An Angiographic Tool for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention

Jailed high-pressure balloon technique is superior to jailed wire technique in protecting side branch of coronary bifurcation lesions

Objectives. This study investigated the influence of higher pressure protection with a small diameter balloon of side branch (SB) on bifurcation lesions. Background. Of the different coronary stent implantation techniques, the modified jailed balloon technique has become a viable option for bifurcation lesions. However, there was no detailed study on the relationship between the balloon inflation pressure of the main vessel (MV) and SB. Methods. In this study, we collected information of patients who underwent percutaneous coronary intervention (PCI) for bifurcated lesions between March 2019 and December 2022. They were divided into two groups according to the operation way: active jailed balloon technique (A-JBT) group and jailed wire technique (JWT) group. Results. A total of 216 patients were enrolled. The A-JBT group had a larger SB stenosis diameter (1.53 ± 0.69 vs. 0.95 ± 0.52, p < .001), the lower degree of stenosis (44.34 ± 18.30 vs. 63.69 ± 17.34, p < .001) compared to the JWT group. However, the JWT group had a higher incidence of SB occlusion (18.0% vs. 1.9%, p < .001) compared to the A-JBT group. Nevertheless, the success rate for both groups was 100%. Conclusions. This novel high inflation pressure and small diameter balloon approach we propose has significant advantages. There is a lower rate of SB occlusion and SB dissection, which is more cost-effective and provides better clinical outcomes for the patient. This method should be considered in the future for treating bifurcation lesions.

Risk Assessment of Side Branch Compromise After Coronary Bifurcation Stenting - A Substudy of the 3D-OCT Bifurcation Registry

BACKGROUND

Side branch (SB) occlusion during bifurcation stenting is a serious complication. This study aimed to predict SB compromise (SBC) using optical coherence tomography (OCT).Methods and Results: Among the 168 patients who enrolled in the 3D-OCT Bifurcation Registry, 111 bifurcation lesions were analyzed to develop an OCT risk score for predicting SBC. SBC was defined as worsening of angiographic SB ostial stenosis (≥90%) immediately after stenting. On the basis of OCT before stenting, geometric parameters (SB diameter [SBd], length from proximal branching point to carina tip [BP-CT length], and distance of the polygon of confluence [dPOC]) and 3-dimensional bifurcation types (parallel or perpendicular) were evaluated. SBC occurred in 36 (32%) lesions. The parallel-type bifurcation was significantly more frequent in lesions with SBC. The receiver operating characteristic curve indicated SBd ≤1.77 mm (area under the curve [AUC]=0.73, sensitivity 64%, specificity 75%), BP-CT length ≤1.8 mm (AUC=0.83, sensitivity 86%, specificity 68%), and dPOC ≤3.96 mm (AUC=0.68, sensitivity 63%, specificity 69%) as the best cut-off values for predicting SBC. To create the OCT risk score, we assigned 1 point to each of these factors. As the score increased, the frequency of SBC increased significantly (Score 0, 0%; Score 1, 8.7%; Score 2, 28%; Score 3, 58%; Score 4, 85%; P<0.0001).

CONCLUSIONS

Prediction of SBC using OCT is feasible with high probability.

Comparison of angiographic change in side-branch ostium after drug-coated balloon vs. drug-eluting stent vs. medication for the treatment of de novo coronary bifurcation lesions

OBJECTIVES

Data on side-branch (SB) ostial effect after drug-coated balloon (DCB) treatment in the context of de novo coronary bifurcation lesions are limited. We aimed to investigate the angiographic outcomes of SB ostium after DCB treatment compared with drug-eluting stents (DESs) implantation in the main vessel (MV) or optimal medical therapy (OMT) for the treatment of de novo coronary bifurcation lesions.

METHODS

Serial angiographic changes in the SB ostium were compared between DCB, DES, and medication alone for MV treatment. Δ value was calculated by subtracting the follow-up value from the pre-procedure value.

RESULTS

A total of 132 bifurcation lesions were included for analysis (44 lesions in DCB group; 38 lesions in DES group; 50 lesions in OMT group). The minimal lumen diameter (MLD) of SB ostium showed an increase at follow-up in the DCB group, whereas a decrease was observed in both the DES and OMT groups (ΔMLD: -0.16 ± 0.45 mm for DCB group vs. 0.50 ± 0.52 mm for DES group vs. 0.08 ± 0.38 mm for OMT group, p < 0.001). The diameter stenosis (DS) of SB ostium showed a marked decrease at follow-up in the DCB group, in contrast to an increase observed in both the DES and OMT groups (ΔDS: 8.01 ± 18.96% for DCB group vs. -18.68 ± 18.60% for DES group vs. -2.05 ± 14.58% for OMT group, p < 0.001).

CONCLUSIONS

In de novo coronary bifurcation lesions, DCB treatment on the MV demonstrated favorable angiographic outcomes in the SB ostium at 6-9 month follow-up compared to DES implantation or OMT.

A New Scoring System Predicting Side-Branch Occlusion in Patients Undergoing Left Main Bifurcation Intervention: The LM V-RESOLVE Score

BACKGROUND

The risk of side-branch (SB) occlusion is pivotal for decision making of stenting strategies during unprotected left main (LM) bifurcation percutaneous coronary intervention (PCI). Accordingly, this study aimed to develop a scoring system for predicting SB occlusion during unprotected LM bifurcation PCI.

METHODS

A total of 855 consecutive patients undergoing unprotected LM bifurcation PCI with provisional strategy at Fuwai Hospital from January 2014 to December 2016 were recruited. A prediction model was selected by means of all-subsets logistic regression, and a multivariable risk score (Left Main Visual Estimation for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention [LM V-RESOLVE]) was then established with incremental weights attributed to each component variable based on its estimate coefficients. SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction (TIMI) flow grade or absence of flow in SB after main vessel (MV) stenting.

RESULTS

SB occlusion occurred in 19 LM bifurcation lesions (2.22%). In multivariable model, 3 variables, including MV/SB diameter ratio, MV plaque ipsilateral to SB, and baseline diameter stenosis of SB, were independent predictors for SB occlusion (model C-statistic 0.829, 95% confidence interval [CI] 0.735-0.923, with good calibration). The risk score had a C-statistics of 0.830 (95% CI 0.738-0.923) with good calibration. Satisfactory discriminative ability of the risk score was also preserved in external validation (C-statistic 0.794, 95% CI 0.691-0.896).

CONCLUSIONS

The LM bifurcation-specific novel scoring system, LM V-RESOLVE, based on 3 simple baseline angiographic findings, could help to rapidly discriminate lesions at risk of SB occlusion during LM bifurcation PCI.

Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations

The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

Multislice computerized tomography coronary angiography can be a comparable tool to intravascular ultrasound in evaluating "true" coronary artery bifurcations

Aim

Coronary bifurcation atherosclerosis depends on its angles, flow, and extensive branching. We investigate the ability of CT coronary angiography (CTCA) to determine atherosclerotic plaque characteristics of "true" bifurcation compared with intravascular ultrasound (IVUS) and the influence on side branch (SB) fate after percutaneous coronary intervention (PCI).

Methods and results

The study included 70 patients with 72 "true" bifurcations. Most of the bifurcations were in the left anterior descending-diagonal (Dg) territory [50 out of 72 (69.4%)]. Longitudinal plaque evaluation at the polygon of confluence [carina and 5 mm proximal and distal in the main branch (MB)] showed that carina side MB and SB plaque had occurred with the lowest incidence with fibro-lipid structure (115 ± 63 HU and 89 ± 73 HU, p < 0.001 for all). Bland-Altman analysis showed a discrepancy in measuring mainly the lumen area between CTCA and IVUS in proximal MB [lumen 5.10, 95% CI (95% confidence interval, 4.53-5.68) mm2, p < 0.001; vessel -1.42, 95% CI (-2.63 to -0.21) mm2, p = 0.023], carina MB [lumen 3.74, 95% CI (3.37-4.10) mm2, p < 0.001; vessel -0.48, 95% CI (-1.45 to 0.48) mm2, p = 0.322], and distal MB [lumen 4.72, 95% CI (4.27-5.18) mm2, p < 0.001; vessel 0.62, 95% CI (-0.53 to 1.77) mm2, p = 0.283]. A significant correlation existed between average plaque density on CTCA with a percentage of calcified plaque on IVUS tissue characterization (proximal r = 0.307/p = 0.024, carina 0.469/0.008, distal 0.339/0.024, minimal lumen diameter 0.318/0.020). Circumferential plaque in the proximal MB segment remained an independent predictor of SB compromise [OR 3.962 (95% CI 1.170-13.418)].

Conclusion

Detection and characterization of atherosclerotic plaque by CTCA in non-left main "true" coronary bifurcations can provide useful information about bifurcation anatomy and plaque distribution that can predict outcomes after provisional stenting, thus guiding the interventional strategy to bifurcation PCI.

High triglyceride-glucose index predicts cardiovascular events in patients with coronary bifurcation lesions: a large-scale cohort study

BACKGROUND

Coronary bifurcation lesion, as a complex coronary lesion, is associated with higher risk of long-term poor prognosis than non-bifurcation lesions. The triglyceride-glucose (TyG) index has been shown to predict cardiovascular (CV) events in patients with coronary artery disease (CAD). However, the prognostic value of the TyG index in patients with bifurcation lesions who are at high risk of CV events remains undetermined. Therefore, this study aimed to investigate the association between the TyG index and CV events in patients with bifurcation lesions.

METHODS

A total of 4530 consecutive patients with angiography-proven CAD and bifurcation lesions were included in this study from January 2017 to December 2018. The TyG index was calculated as Ln [fasting triglyceride (mg/dL) × fasting plasma glucose (mg/dL)/2]. Patients were assigned into 3 groups according to TyG tertiles (T) (T1: <8.633; T2: 8.633-9.096 and T3: ≥9.096). The primary endpoint was CV events, including CV death, nonfatal myocardial infarction and nonfatal stroke at 3-year follow-up. Restricted cubic spline (RCS) analysis, Kaplan-Meier curves and Cox proportional hazard models were used to investigate the associations between the TyG index and study endpoints.

RESULTS

During a median follow-up of 3.1 years, 141 (3.1%) CV events occurred. RCS analysis demonstrated a linear relationship between the TyG index and events after adjusting for age and male sex (non-linear P = 0.262). After multivariable adjustments, elevated TyG index (both T2 and T3) was significantly associated with the risk of CV events (hazard ratio [HR], 1.68; 95% confidence interval [CI],1.06-2.65; HR, 2.10; 95%CI, 1.28-3.47, respectively). When study patients were further stratified according to glycemic status, higher TyG index was associated with significantly higher risk of CV events in diabetic patients after adjusting for confounding factors (T3 vs. T1; HR, 2.68; 95%CI, 1.17-6.11). In addition, subgroup analysis revealed consistent associations of the TyG index with 3-year CV events across various subgroups. Furthermore, adding the TyG index to the original model significantly improved the predictive performance.

CONCLUSIONS

High TyG index was associated with CV events in patients with bifurcation lesions, suggesting the TyG index could help in risk stratification and prognosis in this population.

Impact of coronary bifurcation angle on stent malapposition in a randomized comparison between proximal optimization technique followed by side branch dilatation and kissing balloon inflation

Background

The impact of coronary bifurcation angle (BA) on incomplete stent apposition (ISA) after crossover stenting followed by side branch (SB) intervention has not been established.

Methods

A total of 100 crossover stentings randomly treated with proximal optimization technique followed by short balloon dilation in the SB (POT-SBD group, 48 patients) and final kissing balloon technique (KBT group, 52 patients) were analyzed in the PROPOT trial. Major ISA with maximum distance > 400 μm and its location was determined using optical coherence tomography before SB intervention and at the final procedure. The BA was defined as the angle between the distal main vessel and SB. Optimal POT was determined when the difference in stent volume index between the proximal and distal bifurcation was greater than the median value (0.86 mm3/mm) before SB intervention.

Result

Major ISA was more frequently observed in the POT-SBD than in the KBT group (35% versus 17%, p < 0.05). In the POT-SBD group, worsening ISA after SBD was prominent at the distal bifurcation. The BA was an independent predictor of major ISA (odds ratio 1.04, 95% confidence interval 1.00-1.07, p < 0.05) with a cut-off value of 59.5° (p < 0.05). However, the cases treated with optimal POT in the short BA (<60°) indicated the lowest incidence of major ISA. In the KBT group, BA had no significant impact.

Conclusion

A wide BA has a potential risk for the occurrence of major ISA after POT followed by SBD in coronary bifurcation stenting.

The 17th expert consensus document of the European Bifurcation Club - techniques to preserve access to the side branch during stepwise provisional stenting

Provisional stenting has become the default technique for the treatment of most coronary bifurcation lesions. However, the side branch (SB) can become compromised after main vessel (MV) stenting and restoring SB patency can be difficult in challenging anatomies. Angiographic and intracoronary imaging criteria can predict the risk of side branch closure and may encourage use of side branch protection strategies. These protective approaches provide strategies to avoid SB closure or overcome compromise following MV stenting, minimising periprocedural injury. In this article, we analyse the strategies of SB preservation discussed and developed during the most recent European Bifurcation Club (EBC) meetings.

Impact of technique on bifurcation stent outcomes in the European Bifurcation Club Left Main Coronary Trial

BACKGROUND

Techniques for provisional and dual-stent left main bifurcation stenting require optimization.

AIM

To identify technical variables influencing procedural outcomes and periprocedural myocardial infarction following left main bifurcation intervention.

METHODS

Procedural and outcome data were analyzed in 438 patients from the per-protocol cohort of the European Bifurcation Club Left Main Trial (EBC MAIN). These patients were randomized to the provisional strategy or a compatible dual-stent extension (T, T-and-protrude, or culotte).

RESULTS

Mean age was 71 years and 37.4% presented with an acute coronary syndrome. Transient reduction of side vessel thrombolysis in myocardial infarction flow occurred after initial stent placement in 5% of procedures but was not associated with periprocedural myocardial infarction. Failure to rewire a jailed vessel during any strategy was more common when jailed wires were not used (9.5% vs. 2.5%, odds ratio [OR]: 6.4, p = 0.002). In the provisional cohort, the use of the proximal optimization technique was associated with less subsequent side vessel intervention (23.3% vs. 41.9%, OR: 0.4, p = 0.048). Side vessel stenting was predominantly required for dissection, which occurred more often following side vessel preparation (15.3% vs. 4.4%, OR: 3.1, p = 0.040). Exclusive use of noncompliant balloons for kissing balloon inflation was associated with reduced need for side vessel intervention in provisional cases (20.5% vs. 38.5%, OR: 0.4, p = 0.013), and a reduced risk of periprocedural myocardial infarction across all strategies (2.9% vs. 7.7%, OR: 0.2, p = 0.020).

CONCLUSION

When performing provisional or compatible dual-stent left main bifurcation intervention, jailed wire use is associated with successful jailed vessel rewiring. Side vessel preparation in provisional patients is linked to increased side vessel dissection requiring stenting. Use of the proximal optimization technique may reduce the need for additional side vessel intervention, and noncompliant balloon use for kissing balloon inflation is associated with a reduction in both side vessel stenting and periprocedural myocardial infarction.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02497014.

Coronary Bifurcation Lesions

Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) for the treatment of coronary bifurcation lesions (CBLs) is still technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. Although provisional stenting (PS) is considered as the preferred strategy for most of the CBLs, a systematic two-stent technique (double kissing [DK] crush) should be considered in patients with complex left main (LM)-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation should be used to optimize CBLs intervention. PCI with DES for the treatment of CBLs is technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. PS is a default strategy for most of the CBLs. Double kissing (DK) crush is associated with better clinical outcomes compared with PS in patients with complex LM-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation are useful tools to guide the treatment of CBLs. The use of drug-coated balloons in CBLs needs further data to support the clinical benefits.

Impact of Clinical and Lesion Features on Outcomes After Percutaneous Coronary Intervention in Bifurcation Lesions

Background

Bifurcation percutaneous coronary intervention (PCI) is associated with higher risk of clinical events.

Objectives

This study aimed to determine clinical and lesion features that predict adverse outcomes, and to evaluate the differential prognostic impact of these features in patients undergoing PCI for bifurcation lesions.

Methods

We analyzed 5,537 patients from the BIFURCAT (comBined Insights From the Unified RAIN and COBIS bifurcAtion regisTries) registry. The primary outcome was major adverse cardiac events (MACE) at 2-year follow-up; secondary outcomes included hard endpoints (all-cause death, myocardial infarction) and lesion-oriented clinical outcomes (LOCO) (target-vessel myocardial infarction, target lesion revascularization). The least absolute shrinkage and selection operator (LASSO) model was used for feature selection.

Results

During the 2-year follow-up period, MACE occurred in 492 patients (8.9%). The LASSO model identified 5 clinical features (old age, chronic renal disease, diabetes mellitus, current smoking, and left ventricular dysfunction) and 4 lesion features (left main disease, proximal main branch disease, side branch disease, and a small main branch diameter) as significant features that predict MACE. A combination of all 9 features improved the predictive value for MACE compared with clinical and lesion features (area under the receiver-operating characteristics curve: 0.657 vs 0.636 vs 0.581; P < 0.001). For secondary endpoints, the clinical features had a higher impact than lesion features on hard endpoints, whereas lesion features had a higher impact than clinical features on LOCO.

Conclusions

In bifurcation PCI, 9 features were associated with MACE. Clinical features were predominant predictors for hard endpoints, and lesion features were predominant for predicting LOCO. Clinical and lesion features have distinct values, and both should be considered in bifurcation PCI.

Impact of coronary bifurcation angle on the pathogenesis of atherosclerosis and clinical outcome of coronary bifurcation intervention–A scoping review

Background

A coronary bifurcation stenting is still a challenging issue due to frequent restenosis and stent thrombosis even with drug-eluting stents. The bifurcation angle (BA) between a main vessel and a side branch is one of the crucial determinants of coronary flow and shear stress that affect the plaque distribution. Previous bench and clinical studies have evaluated the impact of the BA between the proximal main vessel and the side branch (Angle A) and the BA between the distal main vessel and the side branch (Angle B) on the clinical outcomes of bifurcation stenting. However, the impact has not yet been fully elucidated due to a lack of statistical power or different manner of the assessment of BA.

Objectives

To analyze the published studies on coronary artery BA, the modalities used for assessment, and the impact of BA on interventions and attempt to define the pre-procedural protocols.

Data sources

A scoping review was performed using the Joanna Briggs Institute Methodology. A total of 52 relevant references were selected from PubMed, Cochrane Library, and CINAHL databases and categorized into three topic areas.

Results and conclusions

A wider Angle A is associated with the increased likelihood of carina shift and a wider Angle B, with that of side branch occlusion. A wider Angle B promotes stent malapposition and deformation in the side branch ostium and has been reported as an independent predictor of major adverse cardiac events after bifurcation stenting; however, improvement of the drug-eluting stent, refinement of the stenting technique, and accurate 3-dimensional assessment may attenuate the adverse clinical impact of a wider BA.

Implications of key findings

Assessment of the BA is necessary to predict the effect of bifurcation intervention procedure on the stent configuration and coronary flow at the bifurcated vessels. This will help to optimize stent selection and the stenting technique.

Percutaneous coronary intervention of bifurcation lesions

Bifurcation coronary artery disease is common as the development of atherosclerosis is facilitated by altered endothelial shear stress. Multiple anatomical and physiological factors need to be considered when treating bifurcation lesions. To achieve optimal results, various stenting techniques have been developed, each with benefits and limitations. In this state-of-the-art review we describe technically important characteristics of bifurcation lesions and summarise the evidence supporting contemporary bifurcation techniques.

Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations

The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

Functional comparison of different jailed balloon techniques in treating non-left main coronary bifurcation lesions

BACKGROUND

There is a paucity of data comparing functional difference between active jailed balloon technique (A-JBT) and conventional jailed balloon technique (C-JBT) in treating non-left main coronary bifurcation lesions (CBLs).

METHODS

In this retrospective cohort study, we consecutively enrolled 232 patients with non-left main CBLs who underwent percutaneous coronary intervention (PCI) using JBTs between January 2018 and March 2019. Among them, 191 patients entered the final analysis with 12-months angiographic follow-up. We stratified patients into A-JBT group (130 patients) and C-JBT group (61 patients). The functional analysis by Murray law-based quantitative flow ratio (μQFR) and Seattleanginaquestionnaire (SAQ) were performed to compare the two techniques.

RESULTS

Compared with C-JBT group, A-JBT group observed a lower abrupt (0.8% vs. 11.1%, p = 0.002) and final SB occlusion (0 vs. 7.9%, p = 0.005). Meanwhile, A-JBT group had a significantly higher μQFR of side branch (SB) both post-PCI and 12-months follow-up (median [interquartile range (IQR)]: 0.91 (0.86-0.96) vs. 0.82 (0.69-0.92), p < 0.001; median [IQR]: 0.95 (0.89-0.98) vs. 0.85 (0.74-0.93), p < 0.001) than C-JBT group. Besides, A-JBT group gained a μQFR improvement at follow-up period compared with post-PCI data (median [IQR]: 0.95 [0.89-0.98] vs. 0.91[0.86-0.96] of SB, p < 0.001) and a higher SAQ scores at 12-months follow-up compared with C-JBT group (p < 0.001).

CONCLUSIONS

Compared with C-JBT, A-JBT provided excellent SB protection during MV stenting and improved the SB functional blood flow as well as the angina relief even after 12 months.

Fundamentals of percutaneous coronary bifurcation interventions

Coronary bifurcation lesions (CBLs) account for 15%-20% of all percutaneous coronary interventions. The complex nature of these lesions is responsible for poorer procedural, early and late outcomes. This complex lesion subset has received great attention in the interventional cardiac community, and multiple stenting techniques have been developed. Of these, the provisional stenting technique is most often the default strategy; however, the elective double stenting (EDS) technique is preferred in certain subsets of complex CBLs. The double kissing crush technique may be the preferred EDS technique because of its efficacy and safety in comparative trials; however, this technique consists of many steps and requires training. Many new methods have recently been added to the EDS techniques to provide better stent scaffolding and to reduce early and late adverse outcomes. Intravascular imaging is necessary to determine the interventional strategy and postinterventional results. This review discusses the basic concepts, contemporary percutaneous interventional technical approaches, new methods, and controversial treatment issues of CBLs.

Side Branch is the Main Determinant Factor of Bifurcation Lesion Complexity: Critical Review with a Proposal Based on Single-centre Experience

Although bifurcation stenting can be often managed with a simple provisional approach, in some settings, more complex techniques are appropriate. Based on our clinical experience and on data from literature, we propose a simple algorithm that may assist in selecting cases for elective double stenting. We found that, when the side branch is of adequate dimensions and affected by significant disease (longer than 10 mm and/or with presence of ostial calcifications), double stenting is associated with a lower incidence of adverse events, compared with provisional stenting.

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.

KLF2 Mediates the Suppressive Effect of Laminar Flow on Vascular Calcification by Inhibiting Endothelial BMP/SMAD1/5 Signaling

[Figure: see text].

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.

Inflation Pressure in Side Branch during Modified Jailed Balloon Technique Does Not Affect Side Branch Outcomes

Objectives

This study aimed to investigate the optimal jailed balloon inflation in the side branch during the modified jailed balloon technique for bifurcated lesions.

Background

The modified jailed balloon technique is one of the effective techniques to minimize the emergence of side branch (SB) compromise by preventing plaque or carina shifting during a single stent strategy in the main vessel with provisional SB treatment. However, there are no detailed studies on the method of optimal jailed balloon inflation.

Methods

We analyzed 51 consecutive patients who underwent percutaneous coronary intervention (PCI) for bifurcated lesions with a modified jailed balloon technique between September 2018 and December 2020. These 51 patients were divided into two groups according to the magnitude of inflation pressure of the jailed balloon: a higher pressure (HP) group and lower pressure (LP) group.

Results

No significant differences in procedural outcomes were observed between the two groups. The findings of SB compromise were relatively common with our procedure (30.0% in the HP group; 33.3% in the LP group). The patterns of SB compromise such as dissection or stenosis increase were observed at similar frequencies between them. In particular, SB dissection was noted in the SB lesion with some plaque burden, irrespective of the magnitude of the jailed balloon inflation pressure. Univariate analysis showed that calcification in the main vessel and SB lesion length was significantly associated with SB compromise. Finally, all PCI procedures were successfully completed without any provisional stent deployment in SB.

Conclusions

We speculate that lesion characteristics rather than the PCI procedural factors may be critical determinants to cause SB compromise.

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.

Asia Pacific consensus document on coronary bifurcation interventions

Coronary bifurcation intervention is common but complex. Progress in this field has been made in recent years with considerable contribution from the Asia Pacific (APAC) region. However, the standard of practice varies across the APAC region due to differences in culture, socioeconomic state and healthcare set-up. Practice may also differ from the rest of the world. Hence, a panel of experts was invited to discuss topics relevant to bifurcation intervention in order to make a concerted effort to achieve consensus that is applicable within the region and in line with available evidence.

The Cone Flare Crush Modified-T (CFCT) stenting technique for coronary artery bifurcation lesions

Background

The present study is a prospective observational single arm clinical investigation, with parallel bench test interrogation, aimed at investigating the technical feasibility, safety and clinical outcomes with the cone flare crush modified-T (CFCT) bifurcation stenting technique. Bifurcation percutaneous coronary intervention (PCI) remains an area of ongoing procedural evolution. More widely applicable and reproducible techniques are required.

Methods

From April 2018 until March 2019, 20 consecutive patients underwent bifurcation PCI using the CFCT technique with a Pt-Cr everolimus drug-eluting stent with a bioresorbable polymer. Exercise stress echocardiography was performed at 12-month follow-up. The primary outcome was a composite of cardiac related mortality, myocardial infarction, target lesion/vessel revascularization and stroke. Safety secondary endpoints included bleeding, all-cause mortality and stent thrombosis.

Results

All patients underwent a successful CFCT bifurcation procedure with no complications to 30-day follow-up. One patient met the primary endpoint requiring target lesion revascularization at 9 months for stable angina. There were no other primary or secondary outcome events in the cohort. There were no strokes, deaths, stent thrombosis or myocardial infarction during the follow-up period. The mean CCS score improved from 2.25 to 0.25 (p < 0.0001). Optical coherence tomography (OCT) and bench test findings indicated optimal side branch ostial coverage and minimal redundant strut material crowding the neo-carina.

Conclusions

The CFCT technique appears to be a safe, efficacious and feasible strategy for managing coronary artery bifurcation disease. Expanded and randomized datasets with longer term follow-up are required to further explore confirm this feasibility data. (ANZCTR ID: ACTRN12618001145291).

Optimal strategy for side branch treatment in patients with left main coronary bifurcation lesions

INTRODUCTION AND OBJECTIVES

There are no guidelines regarding the most appropriate approach for provisional side branch (SB) intervention in left main (LM) bifurcation lesions.

METHODS

The present prospective, randomized, open-label, multicenter trial compared conservative vs aggressive strategies for provisional SB intervention during LM bifurcation treatment. Although the trial was designed to enroll 700 patients, it was prematurely terminated due to slow enrollment. For 160 non-true bifurcation lesions, a 1-stent technique without kissing balloon inflation was applied in the conservative strategy, whereas a 1-stent technique with mandatory kissing balloon inflation was applied in the aggressive strategy. For 46 true bifurcation lesions, a stepwise approach was applied in the conservative strategy (after main vessel stenting, SB ballooning when residual stenosis> 75%; then, SB stenting if residual stenosis> 50% or there was a dissection). An elective 2-stent technique was applied in the aggressive strategy. The primary outcome was a 1-year target lesion failure (TLF) composite of cardiac death, myocardial infarction, or target lesion revascularization.

RESULTS

Among non-true bifurcation lesions, the conservative strategy group used a smaller amount of contrast dye than the aggressive strategy group. There were no significant differences in 1-year TLF between the 2 strategies among non-true bifurcation lesions (6.5% vs 4.9%; HR, 1.31; 95%CI, 0.35-4.88; P=.687) and true bifurcation lesions (17.6% vs 21.7%; HR, 0.76; 95%CI, 0.20-2.83; P=.683).

CONCLUSIONS

In patients with a LM bifurcation lesion, conservative and aggressive strategies for a provisional SB approach have similar 1-year TLF rates.

Szabo 2-stent technique for coronary bifurcation lesions: procedural and short-term outcomes

BACKGROUND

Provisional 1-stent technique is currently regarded as the default approach for the majority of bifurcation lesions. Nonetheless, 2-stent techniques may be required for complex bifurcations with high compromise risk or fatal consequences of side branch (SB) occlusion. Limitations exist in current approaches, as stents gap, multiple metal layers and stent malapposition caused by imprecise placement with fluoroscopic guide and intrinsic technical defects. This study was designed to investigate the effectiveness of the novel Szabo 2-stent technique for coronary bifurcation lesions.

METHODS

In the Szabo 2-stent technique, one stent is precisely implanted at the SB ostium with Szabo technique resulting in a single strut protruding into the main vessel (MV). After MV rewiring and SB guidewire withdrawal, another stent is implanted in MV followed by proximal optimization technique, SB rewiring, and final kissing inflation (FKI).

RESULTS

The technique tested successfully in silicone tubes (n = 9) with: procedure duration, 31.2 ± 6.8 min; MV and SB rewiring time, 26.8 ± 11.2 s and 33.3 ± 15 s; easy FKI; and 2.3 ± 0.5 balloons/procedure. Bifurcation lesions (n = 22) were treated with angiographic success in MV and SB, respectively: increased minimal lumen diameter (0.63 ± 0.32 mm to 3.20 ± 0.35 mm; 0.49 ± 0.37 mm to 2.67 ± 0.25 mm); low residual stenosis (12.4 ± 2.4%; 12.4 ± 2.3%); and intravascular ultrasound confirmed (n = 19) full coverage; minimal overlap and malapposition; minimal lumen area (2.4 ± 1.2 mm²; 2.1 ± 1.0 mm²); plaque burden (78.1 ± 11.3%; 71.6 ± 15.5%); and minimal stent area (9.1 ± 1.6 mm²; 6.1 ± 1.3 mm²). Periprocedural cardiac troponin increased in 1 asymptomatic patient without electrocardiographic change. There was no target lesion failure (cardiac death, myocardial infarction, target lesion revascularization) at 6-month follow-up.

CONCLUSIONS

The Szabo 2-stent technique for bifurcation lesions provided acceptable safety and efficacy at short-term follow-up.

Comparison of Computed Tomography Angiography Versus Invasive Angiography to Assess Medina Classification in Coronary Bifurcations

The Medina classification is used to determine the presence of significant stenosis (≥50%) within each of the 3 arterial segments of coronary bifurcation in invasive coronary angiography (ICA). The utility of coronary computed tomography angiography (coronary CTA) for assessment of Medina classification is unknown. We aimed to compare the agreement and reproducibility of Medina classification between ICA and coronary CTA, and evaluate its ability to predict side branch (SB) occlusion following percutaneous coronary intervention (PCI). In total 363 patients with 400 bifurcations were included, and 28 (7%) SB occlusions among 26 patients were noted. Total agreement between CTA and ICA for assessment of Medina class was poor (kappa = 0.189), and discordance between both modalities was noted in 253 (63.3%) lesions. Larger diameter ratio between main vessel and SB in CTA, and larger bifurcation angle in ICA were independently associated with discordant Medina assessment. Whereas the interobserver agreement on Medina classification in CTA was moderate (kappa = 0.557), only fair agreement (kappa = 0.346) was observed for ICA. Finally, Medina class with any proximal involvement of main vessel and SB (1.X.1) on CTA or ICA was the most predictive of SB occlusion following PCI with no significant differences between both modalities (area under the curve 0.686 vs 0.663, p = 0.693, respectively). In conclusion, Medina classification was significantly affected by the imaging modality, and coronary CTA improved reproducibility of Medina classification compared with ICA. Both CTA and ICA-derived Medina class with any involvement of the proximal main vessel and SB was predictive of SB occlusion following PCI.

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).

Noncalcified plaque burden quantified from coronary computed tomography angiography improves prediction of side branch occlusion after main vessel stenting in bifurcation lesions: results from the CT-PRECISION registry

OBJECTIVES

To assess the incremental value of quantitative plaque features measured from computed tomography angiography (CTA) for predicting side branch (SB) occlusion in coronary bifurcation intervention.

METHODS

We included 340 patients with 377 bifurcation lesions in the post hoc analysis of the CT-PRECISION registry. Each bifurcation was divided into three segments: the proximal main vessel (MV), the distal MV, and the SB. Segments with evidence of coronary plaque were analyzed using semi-automated software allowing for quantitative analysis of coronary plaque morphology and stenosis. Coronary plaque measurements included calcified and noncalcified plaque volumes, and corresponding burdens (respective plaque volumes × 100%/vessel volume), remodeling index, and stenosis.

RESULTS

SB occlusion occurred in 28 of 377 bifurcation lesions (7.5%). The presence of visually identified plaque in the SB segment, but not in the proximal and distal MV segments, was the only qualitative parameter that predicted SB occlusion with an area under the curve (AUC) of 0.792. Among quantitative plaque parameters calculated for the SB segment, the addition of noncalcified plaque burden (AUC 0.840, p = 0.003) and low-density plaque burden (AUC 0.836, p = 0.012) yielded significant improvements in predicting SB occlusion. Using receiver operating characteristic curve analysis, optimal cut-offs for noncalcified plaque burden and low-density plaque burden were > 33.6% (86% sensitivity and 78% specificity) and > 0.9% (89% sensitivity and 73% specificity), respectively.

CONCLUSIONS

CTA-derived noncalcified plaque burden, when added to the visually identified SB plaque, significantly improves the prediction of SB occlusion in coronary bifurcation intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03709836 registered on October 17, 2018.

Reduction of Outflow Tract Obstruction After PCI to Proximal LAD in a Patient With HOCM

We present a patient with hypertrophic obstructive cardiomyopathy and accompanying aortic valve stenosis who had a myocardial infarction with a significant proximal left anterior descending coronary artery stenosis. The primary percutaneous coronary intervention resulted in a notable improvement in the left ventricular outflow tract gradient and global longitudinal strain. (Level of Difficulty: Beginner.)

The efficacy of modified jailed balloon technique for true bifurcation lesions

OBJECTIVE

To evaluate the short-, long-term clinical and angiographic outcomes after treatment of true bifurcation lesions using a modified jailed balloon technique (MJBT).

BACKGROUND

Percutaneous coronary intervention (PCI) for true bifurcation lesions has high risk for adverse events. Side branch (SB) occlusion is one of the most serious complications. Therefore, novel strategies to avoid SB occlusion during main branch stenting and to keep its patency are important.

METHODS AND RESULTS

Between February 2015 and February 2018, 328 patients with 349 true bifurcation lesions underwent PCI using MJBT. True bifurcation lesions were defined as Medina classifications (1.1.1), (1.0.1) or (0.1.1) lesions. We investigated the procedural and long-term clinical outcomes. Furthermore, angiographic outcomes were assessed at follow-up diagnostic angiography. The mean age of patients was 71.6 ± 9.9 years. Procedural success was achieved in all patients; postoperative SB occlusion was noted in only one patient (0.3%). The cumulative incidence of all-cause death was 23 patients (7.0%) in the follow-up period (median 717 days). Target lesion revascularization was performed in 19 patients (5.8%) with 23 lesions (6.6%), and 0.6% of myocardial infarction and 0% of definite stent thrombosis were observed. Angiographic follow-up was performed in 243 patients (74.1%); the percent diameter stenosis in SB was not significantly different between after the index procedure and follow-up angiography.

CONCLUSIONS

This MJBT is safe and effective in preserving SB patency for true bifurcation lesions. Furthermore, long-term clinical and angiographic outcomes after MJBT are feasible.

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.

Prediction of side branch occlusions in percutaneous coronary interventions by coronary computed tomography: the CT bifurcation score as a novel tool for predicting intraprocedural side branch occlusion

AIMS

Side branch (SB) occlusion is one of the major technical hurdles in the percutaneous coronary intervention (PCI) of bifurcation lesions. Our aim was to investigate whether preprocedural coronary computed tomography angiography (CCTA) could predict intraprocedural SB occlusion.

METHODS AND RESULTS

A total of 260 bifurcation lesions were enrolled from 246 patients who underwent CCTA before elective bifurcation PCI. Quantitative plaque analysis was performed in the main vessel (MV) and SB. Intraprocedural SB occlusion occurred in 42 lesions (16%). These lesions were characterised by SB plaque, calcified plaque in the MV, low attenuation plaque in the main proximal segment or SB, and a ratio of MV to SB ostium area >4.3, which constituted a point-based CT bifurcation score. The CT bifurcation score was cross-validated, outperforming any angiographic Medina classification or RESOLVE score (c-statistics=0.749 versus 0.631 to 0.551; p<0.05 for all). The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CT bifurcation score ≥1 were 90%, 42%, 23%, 96%, and 50%, respectively.

CONCLUSIONS

Comprehensive CCTA assessment was able to predict intraprocedural SB occlusion better than the current angiographic classification or scoring system. The CT bifurcation score may thus be a helpful guide for selecting the optimal bifurcation PCI strategy.

[Hot issues in bifurcation lesions PCI in 2019]

Coronary bifurcations are involved in 15-20% of all percutaneous coronary interventions (PCI) and remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate as well as long-term cardiac events. The optimal management of bifurcation lesions is still debated but involves careful assessment, planning and a sequential provisional approach. The preferential strategy for PCI of bifurcation lesions remains to use main vessel (MV) stenting with a proximal optimisation technique (POT) and provisional side branch (SB) stenting as a preferred approach. Final kissing balloon inflation is not recommended in all cases. In the minority of lesions where two stents are required, careful deployment and optimal expansion are essential to achieve a long-term result. Intracoronary imaging techniques (IVUS, OCT) and FFR are useful endovascular tools to achieve optimal results.

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.

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

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

Modified balloon-stent kissing technique avoid side-branch compromise for simple true bifurcation lesions

Background

Coronary bifurcation remains one of the most challenging lesion subsets in interventinal cardiology. Provisional stenting (PS) is the dominate technique for bifurcation lesions, but the key problem is the deterioration of side branch. Balloon-stent kissing technique (BSKT) as a new systematic approach which is based on modified jailed balloon technique is applied to improve the procedure success. In our center, we proposed a modified balloon-stent kissing technique(M-BSKT), which routine usage of proximal optimizing technique (POT) after rewiring was added as an optimization step to BSKT. Thus, whether M-BSKT for addressing simple true coronary bifurcation lesions can provide more benefits in intra-operation effect and long term outcomes is still unknown.

Methods

A cohort of 120 consecutive patients underwent Percutaneous Coronary Intervention (PCI) with simple true coronary bifurcation lesions satisfied the criteria were included in this retrospective, single-center registry. To assemble a cohort with similar baseline characteristics, a 1:1 propensity-matched score was used. The primary outcomes were the rate of device and procedural success, the situation of side branch (SB) after main vessel (MV) inflation and the complications during intra-operative. The secondary outcomes were the clinical prognosis at 12 months such as rehospitalization for unstable angina and MACEs.

Results

Before propensity matching, there were no significant differences in primary and secondary outcomes between two groups. After propensity-matched was used, 68 patients with similar propensity scores were included. At immediate procedural, M-BSKT was associated with a lower risk of SB deterioration and the application of final kissing balloon inflation (FKBI)[P = 0.036]. For ACS patients, besides the significant differences of immediate SB deterioration [P = 0.014] and FKBI application [P = 0.033], the incidence of TIMI flow< 3 in the PS was statistically significant higher than M-BSKT [P= 0.042]. The prognosis at 12 months such as rehospitalization for unstable angina and MACEs were similar for two groups [P = 0.613].

Conclusion

These observations prove that the M-BSKT enables side branch to be better protected in simple true bifurcation lesions, by a narrow margin. It may improve the angiographic outcomes about side branch deterioration and final kissing balloon performing compared with PS, especially in ACS patients. However, long-term clinical outcomes did not differ between patients treated for M-BSKT and PS at 12 months.

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.

A novel &ldquo;nano-crush&rdquo; technique for the management of coronary bifurcation lesions: in vitro bench test analysis and preliminary report on real-world clinical evaluation in patients with one-year angiographic follow-up

AIMS

Although provisional stenting with a single drug-eluting stent has proven clinical efficacy in the treatment of bifurcation stenosis, some patients may require two stents. We propose a novel technique, called "nano-crush", which is easy to perform and can be used in all bifurcation angles.

METHODS AND RESULTS

The feasibility of the nano-crush technique was confirmed in an in vitro bench test and intravascular ultrasound (IVUS) study. Subsequently, 42 patients with de novo coronary bifurcation stenosis were treated by this novel procedure using drug-eluting stents at our centre between January 2008 and December 2015. We experienced procedural success in all (100%) patients without any complications. The primary efficacy endpoint of the one-year incidence of major adverse cardiac events (MACE) was noted in three (7.14%) patients, comprising one case of cardiac death at nine months post procedure and two cases of repeat revascularisation due to in-stent restenosis. There were no cases of periprocedural myocardial infarction or stent thrombosis. Angiographic follow-up at one year indicated intact stent patency in the remaining patients.

CONCLUSIONS

Initial experience with the nano-crush technique demonstrates that it can be performed easily without any procedural complications. Further, the angiographic and clinical follow-up indicates that the nano-crush technique is associated with acceptable clinical outcomes in a real-world scenario.

Treatment strategies for coronary bifurcation lesions made easy in the current era by introduction of the BIFURCAID app

Coronary bifurcation lesions account for 15-20% of all percutaneous coronary interventions. Percutaneous revascularization of these lesions is technically challenging and results in lower success rates than nonbifurcation lesions. There are unique procedural considerations and techniques that are employed in the percutaneous revascularization of these lesions. Our objective is to define the procedural complexities of treating coronary bifurcation lesions and describe the leading provisional and dedicated two stent techniques used to optimize procedural and clinical results, as described in the BIFURCAID app.

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.