Stenting of Unprotected Distal Left Main Coronary Artery Bifurcation Stenoses Using Modified Crush Technique with Double Kissing Balloon Inflation (Sleeve Technique): Immediate Procedure Result and Early Clinical Outcome

Long-term clinical and angiographic outcomes of the sleeve technique on non-left-main coronary bifurcation lesions

AIMS

The purpose of this study was to examine the long-term results of the sleeve technique, which is a modification of the crush technique and capable of increasing the success of final kissing balloon inflation (FKB) in the treatment of non-left-main coronary bifurcation lesions.

METHODS AND RESULTS

Forty-five patients with 45 non-left-main coronary bifurcation stenoses were treated with drug-eluting stents (DES) using the sleeve technique and prospectively evaluated. Follow-up angiography was performed on 41 patients (91%) at nine months. The mean age of patient was 65 years with predominance of male (73%); FKB was successfully performed in all patients. Post-procedure myocardial infarction was observed in four patients, leading to an in-hospital major adverse cardiac event (MACE) rate of 9%. At angiographic follow-up, the late loss in the main vessel and side-branch was 0.18+/-0.26 mm and 0.29+/-0.27 mm, respectively. Binary angiographic restenosis was seen in two patients (4.7%) at main vessel and one patient (2.4%) at side-branch. At 1-year follow-up, there were two non-cardiac deaths and three patients needed revascularisation.

CONCLUSIONS

The use of the sleeve technique and DES in the treatment of non-left-main coronary bifurcation lesions is associated with a low angiographic restenosis, particularly at side branch ostium, and long-term safety.

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Background:

There is a noticeable decline in the number of patients who undergo coronary artery revascularization procedures. The change is definite as it is reported by many centers around the world. This trend is of great concern to cardiac surgeons because of its impact on their practice, its adverse effect on training and the degree of uncertainty it throws into future of the specialty.

Methods:

The data of the cardiac catheterization laboratory at the King Fahad Cardiac Center in the period between 1986 and 2006 was examined looking at the changing pattern of management of patients who undergo cardiac catheterization.

Results:

In the early years, angioplasty was attempted in around 10% of patients leaving the rest for surgical consideration or medical therapy. Currently only 15% of patients who undergo selective coronary angiography are referred for surgery. The majority are offered angioplasty and stenting. The trend is towards more catheter-based interventions and less towards surgery.

Conclusions:

Our findings are in agreement with the general consensus about the specialty. Cardiac surgeons should perhaps consider acquiring new skills which may be outside the operating room. Adding catheter based intervention particularly in valves to cardiac surgery training would be a bonus for the future surgeons that will give them the necessary edge to meet the new challenges. It is incumbent on the leaders in the field to establish a clear strategy for the future.

Mini-Abstract:

Impact of advances in invasive cardiology on cardiac surgery, based on actual analysis of the pattern of referrals to surgery of over two decades.

Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): Immediate procedure result and short-term clinical outcomes

BACKGROUND

Sleeve technique is a modified version of crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter.

OBJECTIVES

The aim of this study was to examine the feasibility, safety, and early clinical outcomes of sleeve technique in stenting different types (de novo, in-stent restenotic or in-stent bifurcation) of coronary bifurcation lesions at different locations.

METHODS

From August 2005 to May 2006, 41 consecutive patients with symptomatic, nonleft-main coronary bifurcation stenoses of diameter narrowing >or=50% were treated with two-stent strategy, using sleeve technique.

RESULTS

The mean age was 63.6 +/- 11.6 years with male predominance (70.7%). High prevalence of diabetes mellitus (31.7%), total occlusion (22.0%), and multi-vessel disease (65.9%) was observed in this cohort. Intravenous abciximab was given in 35 (85.4%) patients. Final kissing balloon inflation was successfully performed in all patients. The minimal luminal diameter in main vessel and side branch was increased from 0.97 +/- 0.53 mm and 0.81 +/- 0.45 mm to 2.76 +/- 0.34 mm and 2.22 +/- 0.35 mm, respectively. The mean procedure time was only 66.6 +/- 24.6 min. There was one (2.4%) case of subacute stent thrombosis presented as non-Q-wave myocardial infarction at day 3 postprocedure. The resultant in-hospital and 30-day major adverse cardiac event rate were both 2.4%.

CONCLUSIONS

Sleeve technique is a feasible and efficient approach in stenting of coronary bifurcation stenoses.