Effect of Wire Jailing at Side Branch in 1-Stent Strategy for Coronary Bifurcation Lesions

Impact of Side Branch Occlusion on Patient Outcomes After Bifurcation Percutaneous Coronary Intervention

BACKGROUND

The outcomes and characteristics of patients with side branch occlusion (SBO) after bifurcation percutaneous coronary intervention (PCI) have received limited study.

METHODS

We compared the procedural characteristics and outcomes of patients with and without SBO among 933 provisional bifurcation PCIs performed in 803 patients at six centers between 2014 and 2024.

RESULTS

The prevalence of SBO was 13% (n = 121). SBO patients had lower rates of hypertension, prior coronary artery bypass graft surgery (CABG), and prior PCI but higher angiographic complexity, with higher prevalence of left anterior descending artery stenoses, smaller side branch diameter and more severe side branch diameter stenoses. SBO patients were more likely to convert from provisional to two-stent strategies (24.8% vs 6.0%, p < 0.001), and to require plaque modification (39.7% vs 17.5%, p < 0.001) and side branch percutaneous transluminal coronary angioplasty (PTCA) (25.6% vs 12.9%, p < 0.001). SBO patients had lower technical (78.5% vs 96.2%, p < 0.001) and procedural (73.5% vs 92.2%, p < 0.001) success and similar in-hospital major adverse cardiovascular events (MACE), but higher dissection rates (7.1% vs 2.0%, p = 0.007). Patients with untreated SBO had similar in-hospital MACE with untreated SBO patients. During a median follow-up of 1,095 days patients with treated SBO (83.9%, n = 94) had lower follow-up MACE (hazard ratio [HR]: 0.29, 95% confidence intervals [CI]: 0.10, 0.84, p = 0.023) and mortality (HR: 0.22, CI: 0.065, 0.755, p = 0.016) compared with patients with untreated SBO.

CONCLUSIONS

SBO occurs in 13% of provisional PCIs. SBO patients had more complex coronary lesions and worse follow-up clinical outcomes if the SBO was left untreated.

Benefit of Systematic "Jailed Wire" Technique for Bifurcation Provisional Stenting. A CABRIOLET Substudy

BACKGROUND

Jailed wire (JW) in the side branch (SB) is recommended during coronary bifurcation provisional stenting, but there is uncertainty about the real benefit. Our objective was to evaluate the benefit of a JW technique in the Coronary Artery Bifurcation Revascularization Without kIssing ballOon infLation by rEpoT (CABRIOLET) registry.

METHODS

In CABRIOLET, which included 500 patients, we compared the primary composite end point of a poor final SB angiographic result (of Thrombolysis in Myocardial Infarction (TIMI) flow < III, dissection grade > B, thrombosis, residual stenosis > 70%, or additional SB stenting) whether JW was performed or not. On the basis of the usual operator practice, we also compared a systematic JW strategy: operators known to place JW frequently (> 75% performed), to a conditional strategy: selective JW practices (< 20% of JW).

RESULTS

JW was performed in 251 patients (50.2%), without significant baseline clinical and angiographic differences compared with those who received no JW. JW was associated with higher primary end point (15.1% vs 8.4%; P < 0.05), and increased fluoroscopy time and contrast volume (15.9 ± 7.3 minutes and 181 ± 62 mL vs 13.3 ± 6.5 minutes and 161 ± 74 mL; P < 0.05). JW was performed in 12.1% of patients (26 of 214) in the conditional JW group and 78.7% (225 of 286) in systematic group. The primary end point was similar in both strategies (11.2% and 12.2%; P = 0.78), although with greater fluoroscopy time and contrast volume for systematic JW (180 ± 57 mL and 15.3 ± 7.5 minutes vs 162 ± 79 mL and 13.7 ± 6.1 minutes; P < 0.05). There was no difference in 1-year major adverse cardiovascular events depending on whether JW was performed or not and between conditional or systematic strategies.

CONCLUSIONS

In a large registry, JW was associated with poorer final SB angiographic results than no JW. Final SB angiographic results were similar between conditional or systematic JW strategies.

Research on the Current Application Status of Magnesium Metal Stents in Human Luminal Cavities

The human body comprises various tubular structures that have essential functions in different bodily systems. These structures are responsible for transporting food, liquids, waste, and other substances throughout the body. However, factors such as inflammation, tumors, stones, infections, or the accumulation of substances can lead to the narrowing or blockage of these tubular structures, which can impair the normal function of the corresponding organs or tissues. To address luminal obstructions, stenting is a commonly used treatment. However, to minimize complications associated with the long-term implantation of permanent stents, there is an increasing demand for biodegradable stents (BDS). Magnesium (Mg) metal is an exceptional choice for creating BDS due to its degradability, good mechanical properties, and biocompatibility. Currently, the Magmaris® coronary stents and UNITY-BTM biliary stent have obtained Conformité Européene (CE) certification. Moreover, there are several other types of stents undergoing research and development as well as clinical trials. In this review, we discuss the required degradation cycle and the specific properties (anti-inflammatory effect, antibacterial effect, etc.) of BDS in different lumen areas based on the biocompatibility and degradability of currently available magnesium-based scaffolds. We also offer potential insights into the future development of BDS.

Late stent thrombosis as a complication of T and small protrusion bifurcation stenting: a case report

Background

A case of stent thrombosis as a complication of coronary bifurcation stenting is described. We review potential complications of bifurcation stenting and established guidelines.

Case summary

A 64-year-old man presented with a non-ST segment elevation myocardial infarction. High-sensitivity troponin I peaked at 99 000 ng/L (normal <5). He previously had coronary stenting for stable angina when residing in another country 2 years previously. Coronary angiography revealed no significant stenosis with TIMI 3 flow in all vessels. Cardiac magnetic resonance imaging demonstrated a left anterior descending artery (LAD) territory regional motion abnormality, late gadolinium enhancement consistent with recent infarction, and a left ventricular apical thrombus. Repeat angiography and intravascular ultrasound (IVUS) confirmed bifurcation stenting at the junction of the LAD and second diagonal (D2) with protrusion of several millimetres of the uncrushed proximal segment of the D2 stent in the LAD vessel lumen. There was under-expansion of the LAD stent in the mid-vessel and stent malapposition in the proximal LAD, extending into the distal left main stem coronary artery and involving the ostium of the left circumflex coronary artery. Percutaneous balloon angioplasty was performed along the length of the stent, including an internal crush of the D2 stent. Coronary angiography confirmed a uniform expansion of the stented segments and TIMI 3 flow. Final IVUS confirmed full stent expansion and apposition.

Discussion

This case highlights the importance of provisional stenting as a default strategy and familiarity with procedural steps in bifurcation stenting. Furthermore, it emphasizes the benefit of intravascular imaging for lesion characterization and stent optimization.

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.

Jailed pressure wire technique for coronary bifurcation lesions: structural damage and clinical outcomes

INTRODUCTION AND OBJECTIVES

The use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes.

METHODS

We enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up.

RESULTS

Significant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P<.001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P=.001; stenting, 0.0% vs 2.6%, P=.104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HR_adj, 0.42; 95%CI, 0.10-1.73; P=.229).

CONCLUSIONS

Pressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique.

Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club

Stepwise layered provisional stenting (PS) is the most commonly used strategy to treat coronary bifurcation lesions (CBL). The term 'stepwise layered' emphasises the versatility of this approach that allows the adjustment of the procedure plan according to the CBL complexity, starting with stent implantation in one branch and implantation of a second stent in the other branch only when required. A series of refinements have been implemented over the years to facilitate the achievement of predictable procedural results using this approach. However, despite its simplicity and versatility, operators using this technique require full knowledge of the pitfalls of each procedural step. Part I of this 16^th European Bifurcation Club consensus paper provides a detailed step-by-step overview of the pitfalls and technical troubleshooting during the implantation of the first stent using the PS strategy for the treatment of CBL.