Incidence and short-term clinical outcomes of small side branch occlusion after implantation of an everolimus-eluting bioresorbable vascular scaffold: an interim report of 435 patients in the ABSORB-EXTEND single-arm trial in comparison with an everolimus-eluting metallic stent in the SPIRIT first and II trials

Research on the influence of maker spirit on knowledge workers' innovative behavior

Motivating the innovative behavior of knowledge workers with the "maker spirit" is important for enhancing innovation efficiency. Based on the unique "maker spirit" embodied in knowledge workers in Chinese, this study comprehensively considers elements of job crafting and superiors' developmental feedback, and uses questionnaire survey method and mathematical statistical analysis method to explore the relationship between the maker spirit and the innovative behavior of knowledge workers in order to provide theoretical support for further promoting the development of social innovation. The results of the study show that the spirit of innovation, sharing, practice, and entrepreneurship in the maker spirit all have a positive contribution to innovative behavior; job crafting mediates between the spirit of innovation, sharing, practice, entrepreneurship, and innovative behavior; and superiors' developmental feedback plays a positive moderating role between the spirit of innovation, sharing, practice, entrepreneurship, and job crafting.

Post-procedural and long-term functional outcomes of jailed side branches in stented coronary bifurcation lesions assessed with side branch Murray law-based quantitative flow ratio

Introduction

In coronary bifurcation lesions treated with percutaneous coronary intervention (PCI) using a 1-stent strategy, the occurrence of side branch (SB) compromise may lead to long-term myocardial ischemia in the SB territory. Murray law-based quantitative flow ratio (μQFR) is a novel angiography-based approach estimating fractional flow reserve from a single angiographic view, and thus is more feasible to assess SB compromise in routine practice. However, its association with long-term SB coronary blood flow remains unknown.

Methods

A total of 146 patients with 313 non-left main bifurcation lesions receiving 1-stent strategy with drug-eluting stents was included in this retrospective study. These lesions had post-procedural Thrombolysis in Myocardial Infarction (TIMI) flow grade 3 in SBs, and documented angiographic images of index procedure and 6- to 24-month angiographic follow-up. Post-procedural SB μQFR was calculated. Long-term SB coronary blood flow was quantified with the TIMI grading system using angiograms acquired at angiographic follow-up.

Results

At follow-up, 8 (2.6%), 16 (5.1%), 61 (19.5%), and 228 (72.8%) SBs had a TIMI flow grade of 0, 1, 2, and 3, respectively. The incidences of long-term SB TIMI flow grade ≤1 and ≤2 both tended to decrease across the tertiles of post-procedural SB μQFR. The receiver operating characteristic curve analyses indicated the post-procedural SB μQFR ≤0.77 was the optimal cut-off value to identify long-term SB TIMI flow grade ≤1 (specificity, 37.50%; sensitivity, 87.20%; area under the curve, 0.6673; P = 0.0064), and it was independently associated with 2.57-fold increased risk (adjusted OR, 2.57; 95% CI, 1.02-7.25; P = 0.045) in long-term SB TIMI flow grade ≤1 after adjustment.

Discussion

Post-procedural SB μQFR was independently associated with increased risk in impaired SB TIMI flow at long-term follow-up. Further investigations should focus on whether PCI optimization based on μQFR may contribute to improve SB flow in the long term.

Periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention

Percutaneous coronary intervention (PCI) in addition to guideline-directed medical therapy reduces the risk of spontaneous myocardial infarction (MI), urgent revascularization, and improves angina status; however, PCI is associated with an increased risk of periprocedural myocardial injury and MI. Numerous studies have investigated the mechanisms, predictors, and therapeutic strategies for periprocedural MI. Various definitions of periprocedural MI have been proposed by academic groups and professional societies requiring different cardiac biomarker thresholds and ancillary criteria for myocardial ischemia. The frequency and clinical significance of periprocedural MI substantially varies according to the definitions applied. In daily practice, accurate diagnosis of clinically-relevant periprocedural MI is essential because it may have a substantial impact on subsequent patient management. In the clinical trial setting, only clinically relevant periprocedural MI definitions should be applied as a clinical endpoint in order to avoid obscuring meaningful outcomes. In this review, we aim to summarize the mechanisms, predictors, frequency, and prognostic impact of periprocedural MI in patients undergoing PCI and to provide the current perspective on this issue.

Jailed Balloon Technique Is Superior to Jailed Wire Technique in Reducing the Rate of Side Branch Occlusion: Subgroup Analysis of the Conventional Versus Intentional StraTegy in Patients With High Risk PrEdiction of Side Branch OccLusion in Coronary Bifurcation InterVEntion Trial

Objective

Jailed balloon technique (JBT) is an active side branch (SB) protection strategy and is considered to be superior to the jailed wire technique (JWT) in reducing SB occlusion. However, no randomized trials have proved that. We aim to investigate whether JBT could decrease the SB occlusion rate.

Methods

Conventional versus Intentional straTegy in patients with high Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion (CIT-RESOLVE) (NCT02644434, registered on December 31, 2015) (https://clinicaltrials.gov) is a randomized trial that assessed the effects of different strategies on SB occlusion rate in patients with a high risk of SB occlusion. The present subgroup analysis enrolled bifurcation lesions (2 mm ≤ reference vessel diameter of SB < 2.5 mm) with Visual estimation for Risk prEdiction of Side branch OccLusion in coronary bifurcation intervention (V-RESOLVE) score ≥ 12 points. The primary endpoint is SB occlusion. One-year clinical events were compared.

Results

A total of 284 subjects at 16 sites were randomly assigned to the JBT group (n = 143) or the JWT group (n = 141). The rate of SB occlusion (9.1 vs. 19.9%, p = 0.02) and periprocedural myocardial infarction (defined by WHO, 7 vs. 14.9%, p = 0.03) is significantly lower in the JBT group than in the JWT group. The JBT and JWT groups showed no significant differences in cardiac death (0.7 vs. 0.7%, p = 1), myocardial infarction (MI, 6.3 vs. 7.1%, p = 0.79), target lesion revascularization (TLR, 1.4 vs. 2.1%, p = 0.68), and major cardiac adverse events (MACE, a composite of all-cause death, MI, or TLR, 8.4 vs. 10.6%, p = 0.52) during a 1-year follow-up.

Conclusion

In patients with a high risk of SB occlusion (V-RESOLVE score ≥ 12 points), JBT is superior to JWT in reducing SB occlusion. However, no significant differences were detected in 1-year MACE.

Safety and Efficacy of Bioresorbable Vascular Scaffolds in Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis

INTRODUCTION

Coronary bifurcation lesions (CBL) are one fifth of all coronary lesions and they do not have an optimal strategy for stenting yet. Bioresorbable scaffolds (BRS) are novel inventions proposed to be the optimal solution. The aim of this systematic review was to assess the role of BRS in treating CBL by comparing it to dedicated bifurcation stents (DBS).

METHODS

A systematic review was conducted following the PRISMA guidelines, searching databases such as ScienceDirect, EMBASE, MEDLINE, NIH, TRIP, PUBMED, and ClinicalTrials. gov. The risk of bias was assessed by MINORS and modified Cowley's criteria. Q statistic was used for heterogeneity testing and a meta-analysis was conducted using the "meta" package in the R software application.

RESULTS

Fourteen studies were included with an average follow-up period of twelve months. Almost 80% of the participants were male (p-value= 0.148) and around two-thirds were smokers. Meta-analysis was performed for myocardial infarction (MI), target lesion revascularisation (TLR), major adverse cardiac events (MACE), and stent thrombosis (ST). These showed statistically nonsignificant differences, with a slight trend favouring BRS except with stent thrombosis.

CONCLUSION

There is a lack of randomised trials on the topic, which may be an area for further research. But the results showed favourable yet statistically insignificant outcomes for BRS except for ST, an issue that can be addressed with technological advancement.

Active Versus Conventional Side Branch Protection Strategy for Coronary Bifurcation Lesions

The side branch (SB) provisional stenting strategy is currently the recommended approach for most coronary bifurcation lesions. However, this strategy may result in SB deterioration, which is associated with an increased incidence of periprocedural myocardial infarction (PMI) and may adversely affect the long-term prognosis. Various techniques for SB protection (SB-P) have been developed to reduce SB occlusion and improve the clinical prognosis. This meta-analysis was performed to compare the outcomes of an active SB-P strategy of jailed balloon technique, balloon-stent kissing technique, and jailed Corsair technique versus the conventional SB-P strategy based on jailed wire technique.This meta-analysis included 5 studies (4 randomized and 1 observational) involving a total of 1,174 patients in whom the active and conventional SB-P strategies were compared. Fixed- and random-effects models were used to calculate summary risk ratios (RRs).The risk of SB occlusion was significantly lower in active SB-P strategy [RR 0.47, 95% confidence interval (CI) 0.30-0.73 in fixed-effect model; RR 0.52, 95% CI 0.31-0.87 in random-effect model]. The risk of PMI was similar between the two strategies (RR 0.63, 95% CI 0.30-1.33 in fixed-effect model; RR 0.71, 95%CI 0.20-2.48 in random-effect model). The rate of long-term major adverse cardiovascular events was similar between the groups (RR 0.48, 95% CI 0.15-1.48 in fixed-effect model; RR 0.49, 95% CI 0.16-1.52 in random-effect model).The active SB-P strategy in coronary bifurcation lesions is associated with reduced SB deterioration, but it does not decrease PMI or improve the long-term prognosis.

The relationship between coronary stent strut thickness and the incidences of clinical outcomes after drug-eluting stent implantation: A systematic review and meta-regression analysis

BACKGROUND

Drug-eluting stents (DESs) have been developed with thinner stent struts, and more biocompatible polymers and anti-proliferative drugs to improve the clinical performance. However, it remains unclear whether thinner struts are associated with favorable short- and long-term clinical outcomes such as target lesion revascularization (TLR), periprocedural myocardial infarction (PMI), and stent thrombosis (ST).

METHODS

We searched MEDLINE, Embase and other online sources for randomized controlled trials (RCTs) comparing clinical outcomes between a DES and other stent(s), with independent clinical event adjudication. We investigated stent-related events (TLR, PMI, and ST) in 5 years. Each outcome was analyzed with random-effects meta-regression model against strut thickness, then adjusted for DES generation and patient and lesion characteristics.

RESULTS

We identified 49 RCTs enrolling 97,465 patients, of which strut thickness ranged from 60 to 140 μm. Incidences of 1-year TLR, PMI, and early ST were reduced with thinner stent struts, when adjusted for stent generation (adjusted relative risk [RR] per 10 μm increase 1.12 [95% CI 1.04-1.21], 1.15 [95% CI 1.05-1.26], and 1.15 [95% CI 1.06-1.25], respectively). Strut thickness was not independently associated with incidences of 5-year TLR, late and very late ST. In addition, early DESs contributed to a higher incidence of very late ST (adjusted RR 2.97 [95% CI 1.36-6.50]).

CONCLUSIONS

In this meta-regression analysis, a thinner strut thickness was associated with reduced incidences of early stent-related adverse events (1-year TLR, PMI, and early ST), but not with later events (5-year TLR, late ST, and very late ST).

Prognostically relevant periprocedural myocardial injury and infarction associated with percutaneous coronary interventions: a Consensus Document of the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI)

A substantial number of chronic coronary syndrome (CCS) patients undergoing percutaneous coronary intervention (PCI) experience periprocedural myocardial injury or infarction. Accurate diagnosis of these PCI-related complications is required to guide further management given that their occurrence may be associated with increased risk of major adverse cardiac events (MACE). Due to lack of scientific data, the cut-off thresholds of post-PCI cardiac troponin (cTn) elevation used for defining periprocedural myocardial injury and infarction, have been selected based on expert consensus opinions, and their prognostic relevance remains unclear. In this Consensus Document from the ESC Working Group on Cellular Biology of the Heart and European Association of Percutaneous Cardiovascular Interventions (EAPCI), we recommend, whenever possible, the measurement of baseline (pre-PCI) cTn and post-PCI cTn values in all CCS patients undergoing PCI. We confirm the prognostic relevance of the post-PCI cTn elevation >5× 99th percentile URL threshold used to define type 4a myocardial infarction (MI). In the absence of periprocedural angiographic flow-limiting complications or electrocardiogram (ECG) and imaging evidence of new myocardial ischaemia, we propose the same post-PCI cTn cut-off threshold (>5× 99th percentile URL) be used to define prognostically relevant ‘major’ periprocedural myocardial injury. As both type 4a MI and major periprocedural myocardial injury are strong independent predictors of all-cause mortality at 1 year post-PCI, they may be used as quality metrics and surrogate endpoints for clinical trials. Further research is needed to evaluate treatment strategies for reducing the risk of major periprocedural myocardial injury, type 4a MI, and MACE in CCS patients undergoing PCI.

Double kissing inflation outside the stent secures the patency of small side branch without rewiring

BACKGROUND

The jailed balloon technique is widely used for coronary bifurcation lesions, but a residual risk of SB occlusion remains, necessitating SB rewiring and further interventions, including balloon inflation or stenting, which may result in failure and SB loss. This study introduced a novel modified technique of small side branch (SB) protection, namely, double kissing inflation outside the stent (DKo) technique, for coronary bifurcations without the need for SB rewiring.

METHODS

We performed the DKo technique in consecutive patients in our center from 1/2019 to 12/2019. The procedure was as follows. We inserted a guide wire into both branches followed by proper preparation. The SB balloon was simultaneously inflated with main vessel (MV) stenting. The SB balloon remained in situ until it was kissing inflated with postdilation of the bifurcation core, which is different from traditional strategies. The proximal optimization technique was performed with a short noncompliant balloon strictly not exceeding the bifurcation. Rates of SB loss and in-hospital outcomes were evaluated.

RESULTS

The technique was successfully performed in all 117 enrolled patients without any rewiring or SB loss. The mean lesion lengths of the MV and SB were 38.3 ± 19.9 mm and 11.7 ± 7.1 mm, respectively. On average, 1.5 ± 0.6 stents were used per patient, while the mean pressure of the SB balloon was 7.4 ± 3.1 atm. DKo achieved excellent procedural success in the proximal and distal MVs: increased minimal lumen diameter (0.64 ± 0.58 mm to 3.05 ± 0.38 mm, p < 0.001; 0.57 ± 0.63 mm to 2.67 ± 0.35 mm, p < 0.001) and low residual stenosis (11.4 ± 3.4%; 7.2 ± 4.6%). DKo secured the patency of the SB without any rewiring and improved the SB stenosis with minimal lumen diameter (0.59 ± 0.48 mm to 1.20 ± 0.42 mm, p < 0.001) and stenosis (71.9 ± 19.4% to 42.2 ± 14.0%, p < 0.001). No MACE was noted in the hospital.

CONCLUSIONS

DKo for bifurcation lesions was shown to be acceptable with high procedural success and excellent SB protection.

Visually Estimated RESOLVE Score Based on Coronary Computed Tomography to Predict Side Branch Occlusion in Percutaneous Bifurcation Intervention

PURPOSE

The quantitative RESOLVE (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion) score derived from coronary computed tomography angiography (coronary CTA) was developed as a noninvasive and accurate prediction tool for side branch (SB) occlusion in coronary bifurcation intervention. We aimed to determine the ability of a visually estimated CTA-derived RESOLVE score (V-RESOLVE score) to predict SB occlusion in coronary bifurcation intervention.

MATERIALS AND METHODS

The present study included 363 patients with 400 bifurcation lesions. CTA-derived V-RESOLVE score was derived and compared with the quantitative CTA-derived RESOLVE score. The scoring systems were divided into quartiles, and classified as the high-risk and non-high-risk groups. SB occlusion was defined as any decrease in thrombolysis in myocardial infarction flow grade after main vessel stenting.

RESULTS

In total, 28 SB occlusions (7%) occurred. The concordance between visual and quantitative CTA analysis showed poor to excellent agreement (weighted κ range: 0.099 to 0.867). The area under the receiver operating curve for the prediction of SB occlusion was significantly higher for the CTA-derived V-RESOLVE score than for quantitative CTA-derived RESOLVE score (0.792 vs. 0.709, P=0.049). The total net reclassification index was 42.7% (P=0.006), and CTA-derived V-RESOLVE score showed similar capability to discriminate between high-risk group (18.6% vs. 13.8%, P=0.384) and non-high-risk group (3.8% vs. 4.9%, P=0.510) as compared with quantitative CTA-derived RESOLVE score.

CONCLUSIONS

Visually estimated CTA-derived V-RESOLVE score is an accurate and easy-to-use prediction tool for the stratification of SB occlusion in coronary bifurcation intervention.

Periprocedural Myocardial Injury: Pathophysiology, Prognosis, and Prevention

The definition and clinical implications of myocardial infarction occurring in the setting of percutaneous coronary intervention have been the subject of unresolved controversy. The definitions of periprocedural myocardial infarction (PMI) are many and have evolved over recent years. Additionally, the recent advancement of different imaging modalities has provided useful information on a patients' pre-procedural risk of myocardial infarction. Nonetheless, questions on the benefit of different approaches to prevent PMI and their practical implementation remain open. This review aims to address these questions and to provide a current and contemporary perspective.

Active SB-P Versus Conventional Approach to the Protection of High-Risk Side Branches: The CIT-RESOLVE Trial

OBJECTIVES

The aim of this study was to determine whether an active side branch protection (SB-P) strategy is superior to the conventional strategy in reducing side branch (SB) occlusion in high-risk bifurcation treatment.

BACKGROUND

Accurate prediction of SB occlusion after main vessel stenting followed by the use of specific strategies to prevent occlusion would be beneficial during bifurcation intervention.

METHODS

Eligible patients who had a bifurcation lesions with high risk for occlusion as determined using the validated V-RESOLVE (Visual Estimation for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention) score were randomized to an active SB-P strategy group (elective 2-stent strategy for large SBs and jailed balloon technique for small SBs) or a conventional strategy group (provisional stenting for large SBs and jailed wire technique for small SBs) in a 1:1 ratio stratified by SB vessel size. The primary endpoint of SB occlusion was defined as an angiography core laboratory-assessed decrease in TIMI (Thrombolysis In Myocardial Infarction) flow grade or absence of flow in the SB immediately after full apposition of the main vessel stent to the vessel wall.

RESULTS

A total of 335 subjects at 16 sites were randomized to the SB-P group (n = 168) and conventional group (n = 167). Patients in the SB-P versus conventional strategy group had a significantly lower rate of SB occlusion (7.7% [13 of 168] vs. 18.0% [30 of 167]; risk difference: -9.1%; 95% confidence interval: -13.1% to -1.8%; p = 0.006), driven mainly by the difference in the small SB subgroup (jailed balloon technique vs. jailed wire technique: 8.1% vs. 18.5%; p = 0.01).

CONCLUSIONS

An active SB-P strategy is superior to a conventional strategy in reducing SB occlusion when treating high-risk bifurcation lesions. (Conventional Versus Intentional Strategy in Patients With High Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention [CIT-RESOLVE]; NCT02644434).

Accuracy of RESOLVE score derived from coronary computed tomography versus visual angiography to predict side branch occlusion in percutaneous bifurcation intervention

INTRODUCTION

Visually estimated angiographic V-RESOLVE score was developed as a simple and accurate prediction tool for side branch (SB) occlusion in patients undergoing coronary bifurcation intervention. Data on the use of coronary computed tomography angiography (coronary CTA) for guiding percutaneous coronary intervention in bifurcation lesions is scarce.

OBJECTIVES

We aimed to validate the ability of quantitative CTA-derived RESOLVE score for predicting SB occlusion in coronary bifurcation intervention and to compare its predictive value with that of the angiography-based V-RESOLVE score.

METHODS

We included 363 patients with 400 bifurcation lesions. Angiographic V-RESOLVE score and CTA-derived RESOLVE score were calculated utilizing the weights from the QCA-based RESOLVE score. The scoring systems were divided into quartiles, and classified as the non-high-risk group and the high-risk group. Accuracy was assessed using areas under the receiver-operator characteristic curve (AUC). SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction flow grade (including the absence of flow) in the SB after main vessel stenting.

RESULTS

In total, 28 SB occlusions (7%) occurred. CTA-derived RESOLVE and V-RESOLVE scores achieved comparable predictive accuracy (0.709 vs. 0.752, respectively, p = 0.531) for predicting SB occlusion, and the analysis of AUC for each constituent element of the scores did not show any significant difference between CTA and visual angiography. The total net reclassification index was -18.6% (p = 0.194), and there were no significant differences in the rates of SB occlusion in the non-high-risk group (4.9% vs. 3.8%, p = 0.510) and the high-risk group (13.8% vs. 18.6%, p = 0.384) between CTA-derived RESOLVE and V-RESOLVE scores.

CONCLUSIONS

The quantitative CTA-derived RESOLVE score is an accurate and reliable alternative to the visually estimated angiographic V-RESOLVE score for prediction of SB occlusion in coronary bifurcation intervention.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03709836.

Carina Bifurcation Angle and Side Branch Occlusion in Coronary Bifurcation Lesions Intervention: Angiographic Lesions Characteristic Role in Determining Its Relation

Side branch occlusion has been implicated as a complication after percutaneous coronary intervention in coronary bifurcation lesions. The role of carina bifurcation angle as one of the characteristics of the coronary bifurcation lesions in causing side branch occlusion after percutaneous coronary intervention is still debated. This study aims to assess the correlation between carina bifurcation angles as one of the characteristics of the coronary bifurcation lesions and side branch occlusion in elective percutaneous coronary intervention. This is a cross-sectional study which utilizes CAAS 5.1 software to measure carina bifurcation angle. We collected 113 lesions in 108 patients that met the inclusion criteria from January 2016 to October 2016. Side branch occlusion occurred in 15 lesions (13.3%), with median carina bifurcation angle 19.17 degrees ( p  < 0.001). Multivariate analysis showed there is a correlation between carina bifurcation angle with side branch occlusion, OR (odds ratio) 0.86 (95% CI [confidence interval]: 0.80-0.92) with ≤ 33.71 degrees cut off value. Increased risk of side branch occlusion was found in small carina bifurcation angle.

A novel technique for coronary bifurcation intervention: Double rewire crush technique and its clinical outcomes after 2 years of follow-up

OBJECTIVES

To describe procedural details of the double rewire (DR) crush technique, a novel modified crush technique, and report the clinical outcomes of patients who underwent the procedure.

BACKGROUND

In the management of complex bifurcation lesions, there is a need to use elective two-stent techniques that stent the side branch (SB) before main vessel (MV) stenting and keep SB open.

METHODS

We studied 48 patients with 49 bifurcation lesions who underwent percutaneous coronary intervention (PCI) using the DR-crush technique between January and December 2013. Baseline, postprocedural, and follow-up quantitative coronary angiographic analyses were performed. Procedural characteristics and clinical outcomes at follow-up were assessed.

RESULTS

Majority of the patients (60.4%, 29/48) had acute coronary syndrome. Most bifurcation lesions (77.6%, 38/49) were classified as Medina 1, 1, 1. Final kissing balloon inflation was successfully performed in all patients. After PCI, MV and SB of all patients had Thrombolysis In Myocardial Infarction 3 blood flow. None of the patients had MV or SB diameter stenosis ≥50% after PCI. At a mean follow-up period of 2.4 years, target vessel revascularization occurred in 2.1% and myocardial infarction in 2.1%. No deaths occurred in this period.

CONCLUSIONS

The DR-crush technique is feasible in coronary bifurcation stenting. Patients who underwent this procedure had relatively low incidence of adverse events. Larger studies are warranted for further confirmation of the findings.

Angiographic and Midterm Outcomes of Bioresorbable Vascular Scaffold for Coronary Bifurcation Lesions

Data on the angiographic and clinical performance of bioresorbable vascular scaffolds (BVS) for bifurcation lesions treatment are still limited. Data were examined of 107 patients with at least 1 coronary bifurcation lesion involving a side branch ≥2mm. Angiographic and clinical outcomes were collected. Optical coherence tomography analysis was performed in a subgroup of patients. Between July 2009 and December 2015, 423 patients underwent PCI with Absorb BVS. A total of 110 lesions were identified as bifurcations, of which 24.5% were classified as true bifurcation lesions. Lesion complexity B2/C was 68.1%. Ninety-five out of 110 lesions were treated by provisional stenting technique while 2 stenting strategy was the final approach in 15 lesions. Procedural success of main branch was 100% whereas side-branch impairment at the end of the procedure was 4.5%. The mean follow-up was 21 months with one-third of the patients followed up for at least 2 years. The overall target lesion failure and scaffold/stent thrombosis rate at 1 year was 7.8% and 3.9%, respectively. In conclusion the results of the present analysis suggest the BVS implanted in bifurcations lesions are associated with procedural safety and angiographic success as well as acceptable target lesion failure rate at 1 year.

Cardiovascular stents: overview, evolution, and next generation

Compared to bare-metal stents (BMSs), drug-eluting stents (DESs) have been regarded as a revolutionary change in coronary artery diseases (CADs). Releasing pharmaceutical agents from the stent surface was a promising progress in the realm of cardiovascular stents. Despite supreme advantages over BMSs, in-stent restenosis (ISR) and long-term safety of DESs are still deemed ongoing concerns over clinically application of DESs. The failure of DESs for long-term clinical use is associated with following factors including permanent polymeric coating materials, metallic stent platforms, non-optimal drug releasing condition, and factors that have recently been supposed as contributory factors such as degradation products of polymers, metal ions due to erosion and degradation of metals and their alloys utilizing in some stents as metal frameworks. Discovering the direct relation between stent materials and associating adverse effects is a complicated process, and yet it has not been resolved. For clinical success it is of significant importance to optimize DES design and explore novel strategies to overcome all problems including inflammatory response, delay endothelialization, and sub-acute stent thrombosis (ST) simultaneously. In this work, scientific reports are reviewed particularly focusing on recent advancements in DES design which covers both potential improvements of existing and recently novel prototype stent fabrications. Covering a wide range of information from the BMSs to recent advancement, this study mostly sheds light on DES's concepts, namely stent composition, drug release mechanism, and coating techniques. This review further reports different forms of DES including fully biodegradable DESs, shape-memory ones, and polymer-free DESs.

Small side branch compromise related to main vessel stenting: A retrospective cohort study comparing different treatment strategies

Treatment strategies for small side branch compromise related to main vessel stenting are not well investigated and not established.This study is to compare the clinical prognosis of different strategies for bifurcations with or without percutaneous coronary intervention (PCI) of small side branch after it compromised.A total of 119 consecutive bifurcation subjects from January 2013 to March 2015 were enrolled, all bifurcations were characterized by small side branch (1.5 mm ≤side branch diameter ≤2.5 mm). Subjects were assigned into side branch treatment (SBT) group and nonside branch treatment group (NSBT) according to whether advanced treatment of side branch was taken or not after it compromised. Major adverse cardiovascular event (MACE) was evaluated, so were the CCS angina and NYHA heart function classification.SBT subjects were associated with longer procedure time (46.7 vs 19.6 min, P < .001) and more complications (18.9% vs 0.0%, P < .001). 12 MACEs were followed including 4 in SBT group and 8 in NSBT group (10.8% vs 9.8%, P = 1.00). There were no significant difference between 2 groups regarding the CCS and NYHA classification, neither were the calculated classification improvement rate, respectively. In subgroup analysis for true and nontrue bifurcations, no statistical difference was found in terms of the MACE rate, the CCS, and NYHA classification improvement rate.Nontreatment of side branch will not increase the risk of MACE and will not worsen the CCS and NYHA classification when small side branch compromises during the bifurcation PCI.

Thirty-Day and One-Year Clinical Outcomes of Bioresorbable Vascular Scaffold Implantation: A Single-Center Experience

Background

Available data on the use of the Bioresorbable vascular scaffold (BVS) (Abbott Vascular, Santa Clara, CA) in real-world patients is limited, particularly in Asian populations. The aim of this study was to assess clinical outcomes of patients treated with a BVS in real-world practice in Taiwan.

Methods

This study focused on 156 patients with coronary artery disease and a total of 249 lesions who received BVS implantation from October 2012 to October 2015. The study's primary endpoint was major adverse cardiac event (MACE), such as a myocardial infarction (MI), target vessel revascularization (TVR), target lesion revascularization (TLR), definite or possible scaffold thrombosis, cardiovascular death, and all-cause mortality during the thirty-day follow-up period. The secondary endpoint was MACE during the one-year follow-up period. Additionally, the composite clinical secondary endpoint was target lesion failure (TLF), which was called device-oriented composite endpoint.

Results

The average age of the patients was 60.34 ± 10.15 years, and 81.4% were male. The average of Syntax score was 12.42 ± 8.77 points. 44.2 % lesions were type B2 or C. At 31 days, one patient experienced a MACE (1/156) the composite of two TLF (2/249) with ST elevation MI, which was related to scaffold thrombosis. At one-year, 5.1 % (8/156) of the patients experienced a MACE and 3.6% (9/249) of the lesions experienced a TLF. There was no cardiovascular or all-cause mortality in the 30-day follow-up. The one-year cardiovascular and all-cause mortality rates were each 1.3%, respectively. Diabetes, ostial lesion, bifurcation lesion, and non-standard dual anti-platelet therapy (DAPT) were the strong associations of one-year TLF.

Conclusions

Even with difficult and complex lesions of patients in this study, acceptable outcomes were achieved with low definite or possible scaffold thrombosis rates after BVS implantation. And despite anatomical issues, it is important to complete standard DAPT.

Two-year clinical outcomes of patients treated with overlapping absorb scaffolds: An analysis of the ABSORB EXTEND single-arm study

BACKGROUND

Preclinical data showed that overlapping (OVP) scaffolds might result in delayed healing and strut coverage compared to nonOVP scaffold segments. Furthermore, OVP in patients could result in increased periprocedure myocardial infarction (MI) rate secondary to side branch occlusion; however, little is known whether this may have an impact on long-term clinical outcomes.

METHODS

ABSORB EXTEND is a prospective, single-arm, open-label clinical study in which 812 patients were enrolled at 56 sites. In this study, we compared the immediate and 2-year clinical outcomes of patients with OVP scaffolds (n = 115) to those of patients with nonOVP scaffolds (n = 697). The primary objective was the comparison of major adverse cardiac event (MACE) (cardiac death, MI and ischemic-driven target lesion revascularization [TLR]) and scaffold thrombosis (ST) rates up to 2 years.

RESULTS

Baseline clinical and angiographic characteristics were comparable between cohorts except for longer lesions in the OVP patients as expected (16.7 ± 7.3 vs. 11.6 ± 4.4 mm, P < 0.0001), higher lesion complexity (B2) and numerically smaller vessel size. In-hospital, there was a marked increase in MACE in the OVP cohort (7.0 vs. 0.9%, P = 0.002), exclusively driven by a higher rate of periprocedure MI (7.0 vs. 0.9%, P = 0.002). Long-term MACE did not significantly differ between groups (10.4% in the OVP cohort vs. 6.6% in the no-OVP group, P = 0.1) with comparable rates of cardiac death (0.9 vs. 1.2%, P = 1.0) and ischemia-driven TLR (1.7 vs. 2.5%, P = 1.0). Cumulative incidence of MI was higher in the OVP cohort (7.8 vs. 3.0%, P = 0.02). Of note, the rate of MI between hospital discharge and 2-year follow-up was lower in the OVP cohort (0.8 vs. 2.1%, P = 0.04). Cumulative incidence of definite/probable ST was relatively low and comparable between groups (1.8 vs. 1.5%, P = 0.7).

CONCLUSIONS

In this low-to-moderate complex population treated with the ABSORB scaffold the OVP group showed a higher incidence of periprocedure MI with no immediate or long-term increase in cardiac death, TLR or ST.

Procedural resources utilization and clinical outcomes with bioresorbable everolimus-eluting scaffolds and Pt-Cr everolimus-eluting stent with resorbable abluminal polymer in clinical practice. A randomized trial

OBJECTIVES

We sought to compare the procedural implications of using bioresorbable everolimus-eluting scaffolds (BVS) and Pt-Cr everolimus-eluting stent with abluminal bioabsorbable polymer (Synergy).

BACKGROUND

There are important differences in the respective platforms, which could impact on procedural performance, complications and outcomes.

METHODS

A prospective, randomized single center study including consecutive patients in stable clinical condition and with lesions amenable to be treated with BVS according to predefined criteria. Patients were randomized to either treatment with BVS or Synergy. All procedural data were collected and 12 months clinical follow up conducted. Primary objectives were fluoroscopy time, median dose-area product, contras agent volumen, and peri-procedural troponin release.

RESULTS

A total of 200 patients were included, 100 in BVS group and 100 in Synergy group. No significant differences were observed in baseline clinical and angiographic characteristics. Predilatation (97.6 vs. 25.4%; P < 0.001), postdilatation (64.8 vs. 38.4%: P < 0.01), and use of 2 wires (20.8 vs. 10%; P = 0.02) were more frequent with BVS. The BVS group showed a significant increase in fluoroscopy time (18%), dose-area product (20%), and contrast volume (10%). Post-procedural increase of creatinine was similar and amount of TnI release was significantly higher with BVS but incidence of peri-procedural infarction was comparable. Clinical outcomes at 12 months were similar with definite thrombosis being 1% with BVS and 0% with Synergy.

CONCLUSIONS

The use of BVS in comparison with the Synergy stent in a similar lesional setting is associated with a higher use of resources in the procedure, more radiation, and higher TnI release. © 2016 Wiley Periodicals, Inc.

A randomised comparison of Conventional versus Intentional straTegy in patients with high Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion: rationale and design of the CIT-RESOLVE trial

INTRODUCTION

The intentional strategy (aggressive side branch (SB) protection strategy: elective two-stent strategy or jailed balloon technique) is thought to be associated with lower SB occlusion rate than conventional strategy (provisional two-stent strategy or jailed wire technique). However, most previous studies showed comparable outcomes between the two strategies, probably due to no risk classification of SB occlusion when enrolling patients. There is still no randomised trial compared the intentional and conventional strategy when treating bifurcation lesions with high risk of SB occlusion. We aim to investigate if intentional strategy is associated with significant reduction of SB occlusion rate compared with conventional strategy in high-risk patients.

METHODS AND ANALYSIS

The Conventional versus Intentional straTegy in patients with high Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion (CIT-RESOLVE) is a prospective, randomised, single-blind, multicentre clinical trial comparing the rate of SB occlusion between the intentional strategy group and the conventional strategy group (positive control group) in a consecutive cohort of patients with high risk of side branch occlusion defined by V-RESOLVE score, which is a validated angiographic scoring system to evaluate the risk of SB occlusion in bifurcation intervention and used as one of the inclusion criteria to select patients with high SB occlusion risk (V-RESOLVE score ≥12). A total of 21 hospitals from 10 provinces in China participated in the present study. 566 patients meeting all inclusion/exclusion criteria are randomised to either intentional strategy group or conventional strategy group. The primary endpoint is SB occlusion (defined as any decrease in thrombolysis in myocardial infarction flow grade or absence of flow in SB after main vessel stenting). All patients are followed up for 12-month postdischarge.

ETHICS AND DISSEMINATION

The protocol has been approved by all local ethics committee. The ethics committee have approved the study protocol, evaluated the risk to benefit ratio, allowed operators with a minimum annual volume of 200 cases to participate in the percutaneous coronary intervention procedure and permitted them to perform both conventional and intentional strategies. Written informed consent would be acquired from all participants. The findings of the trial will be shared by the participant hospitals and disseminated through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02644434; Pre-results.

Coronary Aneurysm Formation After Bioresorbable Vascular Scaffold Implantation Resulting in Acute Myocardial Infarction

BACKGROUND Development of a true coronary aneurysm after percutaneous coronary intervention is a rare event, and a coronary aneurysm resulting in acute myocardial infarction is even rarer. Coronary aneurysm formation after bioresorbable vascular scaffold (BVS) implantation, eventually leading to thrombosis, embolization, and myocardial infarction, has never been reported before in the literature. CASE REPORT A 62-year-old man received an elective BVS for a proximal left anterior descending lesion. Two months later, he suffered from a non-ST-segment myocardial infarction. Coronary angiography showed a non-significant distal stent edge restenosis over the left anterior descending artery and a small aneurysm after the first diagonal branch. A XIENCE Xpedition stent was used to cover both lesions and final angiography showed shrinkage of the aneurysm and resolution of the restenosis. CONCLUSIONS Since a consensus or an established treatment guideline for treating coronary aneurysms is currently lacking, each case should be treated with caution and should be guided by the accompanying circumstances presented during the procedure. Although size, rapidity of growth, and the presence of high-risk features are the main determinants of whether to treat the lesion, the inherent risk of restenosis or reocclusion after use of drug-eluting stents and the coronary intervention procedure itself should also be taken into consideration. However, one must not take lightly a small coronary aneurysm when discovered, as the abnormal fluid dynamics inside may result in thrombus formation and embolization. The fundamental technical aspects of stent deployment, such as avoiding overstretching during lesion preparation, use of balloons shorter than the implanted device, and normal-to-normal or healthy "landing zone" of the device, should be followed.

Bioresorbable Scaffolds for Coronary Stenosis: When and How Based Upon Current Studies

PURPOSE OF REVIEW

First-generation bioresorbable scaffolds (BRS), largely represented by the poly-l-lactic acid (PLLA) ABSORB (Abbott Vascular, Temecula, Illinois, US), have demonstrated, in low to moderate lesion complexity, similar efficacy to current generation metallic drug-eluting stents. However, a trend toward more device thrombosis has been observed, especially when the scaffolds are used in off-label situations. In this review, we address the most relevant drawbacks of these devices and, based on the available scientific data, we visit the scenarios where there is more uncertainty about their indication, trying to identify the lesions/patients to whom this technology should be voided at its current stage of development.

RECENT FINDINGS

Based on available data from randomized trials and observational real world registries, the use of first generation BRS has been associated with a trend to higher acute/subacute thrombosis rate, which might be partially explained by the peculiarities related to their deployment technique, such as the need for precise vessel sizing and caution on post-dilation. Special attention should be paid when using these devices to treat small coronary arteries (<2.5 mm), long lesions requiring overlapping, and patients with acute coronary syndrome, in particular those with ST-segment elevation myocardial infarction (STEMI). Finally, the role of these devices is still uncertain in more complex lesion anatomies such as bifurcations, ostial lesions, etc. Although based on attractive clinical premises, the current indications of BRS are still limited by significant drawbacks observed in the first generation of these devices. Of note, new generation scaffolds are currently in preclinical and clinical evaluation and present features that might surpass most of these limitations.

Long-Term Clinical Outcomes After Bioresorbable Vascular Scaffold Implantation for the Treatment of Coronary In-Stent Restenosis: A Multicenter Italian Experience

BACKGROUND

Treatment of in-stent restenosis (ISR) is still challenging. In this setting, the use of bioresorbable vascular scaffold (BVS) seems attractive because it allows drug delivery combined with transient vessel scaffolding. We aimed to investigate the long-term results after BVS use in ISR lesions.

METHODS AND RESULTS

A prospective analysis was performed on all patients who underwent percutaneous coronary intervention with BVS implantation for ISR at 7 Italian Centers. Primary end point was the device-oriented composite end point (cardiac death, target vessel myocardial infarction, and ischemia-driven target lesion revascularization) at the longest follow-up available. From April 2012 to June 2014, 116 patients (127 lesions) underwent percutaneous coronary intervention for ISR with BVS implantation. Among the ISR lesions, the majority were drug-eluting stent ISR (78, 61.6%), de novo ISR (92, 72.4%), and diffuse ISR (81, 63.8%). Procedural success was achieved for all (100%) patients. No in-hospital death, myocardial infarction, or revascularization occurred. At 15 months of follow-up, the incidence of the device-oriented composite end point estimated with the Kaplan-Meier method was 9.1%. No significant differences were reported between drug-eluting stent and bare-metal stent ISR groups in terms of device-oriented composite end point (10.9% versus 6.4%; hazard ratio, 1.7; 95% confidence interval, 0.5-6.5; P=0.425) and its singular components (cardiac death: 2.8% versus 2.0%, hazard ratio, 1.3; 95% confidence interval, 0.1-14.1, P=0.843; target vessel myocardial infarction: 1.5% versus 0%, P=0.421; ischemia-driven target lesion revascularization: 9.6% versus 4.4%, hazard ratio, 2.3; 95% confidence interval, 0.5-10.8, P=0.309).

CONCLUSIONS

Our registry suggests that the use of BVS implantation for the treatment of complex drug-eluting stent and bare-metal stent ISR lesions might be associated with acceptable long-term clinical outcomes.

Expanded clinical use of everolimus eluting bioresorbable vascular scaffolds for treatment of coronary artery disease

BACKGROUND

Limited data are currently available on the performance of everolimus eluting bioresorbable vascular scaffold (BVS) for treatment of complex coronary lesions representative of daily practice.

METHODS

This is a prospective, mono-center, single-arm study, reporting data after BVS implantation in patients presenting with stable, unstable angina, or non-ST segment elevation myocardial infarction caused by de novo stenotic lesions in native coronary arteries. No restrictions were applied to lesion complexity. Procedural results and 12-month clinical outcomes were reported.

RESULTS

A total of 180 patients have been evaluated in the present study, with 249 treated coronary lesions. Device Success per lesion was 99.2%. A total of 119 calcified lesions were treated. Comparable results were observed among severe, moderate and noncalcified lesions in term of %diameter stenosis (%DS) (20.3 ± 10.5%, 17.8 ± 7.7%, 16.8 ± 8.6%; P = 0.112) and acute gain (1.36 ± 0.41 mm, 1.48 ± 0.44 mm, 1.56 ± 0.54 mm; P = 0.109). In bifurcations (54 lesions), side-branch ballooning after main vessel treatment was often performed (33.3%) with low rate of side-branch impairment (9.3%). A total of 29 cases with coronary total occlusions were treated. After BVS implantation %DS was not different from other lesion types (17.2 ± 9.4%, vs. 17.7 ± 8.6%; P = 0.780). At one year, all-cause mortality was reported in three cases. The rate of target lesion revascularization and target vessel revascularization was 3.3%. The rate of definite scaffold thrombosis was 2.6%.

CONCLUSIONS

The implantation of the everolimus eluting bioresorbable vascular scaffold in an expanded range of coronary lesion types and clinical presentations was observed to be feasible with promising angiographic results and mid-term clinical outcomes. © 2016 Wiley Periodicals, Inc.

A review of bioresorbable scaffolds: hype or hope?

In the field of percutaneous coronary intervention, the evolution of coronary metal stents has been well established for the past three decades, but research on bioresorbable scaffolds has only gained momentum in the recent past. Although second-generation drug-eluting metal stents are the gold standard for the treatment of obstructive coronary artery disease, a few drawbacks exist. The development of bioresorbable scaffolds is an attempt to overcome the limitations of metal stents. This review highlights the rationale for the bioresorbable scaffold, its properties and potential applications. It also focuses on the current evidence and concerns regarding the application of the bioresorbable scaffold in day-to-day practice.

Update on clinical evidence (Part II): A summary of the main post market studies

Bioresorbable vascular scaffolds (BVS, Absorb, Abbott Vascular, Santa Clara, CA) received the CE mark in October 2011, and were approved by the Food and Drug Administration in July 2016. After their introduction in clinical practice a broad amount of post-marketing clinical experience with BVS has been generated so far in Europe and outside the United States. The available BVS registries differ in many aspects, including their being single-center or multicenter, single-arm or controlled, sponsored or investigator-initiated, published or presented at a large-scale international meeting. This article provides an overview of clinical results of the main post-marketing studies of BVS available. © 2016 Wiley Periodicals, Inc.

The fate of small side branches following drug eluting stent implantation

OBJECTIVES

Although drug eluting stents (DES) have documented convenience in bifurcation lesions, possible unfavorable effects on small side branch ostium (SBO) remain a question. We aimed to explore the effects of DES on small jailed SBs (1.5-2.25 mm) which originated from the lesion on the main vessel and were not treated with either stenting or balloon dilatation.

METHODS

Angiographic data of 107 consecutive patients (129 SB) with Medina 1,1,1 or 1,1,0 lesions were evaluated at the time of procedure and at the follow-up.

RESULTS

Of all DES used, 70 (54.7%) was sirolimus-eluting, 39 (30.5%) was paclitaxel-eluting and 20 (14.8%) was zotarolimus-eluting. The diameter of SBs was 1.84 ± 0.41 mm with a stenosis of 20.7 ± 26.6% at SBO at baseline. The lesion at the SBO had progressed after the procedure when the pre vs postprocedure values and follow-up vs pre-procedure values are compared (20.7 ± 26.6% vs 29.4 ± 27.4%; p < 0.0001 and 25.4 ± 25.1 vs 20.7 ± 26.6%; p = 0.004 respectively). A significant reduction in stenosis was revealed over the follow-up (29.4 ± 27.4 vs 25.4 ± 25.1 respectively; p = 0.013). The severity of the disease at the SBO at baseline was the only parameter that affected the severity of SB stenosis in acute, longterm and follow-up. Additional parameters with influence on SB patency at different times were female gender, stent deployment with low pressure, cTFC of the main lesion, age, cTFC of the lesion, late loss index and the preprocedure TIMI flow grade of the SB.

CONCLUSIONS

Although there was a significant deterioration of SBO immediately after stenting, follow-up data showed that the lesion at SBO improved but remained worse than baseline.

Impact of overlapping on 1-year clinical outcomes in patients undergoing everolimus-eluting bioresorbable scaffolds implantation in routine clinical practice: Insights from the European multicenter GHOST-EU registry

BACKGROUND

Overlapping implantation of bioresorbable scaffolds (BRSs) are frequent in long coronary lesions. Its impact on clinical outcomes is unknown.

OBJECTIVE

To compare the clinical outcomes of patients treated with overlapping BRS with those patients treated with no-overlap BRS.

METHODS

We analyzed the 1-year clinical outcomes of 1,477 patients treated with BRS in the GHOST-EU registry, according to the implantation of overlapping BRS. Primary endpoint was patient oriented composite endpoint (PoCE) of: all-cause death, any myocardial infarction (MI) and any repeated revascularization. Scaffold thrombosis, according to Academic Research Consortium definition, was also analyzed.

RESULTS

A total of 320 (21.7%) patients were treated with overlapping BRS (overlap group), whereas the remaining 1,157 (78.3%) received no-overlap BRS (no-overlap group). The overlap group had significantly higher frequency of male sex, diabetes mellitus, stable angina, B2/C lesion type, SYNTAX score ≥22, lesion length >34 mm, use of intracoronary imaging guidance, pre- and postdilatation. At 1-year, there were no differences in PoCE between the overlap versus no-overlap group (18.4% vs. 18.2%; HR 1.07, [0.80-1.44]; P = 0.636), even after adjustment (HR 1.05, [0.48-2.20]; P = 0.904). Scaffold thrombosis rate did not differ either at one-month (1.3% vs. 1.5%, P = 0.769) or at 1-year (1.9% vs. 2.1%, P = 0.823).

CONCLUSIONS

In "Real-world" clinical practice, overlapping BRS does not appear to have an impact on clinical outcomes as compared to no-overlapping BRS. These preliminary data should be confirmed. © 2016 Wiley Periodicals, Inc.

The ABSORB bioresorbable vascular scaffold: A novel, fully resorbable drug-eluting stent: Current concepts and overview of clinical evidence

The advent of fully bioresorbable stent technology and specifically the ABSORB™, a bioresorbable vascular scaffold (BVS) stent, is heralded as breakthrough technology in the current era of percutaneous coronary interventions. This article reviews the current understanding of this technology along with the clinical evidence from trials and registries of ABSORB BVS that included patients with both simple as well as more complex "real-world" coronary lesions. In addition, considering the current limitations of this device-mostly associated with the mechanical properties of the polymeric scaffold structure-a review of guidelines on successful implantation of the ABSORB BVS is presented. Although expert feedback suggests extensive use of this device in routine clinical practice outside the United States despite a paucity of data on long-term safety in this setting, attention to procedural details and implantation technique is obligatory to achieve optimal clinical outcomes.

Everolimus-eluting bioresorbable vascular scaffolds implanted in coronary bifurcation lesions: Impact of polymeric wide struts on side-branch impairment

BACKGROUND

Limited data are available on bioresorbable vascular scaffolds (BVS) performance in bifurcations lesions and on the impact of BVS wider struts on side-branch impairment.

METHODS

Patients with at least one coronary bifurcation lesion involving a side-branch ≥2mm in diameter and treated with at least one BVS were examined. Procedural and angiographic data were collected and a dedicated methodology for off-line quantitative coronary angiography (QCA) in bifurcation was applied (eleven-segment model), to assess side-branch impairment occurring any time during the procedure. Two- and three-dimensional QCA were used. Optical coherence tomography (OCT) analysis was performed in a subgroup of patients and long-term clinical outcomes reported.

RESULTS

A total of 102 patients with 107 lesions, were evaluated. Device- and procedural-successes were 99.1% and 94.3%, respectively. Side-branch impairment occurring any time during the procedure was reported in 13 bifurcations (12.1%) and at the end of the procedure in 6.5%. Side-branch minimal lumen diameter (Pre: 1.45±0.41mm vs Final: 1.48±0.42mm, p=0.587) %diameter-stenosis (Pre: 26.93±16.89% vs Final: 27.80±15.57%, p=0.904) and minimal lumen area (Pre: 1.97±0.89mm(2) vs Final: 2.17±1.09mm(2), p=0.334), were not significantly affected by BVS implantation. Mean malapposed struts at the bifurcation polygon-of-confluence were 0.63±1.11.

CONCLUSIONS

The results of the present investigation suggest feasibility and relative safety of BVS implantation in coronary bifurcations. BVS wide struts have a low impact on side-branch impairment when considering bifurcations with side-branch diameter≥2mm.

Bioresorbable vascular scaffolds-time to vanish?

The fully bioabsorbable vascular scaffold (BVS) has been developed to reduce late adverse events after coronary stenting such as device thrombosis. The device consists of polylactic acid, which is gradually absorbed within the first few years after its implantation. The initial experience with the device in low-risk patients presenting with simple lesions was satisfying and generated optimism among interventional cardiologists by promising better patient outcomes. However, the unrestricted use of the device in patients presenting with a higher baseline risk and more complex lesions came at the cost of alarmingly high rates of early device thrombosis. The performance of the device largely depends on an optimal implantation technique, which differs from that employed with metallic drug-eluting stents due to the device's distinct physical propensity. Mid-term outcomes in large-scale randomized clinical trial were disappointing. Although its non-inferiority compared to metallic everolimus-eluting stents was formally met, there was a clear trend towards an increased occurrence of myocardial infarction and device thrombosis during the first year after device implantation. However, the BVS's putative advantages are expected to manifest themselves at long-term, that is 3 to 5 years after the device has been implanted. Evidence pertaining to these long-term outcomes is eagerly awaited.

Absorb bioresorbable stents for the treatment of coronary artery disease

Bioresorbable stents are considered to be the 'fourth revolution' in percutaneous coronary intervention. The first clinically available Absorb(®) bioresorbable device is made of poly-l-lactic acid polymer and elutes everolimus. The process of bioresorption is completed in 3 years. The introduction of this device into clinical practice went through several logical phases: first-in-man studies, randomized Absorb II study with moderately complex patients and lesions, registries of real life patient population and reports of challenging cases. The procedural results are excellent; many insights have been gained by intracoronary imaging. Intermediate-term outcomes are very encouraging both from imaging and from clinical perspectives. The issue of increased stent thrombosis rate was raised in one study, but other studies have been reassuring. Excellent lesion preparation, sizing and complete expansion of the Absorb device are crucial for optimal procedural and clinical results. Results of ongoing large randomized studies will determine the future role of this technology.

Bioresorbable scaffolds for treatment of coronary bifurcation lesions: Critical appraisal and future perspectives

Bioresorbable vascular scaffolds have been recently introduced as a novel paradigm for coronary artery disease treatment allowing temporary vessel support and drug delivery without indefinite coronary caging, potentially reducing the long-term limitation of metallic stents. The scientific community has rapidly embraced this concept and bioresorbable devices have been introduced in clinical practice. However, despite the fact that bifurcation lesions represent a large and challenging subset in the field of interventional cardiology, this subgroup of lesions have been avoided in the initial experience with bioresorbable scaffolds and clear recommendations on methodological approaches are lacking. In the present report, we describe the various techniques for bifurcation treatment with bioresorbable scaffolds and the theoretical advantages and disadvantages of this technology in different scenarios, with a glimpse to challenging subsets and possible complications. Therefore, we aim to provide experience based insights and practical guidance for bioresorbable scaffold implantation in bifurcation lesions. © 2016 Wiley Periodicals, Inc.

Beyond the early stages: insights from the ASSURE registry on bioresorbable vascular scaffolds

AIMS

Bioresorbable vascular scaffolds (BVS) have been available on the European market since November 2011. The ASSURE registry aims to investigate the safety and efficacy of the Absorb everolimus-eluting bioresorbable vascular scaffold in a real-world setting.

METHODS AND RESULTS

Patients with de novo coronary artery disease were consecutively enrolled at six German centres in this prospective registry. Outcomes were procedural success, cardiovascular death, myocardial infarction, and ischaemia-driven target lesion revascularisation (TLR). Angiographic parameters were assessed quantitatively and visual estimates of lesion dimensions were studied. One hundred and eighty-three patients were treated. In 128 (64.7%) lesions a complex ACC/AHA morphology was present. Procedural success was achieved in all patients. Acute gain was 1.54±0.51 mm, resulting in a final minimal lumen diameter (MLD), which met the baseline reference vessel diameter (RVD), although visual estimates overrated the RVD by 0.5±0.5 mm. Up to 12 months, one patient (0.5%) had died from gastrointestinal bleeding, three (1.7%) non-target vessel myocardial infarctions occurred, and five (2.8%) TLR had become necessary because of restenosis.

CONCLUSIONS

One-year results suggest that bioresorbable vascular scaffolds for de novo coronary artery disease are associated with favourable clinical and functional outcomes in routine clinical practice despite a visually overestimated RVD.

Plaque morphology predictors of side branch occlusion after provisional stenting in coronary bifurcation lesion: Results of optical coherence tomography bifurcation study (ORBID)

OBJECTIVES

The aim of this study was to identify the predictors of side branch (SB) ostial stenosis developed after provisional stenting of the main vessel (MV) using optical coherence tomography (OCT).

BACKGROUND

Provisional stenting remains the main approach to treatment of bifurcation lesions; however, it may result in the narrowing of SB ostium. There is little information about underlying plaque morphology of the MV lesion and its potential impact on the SB after provisional stenting.

METHODS

Patients with stable coronary disease with angiographic MV lesion not involving SB were included in a prospective single center study. The primary outcome was significant SB ostium stenosis (SBOS), defined as residual stenosis of >50% after MV stenting.

RESULTS

Thirty bifurcation lesions in 30 patients were analyzed in the study. Poststenting significant SBOS was observed in 30% of patients. The MV lesions with SBOS > 50% were characterized by a higher prevalence of lipid rich plaques (100 vs. 64%, p = 0.040) and spotty calcifications (60 vs. 0%, p = 0.005). Maximal lipid arcs were greater (257° vs. 132°, p = 0.001) and lipid volume index was higher (1380 vs. 574, p = 0.012) in the SBOS >50% group. Multivariate logistic regression analysis identified maximal lipid arc (odds ratio (OR): 1.014, p = 0.038) and the presence of lipid plaque contralateral to SB ostium (OR: 8.14, p = 0.046) before stenting as independent predictors of significant SBOS after PCI.

CONCLUSIONS

High lipid content of the MV lesion and a contralateral location of lipid in the bifurcation area may contribute to SBOS after provisional stenting. © 2016 Wiley Periodicals, Inc.