ischemia (odds ratio = 1.51, 95 % confidence interval (CI) 1.16-1.97) and nonemergent PCIs (odds ratio = 3.45, 95 % CI 1.79-6.67) were associated with no postprocedural cardiac biomarker testing. The real-world multicenter PCI registry in Japan revealed an incidence of 2.7 % for pMI; however, cardiac biomarkers were assessed in only 25.2 % of patients after PCI. The results suggest an underuse of postprocedural biomarker testing and room for procedural quality improvement, particularly in cases of silent ischemia and nonemergent cases.

Periprocedural (30-day) risk of myocardial infarction after drug-eluting coronary stent implantation: a meta-analysis comparing cobalt-chromium and stainless steel drug-eluting coronary stents

AIMS

Because of the reduction in the rate events related with in-stent restenosis, most events after drug-eluting stent implantation occur shortly after coronary stenting. Cobalt-chromium alloys allow to reduce strut thickness and improve flexibility and deliverability of coronary stent platforms, and thus could be associated with lower short-term events after stenting. The aim of this study was to test the hypothesis that drug-eluting coronary stents with a cobalt-chromium platform reduce the incidence of periprocedural (30-day) myocardial infarction in comparison with stainless steel drug-eluting coronary stents.

METHODS AND RESULTS

A meta-analysis from nine randomised trials comparing cobalt-chromium and stainless steel drug-eluting coronary stents that overall included 11,313 patients was performed. The incidence of myocardial infarction, stent thrombosis, and cardiac death at 30 days was compared between both types of stents. At 30 days, the incidence of acute myocardial infarction was significantly lower in patients allocated to cobalt-chromium drug-eluting stents (2.3% vs. 3.9%, respectively; p=0.006; odds ratio 0.72, 95% confidence interval 0.58-0.91), due to a significant reduction in the rate of non-Q-wave myocardial infarction (odds ratio 0.67, 95% confidence interval 0.51-0.88). The incidence of stent thrombosis was similar between both groups of patients, (0.5% vs. 0.5%, p=0.76; odds ratio 1.09, 95% confidence interval 0.63-1.89).

CONCLUSIONS

Drug-eluting coronary stents that use cobalt-chromium stent platforms have a better safety profile at 30 days in comparison with stainless steel drug-eluting stents, due to a significant reduction in the rate of myocardial infarction.

Efficacy of high-dose atorvastatin loading before primary percutaneous coronary intervention in ST-segment elevation myocardial infarction: the STATIN STEMI trial

OBJECTIVES

This study sought to determine the efficacy of high-dose atorvastatin in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

BACKGROUND

Previous randomized trials have demonstrated that statin pre-treatment reduced major adverse cardiac events (MACEs) in patients with stable angina pectoris and acute coronary syndrome. However, no randomized studies have been carried out with STEMI patients in a primary PCI setting.

METHODS

A total 171 patients with STEMI were randomized to 80-mg atorvastatin (n = 86) or 10-mg atorvastatin (n = 85) arms for pre-treatment before PCI. All patients were prescribed clopidogrel (600 mg) before PCI. After PCI, both groups were treated with atorvastatin (10 mg). The primary end point was 30-day incidence of MACE including death, nonfatal MI, and target vessel revascularization. Secondary end points included corrected thrombolysis in myocardial infarction frame count, myocardial blush grade, and ST-segment resolution at 90 min after PCI.

RESULTS

MACE occurred in 5 (5.8%) and 9 (10.6%) patients in the 80-mg and 10-mg atorvastatin pre-treatment arms, respectively (p = 0.26). Corrected thrombolysis in myocardial infarction frame count was lower in the 80-mg atorvastatin arm (26.9 +/- 12.3 vs. 34.1 +/- 19.0, p = 0.01). Myocardial blush grade and ST-segment resolution were also higher in the 80-mg atorvastatin arm (2.2 +/- 0.8 vs. 1.9 +/- 0.8, p = 0.02 and 61.8 +/- 26.2 vs. 50.6 +/- 25.8%, p = 0.01).

CONCLUSIONS

High-dose atorvastatin pre-treatment before PCI did not show a significant reduction of MACEs compared with low-dose atorvastatin but did show improved immediate coronary flow after primary PCI. High-dose atorvastatin may produce an optimal result for STEMI patients undergoing PCI by improving microvascular myocardial perfusion. (Efficacy of High-Dose AtorvaSTATIN Loading Before Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction [STATIN STEMI]; NCT00808717).

Evolution of anticoagulant and antiplatelet therapy: benefits and risks of contemporary pharmacologic agents and their implications for myonecrosis and bleeding in percutaneous coronary intervention

Periprocedural myonecrosis, as evidenced by elevated creatine kinase-myocardial bound (CK-MB) levels, occurs in up to 25% of patients undergoing percutaneous coronary intervention (PCI) and has been linked with an increased risk of adverse short- and long-term clinical outcomes. Such myonecrosis arises from three main pathophysiological mechanisms: procedure-related complications, lesion-specific characteristics (e.g., large thrombus burden, plaque volume), and patient-specific characteristics (e.g., genetic predisposition, arterial inflammation). Periprocedural myonecrosis has not been definitively identified as the cause of postprocedural ischemic events, although agents that reduce or prevent thrombosis--including aspirin, thienopyridines, heparin, low-molecular-weight heparins, glycoprotein IIb/IIIa inhibitors, and direct thrombin inhibitors--have been shown to reduce the incidence of ischemic outcomes in this population, as have agents that reduce inflammation (aspirin, statins). At the same time, antithrombotic agents are known to increase the risk of bleeding and the use of transfusions, which have likewise been associated with worse outcomes in these patients. Thus, optimal management of patients undergoing PCI represents a balance between minimizing the risk of ischemic outcomes and simultaneously minimizing the risk of major bleeding. It may be that patients who have only minor, untreated postprocedural elevations in CK-MB level (with no clinical or angiographic signs of ischemia) might have a better prognosis than patients who have normal CK-MB levels but who suffer major bleeding complications.

Meta-analysis of the role of statin therapy in reducing myocardial infarction following elective percutaneous coronary intervention

Statin medications initiated during percutaneous coronary intervention have been evaluated in clinical trials mainly to assess if this therapy reduces subsequent restenosis. The benefit of statin therapy on individual cardiovascular outcomes other than restenosis is largely unknown. Hence, a meta-analysis of the available randomized trials was conducted to evaluate individual cardiovascular outcomes with statin therapy compared with placebo after elective percutaneous coronary intervention. In all, there were 6 studies available for analysis (Prevention of Restenosis by Elisor After Transluminal Coronary Angioplasty [PREDICT], Fluvastatin Angioplasty Restenosis [FLARE], the Lescol Intervention Prevention Study [LIPS], German Atorvastatin Intravascular Ultrasound [GAIN], Atorvastatin for Reduction of Myocardial Damage During Angioplasty [ARMYDA], and a study by Briguori et al) that randomized 3,941 patients (1,967 to statins and 1,974 to placebos). Clinical follow-up ranged from 1 day to 45 months. The incidence of myocardial infarction was 3.0% in the statin group and 5.2% in the placebo group (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.42 to 0.78, p<0.0001). The incidence of all-cause mortality was 2.3% versus 3.0% (OR 0.74, 95% CI 0.50 to 1.1, p=0.14), that of cardiovascular mortality was 0.71% versus 1.2% (OR 0.58, 95% CI 0.30 to 1.11, p=0.10), and that of repeat surgical or percutaneous revascularization was 19.6% versus 21.9% (OR 0.89, 95% CI 0.78 to 1.02, p=0.098) in the statin arm versus the placebo arm, respectively. The incidence of stroke was 0.4% in the statin arm and 0.08% in the placebo arm (OR 3.00, 95% CI 0.60 to 14.77, p=0.18). In conclusion, statin therapy initiated at the time of elective percutaneous coronary intervention significantly reduces myocardial infarction.

Predictors of periprocedural creatine kinase-myocardial band elevation complicating elective percutaneous coronary intervention

Limited data are available regarding the predictors of periprocedural creatine kinase-MB (CK-MB) isoenzyme increase after elective percutaneous coronary intervention (PCI) in the stenting era. We explored the predictors of periprocedural CK-MB increase in 882 consecutive patients with normal preprocedural CK-MB who underwent 919 angiographically successful elective PCIs with (n = 814) or without (n = 105) stenting. Patients were categorized into 3 groups based on their peak CK-MB levels after PCI: (1) normal CK-MB (n = 761), (2) minor CK-MB increase (CK-MB 1 to 3 times normal, n = 112), and (3) major CK-MB increase (CK-MB >3 times normal, n = 46). By logistic regression analysis, independent predictors for minor CK-MB increase included thrombus (odds ratio [OR] 5.09, p = 0.001), platelet IIb/IIIa antagonist use (OR 0.53, p <0.01), number of lesions treated (per additional lesion, OR 1.54, p <0.01), maximum balloon size (per millimeter increase, OR 1.57, p <0.05), American College of Cardiology/American Heart Association type C lesion (OR 1.68, p <0.05), sustained chest pain during procedure (OR 1.94, p <0.05), dissection (OR 2.05, p <0.05), and transient side branch occlusion (OR 4.54, p <0.05). Independent predictors for major CK-MB increase were chest pain at end of procedure (OR 9.66, p <0.001), type C lesion (OR 2.42, p <0.05), Canadian Cardiovascular Society angina class III to IV (OR 3.32, p <0.05), thrombus (OR 5.09, p = 0.001), and abrupt closure (OR 5.30, p <0.05). In conclusion, baseline clinical and angiographic characteristics and procedural complications were associated with minor and major CK-MB increases. Patients with chest pain at the end of the procedure were at the highest risk for major CK-MB increase.

Percutaneous coronary intervention for major bifurcation lesions using the simple approach: risk of myocardial infarction

BACKGROUND

Recent data has suggested that simple (main vessel only) stenting is the preferred approach for patients with bifurcation lesions. We sought to determine the feasibility and outcomes of this approach in a year long inclusive registry.

METHODS

From August, 2004-2005, a registry of 1,600 consecutive patients undergoing PCI was reviewed. Patients undergoing PCI for major bifurcation lesions--> or =70% stenosis in a major (> or =2 mm) side branch and/or main vessel--were identified by review of the angiograms. Angiographic, clinical and treatment predictors of final SB compromise (> or =70% stenosis and/or less than TIMI 3 final flow) were identified.

RESULTS

Hundred and fifty eight patients who underwent initial stenting of the main vessel with subsequent rescue of the side branch if SB compromise occurred ("Provisional Main Vessel Stenting") comprised the analysis population. Permanent SB compromise occurred in 16% of patients and was associated with an increased risk of large periprocedural MI and renal failure. Independent predictors of permanent SB compromise were lack of pre-PCI beta blockers, presence of diabetes mellitus, main vessel eccentric lesion and small SB vessel diameter.

CONCLUSION

Among unselected patients with major bifurcation lesions undergoing a "simple" stenting approach, there is a significant rate of large periprocedural infarction and side branch compromise.