Dedicated bifurcation paclitaxel-eluting stent BiOSS Expert® in the treatment of distal left main stem stenosis

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.

Use of the Bifurcation Optimization Stent System in cardiological settings

The bifurcation optimization stent system (BiOSS) LIM (Balton, Warsaw, Poland) stent is a dedicated coronary bifurcation stent. Its unique construction is developed in accordance with the anatomy of the coronary bifurcations, thus eliminating the carina displacement as a mechanism of side branch ostium compromise. Since its development in 2008, the BiOSS stent underwent several changes with the latest version created of sirolimus eluting cobalt-chromium stent. Results from registries and randomized clinical trials showed that implantation of the BiOSS stent is safe and effective with comparable results for major adverse cardiovascular events (MACE) and target lesion revascularisation rates between the BiOSS and regular drug-eluting stent groups. This stent provides alternative for coronary bifurcation treatment, especially when there is a large difference in diameter between the main vessel and the main branch.

Angiographic Restenosis in Coronary Bifurcations Treatment with Regular Drug Eluting Stents and Dedicated Bifurcation Drug-Eluting BiOSS Stents: Analysis Based on Randomized POLBOS I and POLBOS II Studies

Aim

The marked variation in bifurcation anatomy has brought about an ongoing search for stents specifically constructed for coronary bifurcations. This study aimed to analyze the angiographic restenosis prevalence and patterns and predictors of different patterns in dedicated bifurcation BiOSS® vs. current generation drug-eluting stents implanted in coronary bifurcation lesions based on data from two clinical trials POLBOS I and II.

Methods

Dedicated bifurcation BiOSS® stents were compared with drug-eluting stents (DES) in patients with stable coronary artery disease (CAD) or nonST elevation acute coronary syndrome (NSTE-ACS) (POLBOS I: paclitaxel eluting BiOSS® Expert vs. DES; POLBOS II: sirolimus eluting BiOSS® LIM vs. DES). Provisional T-stenting was the default treatment. Morphological pattern of in-stent restenosis according to the modified Mehran classification adopted for bifurcation lesions was assessed with bifurcation dedicated quantitative coronary angiographic software (CAAS 5.11, Pie Medical Imaging BV, the Netherlands).

Results

In total, 445 patients (222 patients in BiOSS group and 223 patients in DES group) were included into the analysis. In BiOSS group 24 cases of angiographic restenosis (10.8%) were recorded, and in DES group-17 cases (7.6%) at 12 months follow-up (angiographic control rate at follow-up-90.3%). In the BiOSS group most frequent medina classification in restenotic cases was 0.0.1 (25%), whereas in DES-0.0.1 and 0.1.1 (23.5% each). In multivariate regression analysis proximal optimization technique was associated with the lowest chance for restenosis (OR 0.15, 95% CI 0.06-0.33), whereas diabetes on insulin was associated with the highest risk of restenosis (OR 4.21, 95% CI 1.48-11.44).

Conclusions

The angiographic restenosis pattern and rate was similar between BiOSS stents and DES in coronary bifurcation lesions.

Sirolimus-eluting BiOSS LIM dedicated bifurcation stent in the treatment of unprotected distal left main stenosis

BACKGROUND

Proximal optimization technique (POT) has been proposed to adapt the conventional drug-eluting stent (DES) with the fractal anatomy of the bifurcation. However, only few DES are labeled for post-expansion beyond 5.0 mm. Furthermore, recrossing in the side branch (SB) through the main vessel (MV) stent cells may be challenging.

OBJECTIVES

To compare the sirolimus-eluting, balloon-expandable dedicated bifurcation stent BiOSS LIM DES versus the second generation DES in the treatment of distal unprotected left main coronary arteries (ULMCAs) lesions.

METHODS

Forty-two consecutive patients with distal ULMCA lesions were treated with the BiOSS LIM (BiOSS LIM group) in our center. A matched-group of patients treated with second-generation DES was selected from our database (Control group). The primary endpoint was the procedural complication rate, including (a) SB occlusion, defined as intraprocedural TIMI flow grade <3 immediately after MV stenting; and/or (b) trouble in SB access, defined as the need of ≥2 guidewires or a failure to recross in the SB trough the MV stent cells. The need of POT in the two groups was also analyzed.

RESULTS

The primary endpoint occurred in four (9.5%) patients in the BiOSS LIM group and in 13 (31%) in the Control group (p = 0.028; OR = 4.25; 95% confidence interval: 1.25-14.43). POT was performed more often in the Control group (71% vs. 35%; p = 0.004).

CONCLUSIONS

Compared to conventional DES, the BiOSS LIM stent (1) facilitates SB recrossing and (2) fits well with the fractal anatomy of the left main bifurcation.

Rationale and design of the randomized, multicenter, open-label, controlled POLBOS 3 trial aimed to compare regular drug-eluting stents versus the dedicated coronary bifurcation sirolimus-eluting BiOSS LIM C stent

INTRODUCTION

Coronary bifurcations are encountered in about 15% to 20% of percutaneous coronary interventions (PCIs). They are considered technically challenging and associated with worse clinical outcomes than nonbifurcation lesions. The BiOSS LIM C is a dedicated bifurcation balloon expandable stent made of cobalt-chromium alloy (strut thickness 70 μm) releasing sirolimus (1.4 μg/mm) from the surface of a biodegradable coating comprised of a copolymer of lactic and glycolic acids.

CONCLUSION

The aim of the randomized, multicenter, open-label, controlled POLBOS III trial is to compare BiOSS LIM C with limus second-generation drug-eluting stents (DES) in the treatment of non-left main stem coronary bifurcations (ClinicalTrials.gov NCT03548272).

Comparative assessment of three drug eluting stents with different platforms but with the same biodegradable polymer and the drug based on quantitative coronary angiography and optical coherence tomography at 12-month follow-up

The aim of this study was to compare neointima proliferation in three drug-eluting stents (DES) produced by the same company (Balton, Poland) which are covered with a biodegradable polymer and elute sirolimus (concentration: 1.0 and 1.2 µg/mm²), but have different stent platforms and strut thickness: stainless steel Prolim^® (115 µm) and BiOSS LIM^® (120 µm) and cobalt-chromium Alex^® (70 µm). We analyzed data of patients with quantitative coronary angiography (QCA) and optical coherence tomography (OCT) at 12 months from BiOSS LIM Registry, Prolim Registry and Alex OCT clinical trial. There were 56 patients enrolled, in whom 29 Prolim^® stents were deployed, in 11-BiOSS LIM^® and in 16-Alex stents. The late lumen loss was the smallest in Prolim^® subgroup (0.26 ± 0.17 mm) and did not differ from Alex^® subgroup (0.28 ± 0.47 mm). This parameter was significantly bigger in BiOSS^® subgroup (0.38 ± 0.19 mm; p < 0.05). In OCT analysis there was no statistically significant difference between Prolim^® and Alex^® subgroups in terms of mean neointima burden (24.6 ± 8.6 vs. 19.27 ± 8.11%) and neointima volume (28.16 ± 15.10 vs. 24.51 ± 17.64 mm³). In BiOSS^® group mean neointima burden (30.9 ± 6.2%) and mean neointima volume (44.9 ± 4.9 mm³) were significantly larger. The morphological analysis revealed that in most cases in all groups the neointima was homogenous with plaque presence only around stent struts. In the QCA and OCT analysis regular DES (Prolim^® and Alex^®) obtained similar results, whereas more pronounced response from the vessel wall was found in the BiOSS^® subgroup.

Long-term effectiveness and safety of the sirolimus-eluting BiOSS LIM® dedicated bifurcation stent in the treatment of distal left main stenosis: an international registry

AIMS

The aim of this study was to assess prospectively the effectiveness and safety of a new version of the dedicated bifurcation BiOSS stent, the sirolimus-eluting BiOSS LIM, for the treatment of distal left main (LM) stenosis.

METHODS AND RESULTS

This was a prospective international registry which enrolled patients with NSTE-ACS or stable angina. Provisional T-stenting was the mandated strategy. The primary endpoint was the cumulative rate of cardiac death, myocardial infarction (MI) and target lesion revascularisation (TLR) at 12 months. Twelve-month quantitative coronary angiography endpoints included late lumen loss and percent diameter stenosis. A total of 74 patients with distal LM stenosis were enrolled. Seventy-three of the 74 patients (aged 67±9 years, 23% women, 20.3% NSTE-ACS, SYNTAX score 22.4±4.4) were successfully treated with the BiOSS LIM stent, with additional side branch placement of regular DES in 11 patients (14.9%). Periprocedural MI occurred in one (1.4%) patient. The 12-month MACE rate was 9.5% without cardiac death or definite stent thrombosis. TLR and MI rates were 6.8% (n=5) and 2.7% (n=2), respectively.

CONCLUSIONS

The use of the BiOSS LIM dedicated bifurcation stent for the treatment of distal LM stenosis was feasible and safe, with promising long-term clinical effectiveness.

Assessment of vascular response to BiOSS LIM C® stents vs Orsiro® stents in the porcine coronary artery model

AIMS

The optimal treatment strategy for coronary bifurcation lesions is still unknown. The aim of the study was to assess applicability of the new cobalt-chromium version of the sirolimus-eluting dedicated bifurcation BiOSS^® LIM C stent in comparison with regular sirolimus-eluting Orsiro^®  stent in a porcine coronary model.

METHODS

A total of 13 BiOSS^® LIM C stents and 6 Orsiro^® stents were implanted in normal nonatherosclerotic porcine straight coronary arteries of six animals using 1.2:1.0 stent-to-artery ratio. Stent geometry and morphology were evaluated by Faxitron imaging. Vascular response was assessed by quantitative coronary angiography (QCA), optical coherence tomography (OCT), and histological analyses.

RESULTS

OCT performed at 28 days confirmed that all stents were patent with no signs of thrombus. In morphometric analysis, no differences between groups regarding stent diameter (P=.141), neointima area (P=.247), % area stenosis (P=.293), or % diameter stenosis (P=.069) were observed. Also, no significant differences were noted between groups regarding their histopathology scores. The injury and inflammation scores were low (mean grade<1) in all groups.

CONCLUSIONS

The novel BiOSS^® LIM C stent demonstrates good short-term vascular effects in a porcine coronary bifurcation model which are comparable with Orsiro^® stents.

Regular drug-eluting stents versus the dedicated coronary bifurcation sirolimus-eluting BiOSS LIM® stent: the randomised, multicentre, open-label, controlled POLBOS II trial

AIMS

The aim of the POLBOS II randomised trial was to compare any regular drug-eluting stents (rDES) with the dedicated bifurcation sirolimus-eluting stent BiOSS LIM for the treatment of coronary bifurcation lesions. The secondary aim was to study the effect of final kissing balloon inflation (FKBI) on clinical outcomes.

METHODS AND RESULTS

Between December 2012 and December 2013, 202 patients with stable coronary artery disease or non-ST-segment elevation acute coronary syndrome were randomly assigned 1:1 to treatment of the coronary bifurcation lesions either with the BiOSS LIM stent (n=102) or with an rDES (n=100). Coronary re-angiography was performed at 12 months. The primary endpoint was the composite of cardiac death, myocardial infarction (MI), and target lesion revascularisation (TLR) at 12 months. The target vessel was located in the left main in one third of the cases (35.3% in BiOSS and 38% in rDES). Side branch treatment was required in 8.8% (rDES) and 7% (BiOSS). At 12 months, the cumulative MACE incidence was similar in both groups (11.8% [BiOSS] vs. 15% [rDES, p=0.08]), as was the TLR rate (9.8% vs. 9% [p=0.8]). The binary restenosis rates were significantly lower in the FKBI subgroup of the BiOSS group (5.9% vs. 11.8%, p<0.05).

CONCLUSIONS

MACE rates as well as TLR rates were comparable between the BiOSS LIM and rDES. At 12 months, cumulative MACE incidence was similar in both groups (11.8% vs. 15%), as was the TLR rate (9.8% vs. 9%). Significantly lower rates of restenosis were observed in the FKBI subgroup of the BiOSS group.

12-month intravascular ultrasound observations from BiOSS® first-in-man studies

The aim of this study was to analyze the difference in neointima pattern assessed by intravascular ultrasound (IVUS) between two dedicated bifurcation stents, BiOSS® Expert and BiOSS® LIM at 12-month follow-up. This manuscript reports IVUS findings obtained from the analysis of patients enrolled into first-in-man registries initially assessing the BiOSS Expert® (paclitaxel) and BiOSS LIM® (sirolimus) stents. Quantitative angiographic analysis was performed pre, post-stenting, and at follow-up. IVUS examination was performed at 12 months. There were analyzed 34 cases (BiOSS Expert® 11 patients, BiOSS LIM® 23 patients). Procedural characteristics in the two groups were similar, except for rates of main vessel predilatation and FKB/POT, which were higher in BiOSS® LIM group, 54.5 % vs 73.9 % (P < 0.05) and 0 % vs 39.1 % (P < 0.05), respectively. When comparing late lumen loss (LLL) for both stents there were significantly bigger values for main vessel and main branch in the BiOSS® Expert group, but not in side branch. Intravascular ultrasound examination showed that in the BiOSS LIM® group comparing with the BiOSS Expert® group there was lower neointima burden in the whole stent (24.7 ± 7.5 % vs 19.4 ± 8.6 %, P < 0.05) as well as in main vessel (22.8 ± 5.6 % vs 16.9 ± 6.1 %, P < 0.05) and main branch (36.1 ± 6.5 % vs 27.6 ± 8.7 %, P < 0.05), but not at the level of bifurcation (15.1 ± 3.8 % vs 13.6 ± 5.4 %, P = NS). In addition, we found that final kissing balloon/proximal optimization technique (FKB/POT) was associated with significantly smaller value of LLL in main vessel (0.24 ± 0.09 mm vs 0.32 ± 0.14 mm, P < 0.05), which in IVUS analysis resulted in smaller neointima burden in main vessel (13.7 ± 3.9 % vs 18.9 ± 4.45 %, P < 0.05) as well as at the bifurcation site (12.6 ± 4.1 % vs 14.1 ± 2.4 %, P < 0.05). The obtained results suggest that neointima proliferation was the largest in main branches of both stents assessed in quantitative angiography (LLL) as well as in IVUS (neointima burden) and the neointima increase was smaller in BiOSS LIM® stents than in BiOSS Expert® stents. Moreover, the middle part of the stent seems to not to be associated with excessive neointima proliferation and more aggressive protocol of implantation with the use FKB/POT seems to decrease this process.

Practical based approach to left main bifurcation stenting

Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method.

Dedicated stents for distal left main stenting

Left main (LM) coronary bifurcation lesions have different anatomic features from non-LM bifurcation lesions. Dedicated bifurcation devices might facilitate percutaneous coronary intervention (PCI) of LM bifurcations and improve procedural and clinical outcomes. In this review we will discuss the available clinical data on dedicated bifurcation devices for the treatment of LM bifurcation lesions. Furthermore, we will try to discuss all the theoretical advantages and potential drawbacks of these devices in terms of their use in the LM.

Novel sirolimus-eluting stent Prolim® with a biodegradable polymer in the all-comers population: one year clinical results with quantitative coronary angiography and optical coherence tomography analysis

BACKGROUND

The aim of this study was to assess the safety and the efficacy of the novel sirolimus-eluting Prolim® stent with a biodegradable polymer in the all-comers population.

METHODS

We prospectively enrolled all patients with stable coronary artery disease or acute coronary syndrome treated with Prolim® stent between January and December 2013 in two interventional cardiology centers in Poland. Angiographic control was planned at 12 months, in which 15 % of patients (randomly chosen) underwent optical coherence tomography imaging. The primary end-point was the cumulative rate of cardiac death, myocardial infarction, and target lesion revascularization at 12 months.

RESULTS

There were 204 patients enrolled, in whom 238 Prolim® stents were deployed (1.17 stent per patient). The mean age was 68 ± 10 years and 32.8 % were females. The examined stent was implanted in 5.9 % in STEMI patients, in 21.6 % - in NSTE-ACS and in 72.5 % - in patients with stable coronary artery disease. The Prolim® stent was most frequently implanted in right coronary artery (38.2 %) followed by left anterior descending artery (34.0 %). The cumulative major adverse cardiovascular events rate at 12 months was 6.9 %, and the clinically-driven target lesion revascularization rate - 5.4 %. At 12 months in quantitative coronary angiography the late lumen loss was 0.21 ± 0.18 mm, and in optical coherence tomography the mean neointima burden was 24.6 ± 8.6 %.

CONCLUSIONS

Sirolimus-eluting Prolim® stent with a biodegradable polymer is a feasible device with a very good safety profile and long-term clinical effectiveness.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02545985 .

Double bifurcation optimization stent system technique for left main stenosis

We present a first-in-man case with implantation in culottes' fashion of two dedicated coronary bifurcation stents (BiOSS Lim) in distal left main stenosis. The immediate procedural and very short-term result was excellent.