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Burzotta F, Louvard Y, Lassen JF, Lefèvre T, Finet G, Collet C, Legutko J, Lesiak M, Hikichi Y, Albiero R, Pan M, Chatzizisis YS, Hildick-Smith D, Ferenc M, Johnson TW, Chieffo A, Darremont O, Banning A, Serruys PW, Stankovic G. Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club. EUROINTERVENTION 2024; 20:e915-e926. [PMID: 38752714 PMCID: PMC11285041 DOI: 10.4244/eij-d-24-00160] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 04/25/2024] [Indexed: 08/06/2024]
Abstract
The 2023 European Bifurcation Club (EBC) meeting took place in Warsaw in October, and the latest evidence for the use of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to optimise percutaneous coronary interventions (PCI) on coronary bifurcation lesions (CBLs) was a major focus. The topic generated deep discussions and general appraisal on the potential benefits of IVUS and OCT in PCI procedures. Nevertheless, despite an increasing recognition of IVUS and OCT capabilities and their recognised central role for guidance in complex CBL and left main PCI, it is expected that angiography will continue to be the primary guidance modality for CBL PCI, principally due to educational and economic barriers. Mindful of the restricted access/adoption of intracoronary imaging for CBL PCI, the EBC board decided to review and describe a series of tips and tricks which can help to optimise angiography-guided PCI for CBLs. The identified key points for achieving an optimal angiography-guided PCI include a thorough analysis of pre-PCI images (computed tomography angiography, multiple angiographic views, quantitative coronary angiography vessel estimation), a systematic application of the technical steps suggested for a given selected technique, an intraprocedural or post-PCI use of stent enhancement and a low threshold for bailout use of intravascular imaging.
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Affiliation(s)
- Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Yves Louvard
- Ramsay Générale de Santé - Institut cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Jens Flensted Lassen
- Department of Cardiology B, Odense Universitets Hospital & University of Southern Denmark, Odense, Denmark
| | - Thierry Lefèvre
- Ramsay Générale de Santé - Institut cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Gérard Finet
- Department of Interventional Cardiology, Cardiovascular Hospital, Hospices Civils de Lyon, Lyon, France and INSERM U1060, CarMeN Laboratory, Université de Lyon, Lyon, France
| | - Carlos Collet
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
| | - Jacek Legutko
- Department of Interventional Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland and Clinical Department of Interventional Cardiology, Saint John Paul II Hospital, Kraków, Poland
| | - Maciej Lesiak
- Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Yutaka Hikichi
- Heart Centre, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Remo Albiero
- Interventional Cardiology Unit, Ospedale Civile Sondrio, Sondrio, Italy
| | - Manuel Pan
- Department of Cardiology, Reina Sofía Hospital, University of Córdoba (IMIBIC), Córdoba, Spain
| | - Yiannis S Chatzizisis
- Division of Cardiovascular Medicine, Center for Digital Cardiovascular Innovations, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Miroslaw Ferenc
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Thomas W Johnson
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol & Weston NHSFT, Bristol, United Kingdom and University of Bristol, Bristol, United Kingdom
| | - Alaide Chieffo
- Vita-Salute San Raffaele University, Milan, Italy
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Adrian Banning
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland Galway (NUIG), Galway, Ireland and CORRIB Research Centre for Advanced Imaging and Core Laboratory, Galway, Ireland
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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2
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Çizgici AY, Güner A, Alizade E, Çetin İ, Serin E, Doğan A, Gökçe K, Serter B, Çiloğlu K, Kahraman S, Uysal H, Çörekçioğlu B, Demirci G, Tanık VO, Aktürk F, Keskin K, Püşüroğlu H, Akman C, Yıldız M, Ertürk M, Uzun F. Cardiovascular outcomes of complex bifurcation lesions following double kissing crush or nano-crush techniques: The multicenter EVOLUTE-CRUSH V study. Catheter Cardiovasc Interv 2024; 104:191-202. [PMID: 38923152 DOI: 10.1002/ccd.31137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/30/2024] [Accepted: 06/15/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Double kissing crush (DKC) and nano-crush (NC) techniques are frequently used, but the comparison for both techniques is still lacking. The goal of this multicenter study was to retrospectively assess the midterm clinical results of DKC and NC stenting in patients with complex bifurcation lesions (CBLs). METHODS A total of 324 consecutive patients [male: 245 (75.6%), mean age: 60.73 ± 10.21 years] who underwent bifurcation percutaneous coronary intervention between January 2019 and May 2023 were included. The primary endpoint defined as the major cardiovascular events (MACE) included cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (TLR). Inverse probability weighting (IPW) was performed to reduce treatment selection bias. This is the first report comparing the clinical outcomes of DKC and NC stenting in patients with CBL. RESULTS The initial revascularization strategy was DKC in 216 (66.7%) cases and NC in 108 (33.3%) patients. SYNTAX scores [25.5 ± 6.73 vs. 23.32 ± 6.22, p = 0.005] were notably higher in the NC group than the DKC group. The procedure time (76.98 ± 25.1 vs. 57.5 ± 22.99 min, p = 0.001) was notably higher in the DKC group. The incidence of MACE (18.5 vs. 9.7%, p = 0.025), clinically driven TLR (14.8 vs. 6%, p = 0.009), and TVMI (10.2 vs. 4.2%, p = 0.048) were notably higher in the NC group than in the DKC group. The midterm MACE rate in the overall population notably differed between the NC group and the DKC group (adjusted HR (IPW): 2.712, [95% CI: 1.407-5.228], p = 0.003). CONCLUSION In patients with CBLs, applying the DKC technique for bifurcation treatment had better ischemia-driven outcomes than the NC technique.
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Affiliation(s)
- Ahmet Yaşar Çizgici
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Elnur Alizade
- Department of Cardiology, Koşuyolu Kartal Heart Training & Research Hospital, Istanbul, Turkey
| | - İlyas Çetin
- Department of Cardiology, Basaksehir Cam & Sakura City Hospital, Istanbul, Turkey
| | - Ebru Serin
- Department of Cardiology, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Abdullah Doğan
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Kaan Gökçe
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Berkay Serter
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Koray Çiloğlu
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serkan Kahraman
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Hande Uysal
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Büşra Çörekçioğlu
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gökhan Demirci
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Veysel Ozan Tanık
- Department of Cardiology, Ankara Etlik City Hospital, Ankara, Turkey
| | - Faruk Aktürk
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Kudret Keskin
- Department of Cardiology, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Hamdi Püşüroğlu
- Department of Cardiology, Basaksehir Cam & Sakura City Hospital, Istanbul, Turkey
| | - Cemalettin Akman
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Yıldız
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Ertürk
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Fatih Uzun
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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3
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Pir MS, Jovin IS. Editorial: Bifurcation angle in bifurcation intervention: Does it matter? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:60-61. [PMID: 38664132 DOI: 10.1016/j.carrev.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Muhammad S Pir
- Richmond Veterans Affairs Medical Center, Richmond, VA, United States of America; Pauley Heart Center, Virginia Commonwealth University Medical Center, Richmond, VA, United States of America
| | - Ion S Jovin
- Richmond Veterans Affairs Medical Center, Richmond, VA, United States of America; Pauley Heart Center, Virginia Commonwealth University Medical Center, Richmond, VA, United States of America.
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Ungureanu C, Natalis A, Cocoi M, Dumitrascu S, Noterdaeme T, Gach O, Jossart A, Soetens R, Colletti G. The impact of the bifurcation angle for the Nano-Crush two-stent coronary bifurcation technique on long-term outcomes in a real-world clinical population. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 64:54-59. [PMID: 38494371 DOI: 10.1016/j.carrev.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/06/2024] [Accepted: 02/21/2024] [Indexed: 03/19/2024]
Abstract
AIM This study aims to assess the direct impact of bifurcation angle (BA) on immediate procedural outcomes and patient prognosis post-Nano-Crush stenting for coronary bifurcation lesions. METHODS A retrospective analysis was conducted for all consecutive patients treated with the Nano-Crush technique across two high-volume interventional centers from January 2020 to October 2022. PRIMARY ENDPOINT comparison of target lesion failure rate in two cohorts based on bifurcation angle (<70° vs. ≥70°), with secondary endpoints including side branch ostium coverage, rate of successful final kissing balloon inflation (FKBI), need for conversion to another technique, and procedure length. RESULTS Baseline demographics included 71 patients in the BA<70° group and 49 in the BA≥70° group, with well-balanced characteristics. Angiographic characteristics revealed similar trends, including anatomic and morphological lesion characteristics (referencing Syntax score, Medina classification, and presence of calcifications). Both groups predominantly had complex coronary disease, with a baseline mean Syntax score of 24.18 ± 8.19 in the BA<70° group and 23.91 ± 7.29 in the BA≥70° group, respectively. A dedicated debulking device for lesion preparation was used in 25.35 % of patients in the first group and in 28.57 % of patients in the second group. The primary endpoint occurred in 5.63 % of patients in the BA<70° group and in 4.08 % of patients in the BA≥70° group (P = 0.7014) after ≥ 2 years of clinical follow-up. Angiographic success was achieved in 100 % of both groups, with procedural time averaging 74.99 ± 25.55 min in the BA≥70° and 76.94 ± 27.81 min in the BA<70° (P = 0.6922). The rate of successful final kissing balloon inflation was 98.59 % in the BA<70° group and 95.91 % in the BA≥70° group (P = 0.3566). The mean contrast volume was 189.54 ± 73.74 ml in BA<70° and 168.9 ± 62.77 ml in BA≥70° (P = 0.1126). Clinical follow-ups at 30 days and 2 years revealed similar outcomes and complications for each group, as summarized in Table 3. CONCLUSIONS Our results demonstrate that the bifurcation angle does not significantly impact long-term clinical outcomes or procedural parameters, such as side branch ostium coverage, conversion to a modified DK Crush technique, FKBI success rate, and procedure length. These findings suggest that the Nano-Crush technique can be a viable option for bifurcation lesions, irrespective of the bifurcation angle, achieving optimal side branch ostium coverage while preventing excessive protrusion into the main vessel.
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Affiliation(s)
| | - Alexandre Natalis
- Cardiovascular Department, Clinique Saint Joseph, Vivalia, Arlon, Belgium
| | - Mihai Cocoi
- Cardiovascular Department, Institutul Inimii, Cluj, Romania
| | | | | | - Olivier Gach
- Cardiovascular Departement, MontLégia, Liège, Belgium
| | | | | | - Giuseppe Colletti
- Cardiovascular Department, Clinique Saint Joseph, Vivalia, Arlon, Belgium
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Güner A, Uzun F, Çizgici AY, Kahraman S, Demirci G, Çiloğlu K, Gökçe K, Doğan A, Akman C, Uysal H, Gültekin Güner E, Aktürk İF, Yildiz M, Serter B, Yalçin AA, Keskin B, Ertürk M. Long-term cardiovascular outcomes after mini-crush or T and minimal protrusion techniques in complex bifurcation lesions: the EVOLUTE-CRUSH III study. Coron Artery Dis 2024:00019501-990000000-00236. [PMID: 38809138 DOI: 10.1097/mca.0000000000001392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
BACKGROUND Mini-crush (MC) and T-stenting and small protrusion (TAP) techniques are frequently used, but the long-term comparison of both techniques in patients with complex bifurcation lesions (CBLs) is still a debatable issue. This study sought to retrospectively evaluate the long-term outcomes of MC and TAP techniques in patients with CBLs. METHODS A total of 271 patients [male: 202 (78.9%), mean age: 58.90 ± 10.11 years] patients in whom complex bifurcation intervention was performed between 2014 and 2023 were involved. The primary endpoint was major cardiovascular events (MACE) as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization. The Cox proportional hazard models were adjusted by the inverse probability weighting approach to reduce treatment selection bias. RESULTS The initial management strategy was MC in 146 patients and TAP in 125 cases. MACE occurred in 52 patients (19.2%) during a mean follow-up period of 32.43 ± 16 months. The incidence of MACE (13 vs. 26.4%, P = 0.005) and major cardiovascular and cerebral events (15.1 vs. 28.8%, P = 0.006) were significantly lower in the MC group than in the TAP group. Additionally, the incidence of definite or probable stent thrombosis was numerically lower in the MC group compared with the TAP group but did not differ significantly (2.7 vs. 8%, P = 0.059). The long-term MACE was notably higher in the TAP group than the MC group [adjusted hazard ratio (inverse probability weighted): 1.936 (95% confidence interval: 1.053-3.561), P = 0.033]. CONCLUSION In this study involving patients with CBLs, percutaneous coronary intervention with the MC technique had better long-term outcomes than the TAP technique.
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Affiliation(s)
- Ahmet Güner
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Fatih Uzun
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Ahmet Yaşar Çizgici
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Serkan Kahraman
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Gökhan Demirci
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Koray Çiloğlu
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Kaan Gökçe
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Abdullah Doğan
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Cemalettin Akman
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Hande Uysal
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Ezgi Gültekin Güner
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - İbrahim Faruk Aktürk
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Mustafa Yildiz
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
- Department of Cardiology, Istanbul University-Cerrahpasa Cardiology Institute, Istanbul, Turkey
| | - Berkay Serter
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Ahmet Arif Yalçin
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
| | - Berhan Keskin
- Department of Cardiology, Kocaeli City Hospital, Kocaeli
| | - Mehmet Ertürk
- Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul
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XU Y, XU T, NONG JC, KONG XH, ZHAO MY, GAO ZJ, WANG YF, YOU W, MENG PN, ZHOU YH, WU XQ, WU ZM, ZHAN ME, WANG YQ, PAN DF, YE F. Effect of negative remodeling of the side branch ostium on the efficacy of a two-stent strategy for distal left main bifurcation lesions: an intravascular ultrasound study. J Geriatr Cardiol 2024; 21:506-522. [PMID: 38948898 PMCID: PMC11211904 DOI: 10.26599/1671-5411.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024] Open
Abstract
OBJECTIVES To investigate whether negative remodeling (NR) detected by intravascular ultrasound (IVUS) of the side branch ostium (SBO) would affect in-stent neointimal hyperplasia (NIH) at the one-year follow-up and the clinical outcome of target lesion failure (TLF) at the long-term follow-up for patients with left main bifurcation (LMb) lesions treated with a two-stent strategy. METHODS A total of 328 patients with de novo true complex LMb lesions who underwent a 2-stent strategy of percutaneous coronary intervention (PCI) treatment guided by IVUS were enrolled in this study. We divided the study into two phases. Of all the patients, 48 patients who had complete IVUS detection pre- and post-PCI and at the 1-year follow-up were enrolled in phase I analysis, which aimed to analyze the correlation between NR and in-stent NIH at SBO at the 1-year follow-up. If the correlation was confirmed, the cutoff value of the remodeling index (RI) for predicting NIH ≥ 50% was analyzed next. The phase II analysis focused on the incidence of TLF as the primary endpoint at the 1- to 5-year follow-up for all 328 patients by grouping based on the cutoff value of RI. RESULTS In phase I: according to the results of a binary logistic regression analysis and receiver operating characteristic (ROC) analysis, the RI cutoff value predicting percent NIH ≥ 50% was 0.85 based on the ROC curve analysis, with a sensitivity of 85.7%, a specificity of 88.3%, and an AUC of 0.893 (0.778, 1.000), P = 0.002. In phase II: the TLR rate (35.8% vs. 5.3%, P < 0.0001) was significantly higher in the several NR (sNR, defined as RI ≤ 0.85) group than in the non-sNR group. CONCLUSION The NR of LCxO is associated with more in-stent NIH post-PCI for distal LMb lesions with a 2-stent strategy, and NR with RI ≤ 0.85 is linked to percent NIH area ≥ 50% at the 1-year follow-up and more TLF at the 5-year follow-up.
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Affiliation(s)
- Yi XU
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Tian XU
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Jia-Cong NONG
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Xiao-Han KONG
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Meng-Yao ZHAO
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | | | - Yi-Fei WANG
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Wei YOU
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Pei-Na MENG
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Yu-He ZHOU
- Department of Cardiology, Clinical Medicine School of Nanjing University, Nanjing, China
| | - Xiang-Qi WU
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Zhi-Ming WU
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Mei-En ZHAN
- Department of Cardiology, Tianchang People’s Hospital, Tianchang, China
| | - Yan-Qing WANG
- Department of Cardiology, Clinical Medicine School of Nanjing University, Nanjing, China
| | - De-Feng PAN
- Department of Cardiology, the Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Fei YE
- Department of Cardiology, Nanjing First Hospital, Nanjing Hospital Affiliated to Nanjing Medical University, Nanjing Medical University, Nanjing, China
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Andreasen LN, Neghabat O, Laanmets P, Kumsars I, Bennett J, Olsen NT, Odenstedt J, Burzotta F, Johnson TW, O'Kane P, Hartikainen JEK, Spratt JC, Christiansen EH, Holm NR. Unintended Deformation of Stents During Bifurcation PCI: An OCTOBER Trial Substudy. JACC Cardiovasc Interv 2024; 17:1106-1115. [PMID: 38749590 DOI: 10.1016/j.jcin.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/15/2024] [Accepted: 03/08/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Unintended deformation of implanted coronary stents can lead to loss of coronary access, stent thrombosis and coronary events during follow-up. The incidence, mechanisms and clinical outcomes of unintended stent deformations (USD) during complex bifurcation stenting are not well characterized. OBJECTIVES In a prespecified analysis of the OCTOBER (European Trial on Optical Coherence Tomography Optimized Bifurcation Event Reduction) trial, we aimed to: 1) determine the incidence and characterize mechanisms of USD identified by optical coherence tomography (OCT); and 2) evaluate physician's detection and correction of accidental abluminal rewiring and USD. METHODS OCT scans were analyzed for accidental abluminal rewiring and USD. When USD was identified, the plausible mechanism was determined by analysis of all procedural OCT scans and the corresponding angiograms. RESULTS USD was identified by the core lab in 9.3% (55/589) of OCT-guided cases. Accidental abluminal rewiring was the cause in 44% (24/55), and guide catheter collision was the cause in 40% (22/55) of cases. USD was found in 18.5% of all cases with left main bifurcation percutaneous coronary intervention. The total incidence of abluminal rewiring was 33 in 32 OCT-guided cases (5.4%) and was corrected by physicians in 18 of 33 appearances (54.5%). The 2-year major adverse cardiac event rate for patients with untreated USD (n = 30) was 23.3%, whereas patients with confirmed or possibly corrected USD (n = 25) had no events during follow-up. CONCLUSIONS USD was associated with adverse procedural complications and cardiac events during follow-up when not identified and corrected. The predominant mechanisms were undetected abluminal rewiring and guide catheter collision. Left main bifurcation percutaneous coronary intervention was a particular risk with USD detected in 18.5% of cases.
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Affiliation(s)
| | - Omeed Neghabat
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Peep Laanmets
- Department of Cardiology, North Estonia Medical Centre, Tallinn, Estonia
| | - Indulis Kumsars
- Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, University of Latvia, Riga, Latvia
| | - Johan Bennett
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Niels T Olsen
- Department of Cardiology, Gentofte Hospital, Gentofte, Denmark
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Thomas W Johnson
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHS Trust, Bristol, United Kingdom
| | - Peter O'Kane
- Department of Cardiology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Juha E K Hartikainen
- Kuopio University Hospital and Medical School, University of Eastern Finland, Kuopio, Finland
| | - James C Spratt
- Cardiology Care Group, St. George's University Hospitals NHS Foundation Trust and Cardiovascular Clinical Academic Group, St. George's, University of London, London, United Kingdom
| | | | - Niels R Holm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Mukhopadhyay S, Muheeb G, Yusuf J, Kathuria S. Fracture and plastering of distal left main stent during double-kissing Culotte technique: a case report. Eur Heart J Case Rep 2024; 8:ytae215. [PMID: 38756546 PMCID: PMC11098036 DOI: 10.1093/ehjcr/ytae215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024]
Abstract
Background Acute fracture of a left main (LM) stent during angioplasty is a rare complication. Cardiologists should be aware of the risk of stent fracture (SF) following kissing balloon inflation (KBI) even if the effective diameter of the balloons does not exceed the recommended expansion limits of stents. Case summary A 64-year-old female with hypertension and dyslipidaemia presented with crescendo angina since three months in spite of optimal medical therapy. Coronary angiogram showed a distal LM bifurcation lesion. The patient was admitted for LM bifurcation stenting by upfront two-stent technique (inverted double-kissing Culotte technique). Following first KBI of the stent placed from left circumflex artery (LCX) to LM, there was stent deformation in the LM shaft. As we had planned the Culotte technique, we decided to exclude the fractured segment by stenting from left anterior descending artery (LAD) to LM. The stent from LAD-LM successfully excluded the fractured part of the first stent from the lumen of LM. Optical coherence tomography done after final KBI from LCX-LM revealed successful exclusion of the deformed segment of the LCX stent with mild malapposition at the site of the deformed stent. A follow-up angiogram after six months showed normal in-stent flow with no evidence of restenosis or pseudoaneurysm. Discussion Acute LM SF during coronary intervention can occur even if the effective cumulative diameter of the inflated balloons does not exceed the mentioned expansion limit of stents. Intravascular imaging is a helpful modality to define type of SF and its management.
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Affiliation(s)
- Saibal Mukhopadhyay
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Jawaharlal Nehru Marg, New Delhi, Delhi 110002, India
| | - Ghazi Muheeb
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Jawaharlal Nehru Marg, New Delhi, Delhi 110002, India
| | - Jamal Yusuf
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Jawaharlal Nehru Marg, New Delhi, Delhi 110002, India
| | - Sanjeev Kathuria
- Department of Cardiology, Govind Ballabh Pant Institute of Post Graduate Medical Education and Research, Jawaharlal Nehru Marg, New Delhi, Delhi 110002, India
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Gil RJ, Kern A, Bojko K, Gziut-Rudkowska A, Vassilev D, Bil J. The Randomized, Multicenter, Open-Label, Controlled POLBOS 3 Trial Comparing Regular Drug-Eluting Stents and the Sirolimus-Eluting BiOSS LIM C Dedicated Coronary Bifurcation Stent: Four-Year Results. Biomedicines 2024; 12:938. [PMID: 38790900 PMCID: PMC11118130 DOI: 10.3390/biomedicines12050938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
This multicenter, randomized study aimed to compare the sirolimus-eluting BiOSS LIM C dedicated coronary bifurcation stent with second-generation -limus drug-eluting stents (rDESs) in the treatment of non-left main (non-LM) coronary bifurcation. The deployment of a single stent in the main vessel-main branch across a side branch was the default strategy in all patients. The primary endpoint was the rate of major cardiovascular events (cardiac death, myocardial infarction, and target lesion revascularization) at 48 months. We enrolled 230 patients, allocating 116 patients to the BiOSS LIM C group and 114 patients to the rDES group. Most procedures were elective (BiOSS vs. rDES: 48.3% vs. 59.6%, p = 0.09) and performed in bifurcations within the left anterior descending/diagonal branch (BiOSS vs. rDES: 51.7% vs. 61.4%, p = 0.15). At 48 months, there were no statistically significant differences between the BiOSS and rDES groups in terms of major adverse cardiovascular events (MACE), cardiac death, myocardial infarction (MI), or target lesion revascularization (TLR) as follows: MACEs-18.1% vs. 14.9%, HR 1.36, 95% CI 0.62-2.22, and p = 0.33; cardiac death-4.3% vs. 3.5%, HR 1.23, 95% CI 0.33-4.56, and p = 0.75; MI-2.6% vs. 3.5%, HR 0.73, 95% CI 0.17-3.23, and p = 0.68; and TLR-11.2% vs. 7.9%, HR 1.66, 95% CI 0.75-3.71, and p = 0.21. The implantation success rate of the BiOSS LIM C stent was very high, and the cumulative MACE rates were promising. The POLBOS 3 trial sets an important benchmark for treating non-LM coronary bifurcations (ClinicalTrials.gov NCT03548272).
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Affiliation(s)
- Robert J. Gil
- Department of Cardiology, State Medical Institute of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (R.J.G.); (A.G.-R.)
| | - Adam Kern
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury, 10-719 Olsztyn, Poland; (A.K.); (K.B.)
| | - Krystian Bojko
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury, 10-719 Olsztyn, Poland; (A.K.); (K.B.)
| | - Aneta Gziut-Rudkowska
- Department of Cardiology, State Medical Institute of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (R.J.G.); (A.G.-R.)
| | - Dobrin Vassilev
- Medica Cor University Hospital, University of Ruse, 7017 Ruse, Bulgaria;
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, 01-826 Warsaw, Poland
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10
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Bujak K, Brugaletta S. Reply: Cardiovascular outcomes after 2-stent or stepwise provisional techniques for coronary bifurcation lesions. EUROINTERVENTION 2024; 20:e458-e459. [PMID: 38562072 PMCID: PMC10979380 DOI: 10.4244/eij-d-24-00025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Kamil Bujak
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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11
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Džavík V. A Left Main Bifurcation Risk Score: Can It Safely Guide Our Choice of Bifurcation Stenting Technique? Can J Cardiol 2024:S0828-282X(24)00275-7. [PMID: 38522621 DOI: 10.1016/j.cjca.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 03/13/2024] [Indexed: 03/26/2024] Open
Affiliation(s)
- Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada.
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12
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Volet C, Puricel S, Cook ST, di Cicco P, Faucherre Y, Arroyo D, Togni M, Cook S. Proximal optimization technique and percutaneous coronary intervention for left main disease: POTENTIAL-LM. Catheter Cardiovasc Interv 2024; 103:417-424. [PMID: 38297989 DOI: 10.1002/ccd.30961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/27/2023] [Accepted: 01/18/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Optimal stent deployment in left main (LM) bifurcation is paramount, and incomplete stent apposition may cause major adverse cardiac events (MACE). Bench studies show that the proximal optimization technique (POT) provides the best stent apposition. AIMS We aimed to investigate the impact of POT on clinical outcomes in patients treated for unprotected LM (ULM) disease at our institution. METHODS We identified 162 patients who underwent percutaneous coronary intervention (PCI) for ULM coronary disease in the Cardio-FR database. Out of these, 99 (61%) had undergone POT, while 63 patients were treated without POT. The primary outcome was the bifurcation-oriented composite endpoint (BOCE) of cardiac death, target-bifurcation myocardial infarction and target-bifurcation revascularization at maximal follow-up. RESULTS Mean age was 76 years, and 69% presented with acute coronary syndrome. Mean follow-up was 2.25 years (822 days). The BOCE occurred in 43 (27%) of which 20 (20%) in the POT group and 23 (37%) in the no-POT group (p = 0.009). Cardiac death occurred in 15 (15%) patients in the POT- and 17 (27%) in no-POT group (p = 0.26). Target bifurcation revascularization occurred in 4 (4%) patients in the POT- and 6 (10%) patients in the no-POT group (p = 0.19). POT In the multivariate analysis, POT was the strongest parameter and was associated with BOCE, cardiac death, occurrence of any revascularization and all-cause mortality. CONCLUSION The POT improves clinical outcomes. These findings strongly support the systematic use of POT in patients undergoing ULM-PCI.
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Affiliation(s)
- Corentin Volet
- Cardiology, University & Hospital Fribourg, Fribourg, Switzerland
| | - Serban Puricel
- Cardiology, University & Hospital Fribourg, Fribourg, Switzerland
| | - Selma T Cook
- Cardiology, University & Hospital Fribourg, Fribourg, Switzerland
| | | | | | - Diego Arroyo
- Cardiology, University & Hospital Fribourg, Fribourg, Switzerland
| | - Mario Togni
- Cardiology, University & Hospital Fribourg, Fribourg, Switzerland
| | - Stéphane Cook
- Cardiology, University & Hospital Fribourg, Fribourg, Switzerland
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13
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Bianchini F, Burzotta F, Romagnoli E. Is one better than two? The impact of a four-handed approach in left main percutaneous coronary intervention. Minerva Cardiol Angiol 2024; 72:76-78. [PMID: 37987682 DOI: 10.23736/s2724-5683.23.06459-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Affiliation(s)
- Francesco Bianchini
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy -
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14
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Gao C, Li D, Dai H, Liu H, Liu P, Cheng M, Zhang M, Guo W. Review of Progress in Interventional Therapy for Coronary Bifurcation Lesions. Rev Cardiovasc Med 2024; 25:2. [PMID: 39077661 PMCID: PMC11262401 DOI: 10.31083/j.rcm2501002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 10/10/2023] [Accepted: 10/24/2023] [Indexed: 07/31/2024] Open
Abstract
Despite a decade of extensive research and clinical insights, percutaneous coronary intervention strategies for coronary bifurcation lesions have remained a challenging and highly debated area. This article presents a review of the latest findings and advances in defining and classifying coronary bifurcation lesions, in vitro studies, intracoronary imaging, stenting strategies, and the deployment of drug-coated balloons. Based on current evidence, this review provides recommendations for interventional cardiologists to develop individualized interventional strategies and enhance the efficiency of stenting procedures.
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Affiliation(s)
- Chuncheng Gao
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
| | - Dongdong Li
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
| | - Huimiao Dai
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
| | - Hao Liu
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
| | - Pengyun Liu
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
| | - Miaomiao Cheng
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
| | - Mingming Zhang
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
| | - Wangang Guo
- Department of Cardiology, Tangdu Hospital, Air Force Medical University, 710038 Xi’an, Shaanxi, China
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15
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Kim JH, Kang DY, Ahn JM, Kweon J, Choi Y, Kim H, Lee J, Chae J, Kang SJ, Park DW, Park SJ. Optimal Minimal Stent Area and Impact of Stent Underexpansion in Left Main Up-Front 2-Stent Strategy. Circ Cardiovasc Interv 2024; 17:e013006. [PMID: 38227699 DOI: 10.1161/circinterventions.123.013006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/26/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND We previously reported the use of minimal stent area to predict angiographic in-stent restenosis after drug-eluting stent implantation for unprotected left main (LM) disease. We aimed to evaluate the optimal minimal stent area criteria for up-front LM 2-stenting based on long-term clinical outcomes. METHODS We identified 292 consecutive patients with LM bifurcation stenosis who were treated using the crush technique. The final minimal stent area was measured in the ostial left anterior descending artery (LAD), ostial left circumflex artery (LCX), and distal LM. The primary outcome was 5-year major adverse cardiac events, including all-cause death, myocardial infarction, and target lesion revascularization. RESULTS The minimal stent area cutoff values that best predicted the 5-year major adverse cardiac events were 11.8 mm2 for distal LM (area under the curve, 0.57; P=0.15), 8.3 mm2 for LAD ostium (area under the curve, 0.62; P=0.02), and 5.7 mm2 for LCX ostium (area under the curve, 0.64; P=0.01). Using these criteria, the risk of 5-year major adverse cardiac events was significantly associated with stent underexpansion in the LAD ostium (hazard ratio, 3.14; [95% CI, 1.23-8.06]; P=0.02) and LCX ostium (hazard ratio, 2.60 [95% CI, 1.11-6.07]; P=0.03) but not in the distal LM (hazard ratio, 0.81 [95% CI, 0.34-1.91]; P=0.63). Patients with stent underexpansion in both ostial LAD and LCX had a significantly higher rate of 5-year major adverse cardiac events than those with no or 1 underexpanded stent of either ostium (P<0.01). CONCLUSIONS Stent underexpansion in the LAD and LCX ostium was significantly associated with long-term outcomes in patients who underwent up-front 2-stenting for LM bifurcation stenosis.
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Affiliation(s)
- Ju Hyeon Kim
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea (J.H.K.)
| | - Do-Yoon Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
| | - Jung-Min Ahn
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
| | - Jihoon Kweon
- Department of Convergence Medicine, Asan Medical Center, Seoul, Republic of Korea (J.K., J.C.)
| | - Yeonwoo Choi
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
| | - Hoyun Kim
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
| | - Jinho Lee
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
| | - Jihye Chae
- Department of Convergence Medicine, Asan Medical Center, Seoul, Republic of Korea (J.K., J.C.)
| | - Soo-Jin Kang
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
| | - Duk-Woo Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
| | - Seung-Jung Park
- Division of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea (D.-Y.K., J.-M.A., Y.C., H.K., J.L., S.-J.K., D.-W.P., S.-J.P.)
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16
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Dillen DMM, Vlaar PJ, Vermeer AJE, Paradies V, van Kuijk JP, Vink MA, Oemrawsingh RM, Hofma SH, Magro M, Remkes WS, de Smet BJGL, van Rees JB, Somi S, Halim J, Zimmermann FM, Wijnbergen IF, Tijssen JGP, Tonino PAL, Teeuwen K. Bifurcation PCI with a hybrid strategy with drug- eluting balloons versus a stepwise provisional two- stent strategy: Rationale and design of the hybrid DEB study. Am Heart J 2023; 266:168-175. [PMID: 37806333 DOI: 10.1016/j.ahj.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 10/10/2023]
Abstract
The optimal treatment strategy for coronary bifurcation lesions by percutaneous coronary intervention (PCI) is complex and remains a subject of debate. Current guidelines advise a stepwise provisional approach with optional two-stent strategy. However, a two-stent strategy, both upfront and stepwise provisional, is technically demanding. Therefore, there is increasing interest in the use of drug-eluting balloons (DEB) in bifurcation lesions, mainly after a provisional approach with unsatisfactory result of the side branch. Some small pilot studies already showed that the use of DEB in bifurcation lesions is safe and feasible. However, a randomized comparison of this hybrid DEB strategy with a two-stent strategy is currently lacking. TRIAL DESIGN The Hybrid DEB study is a prospective, multicenter, randomized controlled trial investigating noninferiority of a hybrid DEB approach, using a combination of a drug-eluting stent (DES) in the main vessel and DEB in the side branch, compared to stepwise provisional two-stent strategy in patients with true bifurcation lesions. A total of 500 patients with de novo true coronary bifurcation lesions, treated with a stepwise provisional approach and an unsatisfactory result of the side branch after main vessel stenting (≥ 70% stenosis and/or < thrombolysis in myocardial infarction III flow), will be randomized in a 1:1 ratio to receive either treatment with a DEB or with a DES in the side branch. The primary endpoint is a composite endpoint of the occurrence of all-cause death, periprocedural or spontaneous myocardial infarction and/or target vessel revascularization at the anticipated median 2-year follow-up. CONCLUSION The Hybrid DEB study will compare in a multicenter, randomized fashion a hybrid DEB approach with a stepwise provisional two-stent strategy in patients with true bifurcation lesions. TRIAL REGISTRATION ClinicalTrials.gov no. NCT05731687.
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Affiliation(s)
- Daimy M M Dillen
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands.
| | - Pieter Jan Vlaar
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Amy J E Vermeer
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands; Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Valeria Paradies
- Department of Cardiology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Jan-Peter van Kuijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Maarten A Vink
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Rohit M Oemrawsingh
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Sjoerd H Hofma
- Department of Cardiology, Medical Center Leeuwarden, The Netherlands
| | - Michael Magro
- Department of Cardiology, Elisabeth- TweeSteden Hospital, Tilburg, The Netherlands
| | | | - Bart J G L de Smet
- Department of Cardiology, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Samer Somi
- Department of Cardiology, Haga Hospital, The Hague, The Netherlands
| | - Jonathan Halim
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | | | - Inge F Wijnbergen
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Jan G P Tijssen
- Department of Clinical Epidemiology and Biostatistics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Pim A L Tonino
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Koen Teeuwen
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
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17
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Radunović A, Vidaković R, Timčić S, Odanović N, Stefanović M, Lipovac M, Krupniković K, Mandić A, Kojić D, Tomović M, Ilić I. Multislice computerized tomography coronary angiography can be a comparable tool to intravascular ultrasound in evaluating "true" coronary artery bifurcations. Front Cardiovasc Med 2023; 10:1292517. [PMID: 38028491 PMCID: PMC10657987 DOI: 10.3389/fcvm.2023.1292517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Anja Radunović
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Radosav Vidaković
- Department of Cardiology, Clinical Hospital Center Zemun, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Stefan Timčić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Natalija Odanović
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Milica Stefanović
- Department of Cardiology, Clinical Hospital Center Zemun, Belgrade, Serbia
| | - Mirko Lipovac
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Kosta Krupniković
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Aleksandar Mandić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Dejan Kojić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Milosav Tomović
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
| | - Ivan Ilić
- Department of Cardiology, Institute for Cardiovascular Diseases Dedinje, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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18
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Beijk MAM. A 2-Stent Strategy in Complex Bifurcation Lesions: A Matter of Single or Double Kissing Balloon Inflation? Am J Cardiol 2023; 206:362-364. [PMID: 37690939 DOI: 10.1016/j.amjcard.2023.08.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 09/12/2023]
Affiliation(s)
- Marcel A M Beijk
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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19
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Zimarino M, Scorpiglione L, Perfetti M. Shifting focus in bifurcations. EUROINTERVENTION 2023; 19:621-622. [PMID: 37872803 PMCID: PMC10587837 DOI: 10.4244/eij-e-23-00044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Marco Zimarino
- Cardiology Department, SS Annunziata Hospital, ASL2 Abruzzo, Chieti, Italy
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Luca Scorpiglione
- Department of Neuroscience, Imaging and Clinical Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Matteo Perfetti
- Cardiology Department, SS Annunziata Hospital, ASL2 Abruzzo, Chieti, Italy
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20
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Bujak K, Verardi FM, Arevalos V, Gabani R, Spione F, Rajwa P, Milasinovic D, Stankovic G, Gasior M, Sabaté M, Brugaletta S. Clinical outcomes following different stenting techniques for coronary bifurcation lesions: a systematic review and network meta-analysis of randomised controlled trials. EUROINTERVENTION 2023; 19:664-675. [PMID: 37533321 PMCID: PMC10587845 DOI: 10.4244/eij-d-23-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/30/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Controversy still exists regarding the optimal treatment of coronary bifurcation lesions. AIMS We aimed to analyse the evidence from randomised controlled trials (RCTs) to compare outcomes following different bifurcation stenting techniques. METHODS We systematically searched for RCTs comparing different techniques published up to July 2022. We then conducted a pairwise meta-analysis to compare outcomes between provisional stenting (PS) versus upfront 2-stent techniques. Moreover, we performed a network meta-analysis (NMA) to compare all strategies with each other. The primary endpoint was major adverse cardiac events (MACE). RESULTS Twenty-four RCTs (6,890 patients) analysed PS, T-stenting, double-kissing (DK)-crush, crush, or culotte stenting. The pairwise meta-analysis did not reveal a significant difference between the PS and 2-stent techniques. However, the prespecified sensitivity analysis, which included RCTs exclusively enrolling patients with true bifurcation lesions, showed a lower rate of MACE following 2-stent techniques, and meta-regression indicated that a longer side branch lesion was associated with a greater benefit from the 2-stent strategy, which was the most apparent in RCTs with a mean lesion length >11 mm. NMA revealed that DK-crush was associated with the lowest MACE rate (odds ratio 0.47, 95% confidence interval: 0.36-0.62; p<0.01; PS as a reference). CONCLUSIONS Overall, 2-stent techniques were not significantly better than PS in terms of clinical outcomes. However, the results of the sensitivity analysis suggested that there might be a benefit of a 2-stent approach in selected patients with true bifurcation lesions, especially in the case of long side branch lesions. An NMA revealed that DK-crush was associated with the lowest event rates when compared with other techniques.
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Affiliation(s)
- Kamil Bujak
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Filippo Maria Verardi
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy
| | - Victor Arevalos
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Rami Gabani
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Francesco Spione
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Pawel Rajwa
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Mariusz Gasior
- 3rd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Manel Sabaté
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
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21
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Mehmedbegović Z, Jelić D, Mladenović Đ, Stanković G. DES Selection for Left Main and Coronary Bifurcation Stenting. Rev Cardiovasc Med 2023; 24:266. [PMID: 39076391 PMCID: PMC11270060 DOI: 10.31083/j.rcm2409266] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/10/2023] [Accepted: 06/01/2023] [Indexed: 07/31/2024] Open
Abstract
Coronary bifurcation lesions present a challenging lesion subset regarding procedural complexity and worse patient outcomes as compared to simple lesions. Drug eluting stents (DES), as the current standard of care for percutaneous myocardial revascularization, have tubular design and uniform diameter, and therefore, need to be subjected to a standardized set of procedural modifications, to optimally fit and reconstruct underlying bifurcation anatomy. Since contemporary DES have various design platforms, with diverse mechanical properties, we must be aware of the device's favorable characteristics and limitations, to ensure maximal procedural safety and success. This is especially true for bifurcation lesion stenting, during which device integrity will often be eventually tested by undergoing specific procedural steps, such as proximal balloon optimization, kissing-balloon inflations, or even intentional stent crushing. In this review we address the design characteristics of contemporary DES, their bifurcation-specific experimental testing data, and reported clinical results, in an attempt to provide relevant information and help in device selection for bifurcation stenting procedures.
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Affiliation(s)
- Zlatko Mehmedbegović
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Dario Jelić
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Đorđe Mladenović
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Goran Stanković
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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22
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Cangemi S, Burzotta F, Bianchini F, DeVos A, Valenzuela T, Trani C, Aurigemma C, Romagnoli E, Lassen JF, Stankovic G, Iaizzo PA. Configuration of two-stent coronary bifurcation techniques in explanted beating hearts: the MOBBEM study. EUROINTERVENTION 2023; 19:e423-e431. [PMID: 37171514 PMCID: PMC10397672 DOI: 10.4244/eij-d-23-00063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/03/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND In patients with complex coronary bifurcation lesions undergoing percutaneous coronary intervention (PCI), various 2-stent techniques might be utilised. The Visible Heart Laboratories (VHL) offer an experimental environment where PCI results can be assessed by multimodality imaging. AIMS We aimed to assess the post-PCI stent configuration achieved by 2-stent techniques in the VHL and to evaluate the procedural factors associated with suboptimal results. METHODS Bifurcation PCI with 2-stent techniques, performed by expert operators in the VHL on explanted beating swine hearts, was studied. The adopted bifurcation PCI strategy and the specific procedural steps applied in each procedure were classified according to Main, Across, Distal, Side (MADS)-2 and to their adherence to the European Bifurcation Club (EBC) recommendations. Microcomputed tomography (micro-CT) was used to assess the post-PCI stent configuration. The primary endpoint was "suboptimal stent implantation", defined as a composite of stent underexpansion (<90%), side branch ostial area stenosis >50% and the gap between stents. RESULTS A total of 82 PCI with bifurcation stenting were assessed, comprised of 29 crush, 25 culotte, 28 T/T and small protrusion (TAP) techniques. Suboptimal stent implantation was observed in as many as 53.7% of the cases, regardless of baseline anatomy or the stenting strategy. However, less frequent use of the proximal optimisation technique (POT; p=0.015) and kissing balloon inflations (KBI; p=0.027) and no adherence to EBC recommendations (p=0.004, p multivariate=0.006) were significantly associated with the primary endpoint. CONCLUSIONS Commonly practised bifurcation 2-stent techniques may result in imperfect stent configurations. More frequent use of POT/KBI and adherence to expert recommendations might reduce the occurrence of post-PCI suboptimal stent configurations.
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Affiliation(s)
- Stefano Cangemi
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Bianchini
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Amanda DeVos
- Visible Heart Laboratories, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Thomas Valenzuela
- Visible Heart Laboratories, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jens Flested Lassen
- Department of Cardiology B, Odense University Hospital & University of Southern Denmark, Odense C, Denmark
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Paul Anthony Iaizzo
- Visible Heart Laboratories, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
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23
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Pellegrini D, Ielasi A, Tespili M, Guagliumi G, De Luca G. Percutaneous Treatment of Left Main Disease: A Review of Current Status. J Clin Med 2023; 12:4972. [PMID: 37568374 PMCID: PMC10419939 DOI: 10.3390/jcm12154972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/13/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Percutaneous treatment of the left main coronary artery is one of the most challenging scenarios in interventional cardiology, due to the large portion of myocardium at risk the technical complexity of treating a complex bifurcation with large branches. Our aim is to provide un updated overview of the current indications for percutaneous treatment of the left main, the different techniques and the rationale underlying the choice for provisional versus upfront two-stent strategies, intravascular imaging and physiology guidance in the management of left main disease, and the role of mechanical support devices in complex high-risk PCI.
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Affiliation(s)
- Dario Pellegrini
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Alfonso Ielasi
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Maurizio Tespili
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Giulio Guagliumi
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
| | - Giuseppe De Luca
- Division of Cardiology, IRCCS Ospedale Galeazzi-Sant’Ambrogio, Via Cristina Belgioioso, 173, 20161 Milan, Italy; (D.P.)
- Division of Cardiology, AOU “Policlinico G. Martino”, Via Consolare Valeria, 1, 98124 Messina, Italy
- Department of Clinical and Experimental Medicine, University of Messina, Piazza Pugliatti, 1, 98122 Messina, Italy
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24
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Meng S, Kong X, Nan J, Yang X, Li J, Yang S, Zhao L, Jin Z. Comparing the clinical outcomes of single vs. systematic dual stenting strategies for unprotected left main bifurcation lesion: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1145412. [PMID: 37554363 PMCID: PMC10405628 DOI: 10.3389/fcvm.2023.1145412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 07/12/2023] [Indexed: 08/10/2023] Open
Abstract
INTRODUCTION The optimal percutaneous coronary intervention (PCI) strategy for coronary left main (LM) bifurcation lesions remains controversial. This meta-analysis compared the medium and long-term follow-up clinical outcomes of single vs. systematic dual stenting strategies of LM bifurcation lesions. METHODS We systematically identified studies published within 5 years comparing single vs. systematic double stenting strategies for LM bifurcation lesions. The primary endpoint was medium-term (1 year) and long-term (at least 3 years) all-cause death. Secondary outcomes included major adverse cardiovascular events (MACEs), target lesion revascularization (TLR), overall occurrence of stent thrombosis (ST), cardiovascular (CV) mortality, and myocardial infarction (MI). RESULTS Two randomized controlled trials and nine observational studies with 7,318 patients were included in this meta-analysis. In terms of the medium-term follow-up clinical outcomes, our pooled analysis showed that use of the systematic dual stenting strategy was associated with a lower ST risk (odds ratio [OR] = 0.43, 95% confidence interval [CI]: 0.20-0.89, P = 0.02) and cardiac death risk (OR = 0.43, 95% CI: 0.21-0.89, P = 0.02) compared to the single stenting strategy; there was no significant difference between the two strategies regarding rates of all-cause death, MACE, TLR, and MI. Patients with long-term follow-up showed comparable observed clinical outcomes between the two strategies. Most importantly, for patients with true LM bifurcation, the risk of all-cause death, ST, and CV mortality following the systematic dual stenting strategy was significantly lower than the single stenting strategy. CONCLUSIONS For patients with LM bifurcation lesions, both the systematic dual stenting strategy and single stenting strategy demonstrated comparable results in terms of all-cause mortality during medium-term and long-term follow-up. However, the systematic dual stenting strategy showed a tendency towards lower incidence of ST and CV mortality compared to the single stenting strategy during medium-term follow-up. Consequently, the systematic dual stenting strategy yielded superior clinical outcomes for patients with LM bifurcation lesions.
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Affiliation(s)
- Shuai Meng
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiangyun Kong
- Department of General Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Jing Nan
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingsheng Yang
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianan Li
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shenghua Yang
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lihan Zhao
- Department of General Medicine, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Zening Jin
- Department of Cardiology and Macrovascular Disease, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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25
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Offiah G, McGrath P, Kearney P. Late stent thrombosis as a complication of T and small protrusion bifurcation stenting: a case report. Eur Heart J Case Rep 2023; 7:ytad259. [PMID: 37323528 PMCID: PMC10266193 DOI: 10.1093/ehjcr/ytad259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/20/2022] [Accepted: 05/30/2023] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
| | - Paul McGrath
- Department of Cardiology, Cork University Hospital, Wilton, Cork T12 DC4A, Ireland
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26
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Arunothayaraj S, Behan MW, Lefèvre T, Lassen JF, Chieffo A, Stankovic G, Burzotta F, Pan M, Ferenc M, Hovasse T, Spence MS, Brunel P, Cotton JM, Cockburn J, Carrié D, Baumbach A, Maeng M, Louvard Y, Hildick-Smith D. Stepwise provisional versus systematic culotte for stenting of true coronary bifurcation lesions: five-year follow-up of the multicentre randomised EBC TWO Trial. EUROINTERVENTION 2023; 19:EIJ-D-23-00211. [PMID: 37946522 PMCID: PMC10333921 DOI: 10.4244/eij-d-23-00211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/28/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The multicentre European Bifurcation Club Trial (EBC TWO) showed no significant differences in 12-month clinical outcomes between patients randomised to a provisional stenting strategy or systematic culotte stenting in non-left main true bifurcations. AIMS This study aimed to investigate the 5-year clinical results of the EBC TWO Trial. METHODS A total of 200 patients undergoing stent implantation for non-left main bifurcation lesions were recruited into EBC TWO. Inclusion criteria required a side branch diameter ≥2.5 mm and side branch lesion length >5 mm. Five-year follow-up was completed for 197 patients. The primary endpoint was the composite of all-cause mortality, myocardial infarction, or target vessel revascularisation. RESULTS The mean side branch stent diameter was 2.7±0.3 mm and mean side branch lesion length was 10.3±7.2 mm. At 5-year follow-up, the primary endpoint occurred in 18.4% of provisional and 23.7% of systematic culotte patients (hazard ratio [HR] 0.75, 95% confidence interval [CI]: 0.41-1.38). No significant differences were identified individually for all-cause mortality (7.8% vs 7.2%, HR 1.11, 95% CI: 0.40-3.05), myocardial infarction (8.7% vs 13.4%, HR 0.64, 95% CI: 0.27-1.50) or target vessel revascularisation (6.8% vs 9.3%, HR 1.12, 95% CI: 0.37-3.34). Stent thrombosis rates were also similar (1.9% vs 3.1%, HR 0.63, 95% CI: 0.11-3.75). There was no significant interaction between the extent of side branch disease and the primary outcome (p=0.34). CONCLUSIONS In large non-left main true bifurcation lesions, the use of a systematic culotte strategy showed no benefit over provisional stenting for the composite outcome of all-cause mortality, myocardial infarction, or target vessel revascularisation at 5 years. The stepwise provisional approach may be considered preferable for the majority of true coronary bifurcation lesions. CLINICALTRIALS gov: NCT01560455.
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Affiliation(s)
| | | | - Thierry Lefèvre
- Institut Cardiovasculaire Paris Sud, Hôpital privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Jens F Lassen
- Department of Cardiology B, Odense University Hospital, Odense, Denmark and University of Southern Denmark, Odense, Denmark
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Goran Stankovic
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Francesco Burzotta
- Fondazione Policlinico A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuel Pan
- Department of Cardiology, Reina Sofia Hospital, University of Cordoba, (IMIBIC), Cordoba, Spain
| | - Miroslaw Ferenc
- University Heart Center Freiburg - Bad Krozingen, Bad Krozingen, Germany
| | - Thomas Hovasse
- Institut Cardiovasculaire Paris Sud, Hôpital privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Mark S Spence
- Department of Cardiology, Royal Victoria Hospital, Belfast, UK
| | - Philippe Brunel
- Hôpital privé Dijon Bourgogne, Clinique Valmy, Dijon, France
| | - James M Cotton
- Royal Wolverhampton University Hospital NHS Trust, Wolverhampton, UK
| | - James Cockburn
- Sussex Cardiac Centre, University Hospitals Sussex NHS Trust, Brighton, UK
| | - Didier Carrié
- Department of Cardiology, Toulouse University, Rangueil Hospital, Toulouse, France
| | - Andreas Baumbach
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London and Barts Heart Centre, London, UK
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital & Aarhus University, Aarhus, Denmark
| | - Yves Louvard
- Institut Cardiovasculaire Paris Sud, Hôpital privé Jacques Cartier, Ramsay Santé, Massy, France
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27
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Pan M, Lassen JF, Burzotta F, Ojeda S, Albiero R, Lefèvre T, Hildick-Smith D, Johnson TW, Chieffo A, Banning AP, Ferenc M, Darremont O, Chatzizisis YS, Louvard Y, Stankovic G. The 17th expert consensus document of the European Bifurcation Club - techniques to preserve access to the side branch during stepwise provisional stenting. EUROINTERVENTION 2023; 19:26-36. [PMID: 37170568 PMCID: PMC10173756 DOI: 10.4244/eij-d-23-00124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 03/28/2023] [Indexed: 05/13/2023]
Abstract
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.
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Affiliation(s)
- Manuel Pan
- Department of Cardiology, Reina Sofia Hospital, University of Cordoba (IMIBIC), Cordoba, Spain
| | - Jens Flensted Lassen
- Department of Cardiology B, Odense University Hospital & University of Southern Denmark, Odense C, Denmark
| | - Francesco Burzotta
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Soledad Ojeda
- Department of Cardiology, Reina Sofia Hospital, University of Cordoba (IMIBIC), Cordoba, Spain
| | - Remo Albiero
- Interventional Cardiology Unit, Ospedale Civile di Sondrio, Sondrio, Italy
| | - Thierry Lefèvre
- Ramsay Générale de Santé - Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - David Hildick-Smith
- Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Thomas W Johnson
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHSFT & University of Bristol, Bristol, UK
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Adrian P Banning
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, UK
| | - Miroslaw Ferenc
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | | | | | - Yves Louvard
- Ramsay Générale de Santé - Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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28
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Moț ȘDC, Șerban AM, Dădârlat-Pop A, Tomoaia R, Pop D. The Degree of Stent Apposition Measured by Stent Enhancement at the Level of the Side Branch as a Novel Predictor of Procedural Success in Left Main PCI. J Pers Med 2023; 13:jpm13050791. [PMID: 37240961 DOI: 10.3390/jpm13050791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Stent enhancement techniques allow adequate visualization of stent deformation or incomplete stent expansion at the ostium of the side branch. Measuring the stent enhancement side branch length (SESBL) could reflect procedural success in terms of optimal stent expansion and apposition with better long-term outcomes. A longer SESBL may reflect a better stent apposition at the polygon of confluence and at the side branch (SB) ostium. METHODS We evaluated 162 patients receiving the left main (LM) provisional one-stent technique and measured the SESBL, dividing them into two groups: SESBL≤ 2.0 mm and SESBL > 2.0 mm. RESULTS The mean SESBL was 2.0 ± 1.2 mm. More than half of the bifurcations had both main and side branch lesions (Medina 1-1-1) (84 patients, 51.9%) and the length of the SB disease was 5.2 ±1.8 mm. Kissing balloon inflation (KBI) was performed in 49 patients (30.2%). During follow-up (12 months), there was a significantly higher rate of cardiac death in the SESBL ≤ 2.0 mm group (p = 0.02) but no significant difference in all major adverse cardiovascular events (MACEs) (p = 0.7). KBI did not influence the outcomes (p = 0.3). CONCLUSION Suboptimal SESBL is positively correlated with worse outcomes and SB compromise. This novel sign could aid the LM operator to assess the level of stent expansion at the ostium of the SB in the absence of intracoronary imaging.
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Affiliation(s)
- Ștefan Dan Cezar Moț
- Cardiology Department, Heart Institute Niculae Stăncioiu, 19-21 Motilor Street, 400001 Cluj-Napoca, Romania
- 5th Department of Internal Medicine, Faculty of Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Adela Mihaela Șerban
- Cardiology Department, Heart Institute Niculae Stăncioiu, 19-21 Motilor Street, 400001 Cluj-Napoca, Romania
- 5th Department of Internal Medicine, Faculty of Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alexandra Dădârlat-Pop
- Cardiology Department, Heart Institute Niculae Stăncioiu, 19-21 Motilor Street, 400001 Cluj-Napoca, Romania
- 5th Department of Internal Medicine, Faculty of Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Raluca Tomoaia
- 5th Department of Internal Medicine, Faculty of Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Department of Cardiology, Clinical Rehabilitation Hospital, 400347 Cluj-Napoca, Romania
| | - Dana Pop
- 5th Department of Internal Medicine, Faculty of Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- Department of Cardiology, Clinical Rehabilitation Hospital, 400347 Cluj-Napoca, Romania
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Wang Z, Yang J, Li C, Huang J, Fezzi S, Chen E, Cai W, Stankovic G, Wijns W, Chen L, Tu S. Dynamic assessment of the left main-left circumflex bending angle: Implications for ostial left circumflex artery in-stent restenosis after successful two-stent PCI. Int J Cardiol 2023; 378:11-19. [PMID: 36796487 DOI: 10.1016/j.ijcard.2023.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/06/2023] [Accepted: 02/12/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Two-stent techniques for percutaneous coronary intervention (PCI) on left main (LM) bifurcation (LMB) lesions are associated with an increased risk of in-stent restenosis (ISR) at left circumflex artery (LCx) ostium but the underlying mechanisms are incompletely understood. This study sought to investigate the association between cyclic change of LM-LCx bending angle (BALM-LCx) and the risk of ostial LCx ISR following two-stent techniques. METHODS In a retrospective cohort of patients undergoing two-stent PCI for LMB lesions, BALM-LCx and distal bifurcation angle (DBA) were computed with 3-dimensional angiographic reconstruction. The analysis was performed both at end-diastole and end-systole, and the angulation change throughout the cardiac cycle was defined as the cardiac motion-induced angulation change (∆CAngle). RESULTS A total of 101 patients were included. The mean pre-procedural BALM-LCx was 66.8 ± 16.1° at end-diastole and 54.1 ± 13.3° at end-systole with a range of 13.0 ± 7.7°. Pre-procedural ∆CBALM-LCx > 16.4° was the most relevant predictor of ostial LCx ISR (adjusted OR 11.58, 95% CI 4.04-33.19; p < 0.001). Post-procedural ∆CBALM-LCx > 9.8° and stent-induced diastolic BALM-LCx change > 11.6° were also related with ostial LCx ISR. DBA was positively correlated with BALM-LCx and showed a weaker association of pre-procedural ∆CDBA > 14.5° with ostial LCx ISR (adjusted OR 6.87, 95% CI 2.57-18.37; p < 0.001). CONCLUSIONS Three-dimensional angiographic bending angle is a feasible and reproducible novel method for LMB angulation measurement. A large pre-procedural cyclic change of BALM-LCx was associated with an increased risk of ostial LCx ISR following two-stent techniques.
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Affiliation(s)
- Zhiqing Wang
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China; Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Junqing Yang
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chunming Li
- Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Jiayue Huang
- The Lambe Institute for Translational Medicine and Curam, University of Galway, Galway, Ireland
| | - Simone Fezzi
- The Lambe Institute for Translational Medicine and Curam, University of Galway, Galway, Ireland; Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - En Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Wei Cai
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, University of Galway, Galway, Ireland
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Shengxian Tu
- Department of Cardiology, Fujian Medical University Union Hospital, Fuzhou, China; Biomedical Instrument Institute, School of Biomedical Engineering, Shanghai Jiao Tong University, Shanghai, China.
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30
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Moroni A, Marin F, Venturi G, Scarsini R, Ribichini F, De Maria GL, Banning AP. Management of failed stenting of the unprotected left main coronary artery. Catheter Cardiovasc Interv 2023; 101:1001-1013. [PMID: 37002949 DOI: 10.1002/ccd.30636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 02/16/2023] [Accepted: 03/03/2023] [Indexed: 04/03/2023]
Abstract
Percutaneous coronary intervention (PCI) is increasingly accepted as treatment for unprotected left main coronary artery (ULMCA) disease especially in those patients who are unsuitable for cardiac surgery. Treatment of any stent failure is associated with increased complexity and worse clinical outcomes when compared with de novo lesion revascularization. Intracoronary imaging has provided new insight into mechanisms of stent failure and treatment options have developed considerably over the last decade. There is paucity of evidence on the management strategy for stent failure in the specific setting of ULMCA. Treating any left main with PCI requires careful consideration and consequently treatment of failed stents in ULMCA is complex and provides unique challenges. Consequently, we provide an overview of ULMCA stent failure, proposing a tailored algorithm to guide best management and decision in daily clinical practice, with a special focus on intracoronary imaging characterization of causal mechanisms and specific technical and procedural considerations.
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Affiliation(s)
- Alice Moroni
- Clinical and Interventional Cardiology Department, IRCCS Policlinico San Donato, University of Milan, San Donato Milanese, Italy
| | - Federico Marin
- Deparment of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Gabriele Venturi
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Roberto Scarsini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Flavio Ribichini
- Division of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Luigi De Maria
- Deparment of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Adrian P Banning
- Deparment of Cardiology, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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31
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Valenzuela TF, Iaizzo PA. Post-procedure micro-CT analyses of coronary artery stenting in left main vessels of reanimated and perfusion-fixed human hearts. Biomed Eng Online 2023; 22:27. [PMID: 36934270 PMCID: PMC10024839 DOI: 10.1186/s12938-023-01090-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/02/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND Percutaneous coronary interventions (PCIs) within left main coronary arteries are high-risk procedures that require optimization of interactions between stent(s) and diseased vessels. Optical Coherence Tomography (OCT) is a widely accepted tool that enhances physicians' ability to assess proper stent appositions during clinical procedures. The primary aim of this study was to develop complementary post-procedure imaging methodologies to better assess and interpret outcomes of left main PCI procedures, utilizing both reanimated and perfusion-fixed human hearts. METHODS PCIs were performed while obtaining OCT scans within the left main anatomies of six human hearts. Subsequently, each heart was scanned with a micro-CT scanner with optimized parameters to achieve resolutions up to 20 µm. Scans were reconstructed and imported into a DICOM segmentation software to generate computational models of implanted stents and associated coronary vessels. 2D images from OCT that were obtained during PCIs were compared to the 3D models generated from micro-CT reconstructions. In addition, the 3D models were utilized to create virtual reality scenes and enlarged 3D prints for development of "mixed reality" tools relative to bifurcation stenting within human left main coronary arteries. RESULTS We developed reproducible methodologies for post-implant analyses of coronary artery stenting procedures. In addition, we generated high-resolution 3D computational models, with ~ 20-micron resolutions, of PCIs performed within reanimated and perfusion-fixed heart specimens. CONCLUSIONS Generated computational models of left main PCIs performed in isolated human hearts can be used to obtain detailed measurements that provide further clinical insights on procedural outcomes. The 3D models from these procedures are useful for generating virtual reality scenes and 3D prints for physician training and education.
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Affiliation(s)
- Thomas F Valenzuela
- Department of Surgery, University of Minnesota, Visible Heart®Laboratories, 420 Delaware St. SE, B172 Mayo, MMC 195, Minneapolis, MN, 55455, USA
| | - Paul A Iaizzo
- Department of Surgery, University of Minnesota, Visible Heart®Laboratories, 420 Delaware St. SE, B172 Mayo, MMC 195, Minneapolis, MN, 55455, USA.
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Musumeci G, Annibali G. Keep it simple. Catheter Cardiovasc Interv 2023; 101:947-948. [PMID: 36906803 DOI: 10.1002/ccd.30609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 03/13/2023]
Affiliation(s)
- Giuseppe Musumeci
- Division of Cardiology, Azienda Ospedaliera Ordine Mauriziano Umberto I, Turin, Italy
| | - Gianmarco Annibali
- Division of Cardiology, Azienda Ospedaliera Ordine Mauriziano Umberto I, Turin, Italy
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Moulias A, Koros R, Papageorgiou A, Patrinos P, Spyropoulou P, Vakka A, Bozika M, Vasilagkos G, Apostolos A, Nastouli KM, Tsigkas G, Davlouros P. OCT Guidance in Bifurcation Percutaneous Coronary Intervention. Rev Cardiovasc Med 2023; 24:88. [PMID: 39077489 PMCID: PMC11264033 DOI: 10.31083/j.rcm2403088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/14/2023] [Accepted: 02/22/2023] [Indexed: 07/31/2024] Open
Abstract
Coronary bifurcation is defined by the European Bifurcation Consensus as a coronary artery stenosis adjacent to the origin of a significant side branch. Its anatomy is composed of 3 different segments: proximal main vessel, distal main vessel and side branch. Coronary artery bifurcation lesions are encountered in approximately 15-20% of all percutaneous coronary interventions and constitute a complex subgroup of lesions characterized by lower procedural success rates and higher rates of adverse outcomes. In recent years, a growing focus in the European and Japanese bifurcation club meetings has been the emerging role of intravascular imaging, in guiding successful bifurcation percutaneous coronary interventions (PCI). In this review we will present the main ways optical coherence tomography (OCT) can be used to improve outcomes during bifurcation PCI.
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Affiliation(s)
- Athanasios Moulias
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Rafail Koros
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Angeliki Papageorgiou
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Panagiotis Patrinos
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Panagiota Spyropoulou
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Angeliki Vakka
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Maria Bozika
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Georgios Vasilagkos
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Anastasios Apostolos
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | | | - Grigorios Tsigkas
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
| | - Periklis Davlouros
- Department of Cardiology, General University Hospital of Patras, 26504 Patras, Greece
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Milasinovic D. Complex distal left main bifurcation disease requiring a two-stent approach: in search of an accurate DEFINITION. ASIAINTERVENTION 2023; 9:11-13. [PMID: 36936099 PMCID: PMC10015481 DOI: 10.4244/aij-e-22-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Affiliation(s)
- Dejan Milasinovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia and Medical Faculty, University of Belgrade, Belgrade, Serbia
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35
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Stent Thrombosis and Restenosis with Contemporary Drug-Eluting Stents: Predictors and Current Evidence. J Clin Med 2023; 12:jcm12031238. [PMID: 36769886 PMCID: PMC9917386 DOI: 10.3390/jcm12031238] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/08/2023] Open
Abstract
Iterations in stent technologies, advances in pharmacotherapy, and awareness of the implications of implantation techniques have markedly reduced the risk of stent failure, both in the form of stent thrombosis (ST) and in-stent restenosis (ISR). However, given the number of percutaneous coronary interventions (PCI) performed worldwide every year, ST and ISR, albeit occurring at a fairly low rate, represent a public health problem even with contemporary DES platforms. The understanding of mechanisms and risk factors for these two PCI complications has been of fundamental importance for the parallel evolution of stent technologies. Risk factors associated with ST and ISR are usually divided into patient-, lesion-, device- and procedure-related. A number of studies have shown how certain risk factors are related to early (1 month) versus late/very late ST (between 1 month and 1 year and >1 year, respectively). However, more research is required to conclusively show the role of time-dependence of risk factors also in the incidence of ISR (early [1 year] or late [>1 year]). A thorough risk assessment is required due to the complex etiology of ST and ISR. The most effective strategy to treat ST and ISR is still to prevent them; hence, it is crucial to identify patient-, lesion-, device- and procedure-related predictors.
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Arunothayaraj S, Lassen JF, Clesham GJ, Spence MS, Koning R, Banning AP, Lindsay M, Christiansen EH, Egred M, Cockburn J, Mylotte D, Brunel P, Ferenc M, Hovasse T, Wlodarczak A, Pan M, Silvestri M, Erglis A, Kretov E, Chieffo A, Lefèvre T, Burzotta F, Darremont O, Stankovic G, Morice MC, Louvard Y, Hildick-Smith D. Impact of technique on bifurcation stent outcomes in the European Bifurcation Club Left Main Coronary Trial. Catheter Cardiovasc Interv 2023; 101:553-562. [PMID: 36709485 DOI: 10.1002/ccd.30575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/18/2022] [Accepted: 01/15/2023] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Sandeep Arunothayaraj
- Department of Cardiology, Sussex Cardiac Centre, University Hospitals Sussex NHS Trust, Brighton, UK
| | | | - Gerald J Clesham
- Department of Cardiology, Essex Cardiothoracic Centre, Basildon, Essex, UK.,Cardiovascular System Block, MTRC, Anglia Ruskin School of Medicine, Chelmsford, Essex, UK
| | - Mark S Spence
- Department of Cardiology, Belfast Health and Social Care Trust, Belfast, UK
| | - René Koning
- Department of Cardiology, Clinique Saint Hilaire, Rouen, France
| | - Adrian P Banning
- Department of Cardiology, Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mitchell Lindsay
- Department of Cardiology, West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, UK
| | | | - Mohaned Egred
- Department of Cardiology, Freeman Hospital & Newcastle University, Newcastle upon Tyne, UK
| | - James Cockburn
- Department of Cardiology, Sussex Cardiac Centre, University Hospitals Sussex NHS Trust, Brighton, UK
| | - Darren Mylotte
- Department of Cardiology, University Hospital and National University of Ireland, Galway, Ireland
| | - Philippe Brunel
- Interventional Cardiology Unit, Clinique de Fontaine, Dijon, France
| | - Miroslaw Ferenc
- Division of Cardiology and Angiology II, Universitäts-Herzzentrum Bad Krozingem, Bad Krozingen, Germany
| | - Thomas Hovasse
- Department of Cardiology, Institut Cardiovasculaire Paris Sud, Ramsay Santé, Massy, France
| | - Adrian Wlodarczak
- Department of Cardiology, Poland Miedziowe Centrum Zdrowia Lubin, Lubin, Poland
| | - Manuel Pan
- Department of Cardiology, Reina Sofia Hospital, University of Cordoba (IMIBIC), Cordoba, Spain
| | - Marc Silvestri
- Department of Cardiology, GCS Axium, Rambot, Aix en Provence, France
| | - Andrejs Erglis
- Department of Cardiology, Pauls Stradins Clinical University Hospital, University of Latvia, Riga, Latvia
| | - Evgeny Kretov
- Interventional Cardiology Unit, Sibirskiy Fеdеrаl Biomedical Research Center Novosibirsk, Novosibirsk, Russia
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Thierry Lefèvre
- Department of Cardiology, Institut Cardiovasculaire Paris Sud, Ramsay Santé, Massy, France
| | - Francesco Burzotta
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Olivier Darremont
- Department of Cardiology, Clinique Saint-Augustin-Elsan, Bordeaux, France
| | - Goran Stankovic
- Department of Cardiology, University Clinical Center of Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marie-Claude Morice
- Department of Cardiology, Institut Cardiovasculaire Paris Sud, Ramsay Santé, Massy, France
| | - Yves Louvard
- Department of Cardiology, Institut Cardiovasculaire Paris Sud, Ramsay Santé, Massy, France
| | - David Hildick-Smith
- Department of Cardiology, Sussex Cardiac Centre, University Hospitals Sussex NHS Trust, Brighton, UK
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Hidalgo F, González-Manzanares R, Ojeda S, Pastor-Wulf D, Flores G, Gallo I, López J, Dueñas G, Suárez de Lezo J, Romero M, Pan M. Jailed pressure wire technique for coronary bifurcation lesions: structural damage and clinical outcomes. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022:S1885-5857(22)00312-7. [PMID: 36427787 DOI: 10.1016/j.rec.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/08/2022] [Indexed: 11/23/2022]
Abstract
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 (HRadj, 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.
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Affiliation(s)
- Francisco Hidalgo
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Rafael González-Manzanares
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Soledad Ojeda
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain.
| | - Daniel Pastor-Wulf
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Guisela Flores
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Ignacio Gallo
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Josué López
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Guillermo Dueñas
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Javier Suárez de Lezo
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Miguel Romero
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
| | - Manuel Pan
- Servicio de Cardiología, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba, Córdoba, Spain
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38
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Technical Complications of Coronary Bifurcation Percutaneous Interventions. J Clin Med 2022; 11:jcm11226801. [PMID: 36431278 PMCID: PMC9694633 DOI: 10.3390/jcm11226801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/15/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
Coronary bifurcation percutaneous interventions (PCI) comprise a challenging subset of patients with coronary artery disease. Beyond the well-known debate about single versus double stent strategies, which have different outcomes on mid- and long-term follow up, both strategies may be subject, although rarely, to several different technical complications, rarely reported in clinical trials, which need to be defined, classified, and understood by cardiovascular professionals involved in the management of patients with coronary bifurcation disease. The present paper aims to broaden the knowledge of the range of intraprocedural complications and relative treatment during PCI of coronary bifurcations.
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Murasato Y. How to use three-dimensional optical coherence tomography effectively in coronary bifurcation stenting. Front Cardiovasc Med 2022; 9:1023834. [DOI: 10.3389/fcvm.2022.1023834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
Imaging-guided coronary bifurcation intervention has improved clinical outcomes due to the appropriate size selection of the devices and optimization of the procedure (sufficient stent expansion, reduction of stent malapposition, appropriate stent landing zone, and detection of vessel dissection). In particular, three-dimensional optical coherence tomography (3D OCT) facilitates clear visualization of stent configuration and guidewire position, which promotes optimal guidewire crossing to the side branch. Successive side branch dilation leads to wide ostial dilation with less strut malapposition. However, the link connection of the stent located on the bifurcated carina has been found to be an impediment to sufficient opening of the side branch, resulting in incomplete strut apposition. In such cases, the aggressive proximal optimization technique improves the jailing strut pattern, and 3D OCT navigates the guidewire crossing to the optimal cell that is most likely to be expanded sufficiently, which is not always a distal cell. In two-stent deployment, 3D OCT facilitates optimal guidewire crossing, which leads to less metallic carina, clustering, and overlapping. The present review describes a method of clear visualization and assessment with 3D OCT and discusses the efficacy of 3D OCT in coronary bifurcation stenting in clinical practice.
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40
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Gaede L. [Bifurcation lesions : Are new strategies and devices needed?]. Herz 2022; 47:485-494. [PMID: 36269342 DOI: 10.1007/s00059-022-05140-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2022] [Indexed: 11/04/2022]
Abstract
Interventional treatment of bifurcation lesions, especially true complex bifurcation lesions, continue to be a challenge for interventional cardiologists. A primary one stent strategy is always preferred for simple bifurcation lesions, whereas studies in recent years have shown that a two stent strategy may be advantageous for true bifurcations, i.e. those involving at least the distal main branch as well as the side branch. This seems to be even more pronounced when the lesion presents as complex, i.e., the side branch shows high-grade stenosis over longer stretches and the complete lesion fulfils certain criteria, e.g., severe calcification and a bifurcation angle < 45° or > 70°. According to the latest randomized trials and meta-analyses, the double kissing (DK) crush and double kissing mini-crush (DKMC) techniques in particular seem to be advantageous for these lesions; however, in recent years the established techniques have been continuously refined and further developed. The DK culotte technique and the nano-crush technique deserve special attention. Both techniques seem to further improve and simplify the existing underlying strategies; however, further studies to prove the superiority of these techniques over the established ones are still pending. Overall, the implementation of the available randomized study results, the further development of the techniques and also of the materials can continuously improve the outcome of the patients after interventional treatment of bifurcation lesions. This is also confirmed by the latest registry data, which for the first time could show equal event rates in patients after treatment of complex lesions compared to simple lesions in the clinical practice.
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Affiliation(s)
- Luise Gaede
- Medizinische Klinik 2, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Ulmenweg 18, 91054, Erlangen, Deutschland.
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41
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Simsek B, Kostantinis S, Karacsonyi J, Allana S, Vemmou E, Nikolakopoulos I, Burke MN, Garcia S, Wang Y, Chavez I, Gössl M, Sorajja P, Mooney M, Poulose A, Sandoval Y, Traverse J, Rangan BV, Brilakis ES. Outcomes and challenges of the provisional stenting technique: Insights from the PROGRESS-BIFURCATION registry. Catheter Cardiovasc Interv 2022; 100:749-755. [PMID: 36121014 DOI: 10.1002/ccd.30401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/23/2022] [Accepted: 09/06/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Provisional stenting is the most commonly used coronary bifurcation stenting strategy. METHODS We examined the clinical and angiographic characteristics, challenges encountered, and procedural outcomes with the provisional bifurcation stenting strategy in the Prospective Global Registry of Percutaneous Coronary Intervention (PCI) in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). RESULTS Provisional stenting was used in 334 of 430 bifurcation interventions (78%). Technical success was lower (95% vs. 100%, p = 0.017) in provisional, but procedural success (90% vs. 95%, p = 0.095) and incidence of in-hospital major adverse cardiovascular events were similar (5% vs. 5%, p = 0.945) compared with two-stent strategies. Provisional was less often preferred in left main/left anterior descending involvement (47% vs. 73%, p < 0.001). Provisional stenting cases had smaller side branch (SB) diameter (2.4 ± 0.5 vs. 2.7 ± 0.6 mm, p < 0.001), shorter SB lesion length (5 [3-8] vs. 10 [5-10] mm, p < 0.001), less SB diameter stenosis (46 ± 35 vs. 81 ± 20%, p < 0.001), and were less likely to be Medina 1,1,1 (34% vs. 73%, p < 0.001). PCI challenges were less common (30% vs. 58%, p < 0.001) with provisional stenting: (1) rewiring difficulty (43%) that was overcome with use of a different wire (74%) or microcatheter (46%); (2) inability to deliver a stent (22%) or balloon (9%) that was overcome with use of a smaller balloon (88%), rewiring (25%), or increased support/microcatheter (25%). CONCLUSIONS Provisional bifurcation stenting was more often performed in distal lesions with less SB involvement and had lower technical success, but similar procedural success and complications compared with two-stent strategies.
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Affiliation(s)
- Bahadir Simsek
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Spyridon Kostantinis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Judit Karacsonyi
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Salman Allana
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Evangelia Vemmou
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ilias Nikolakopoulos
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Martin Nicholas Burke
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Santiago Garcia
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Yale Wang
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Ivan Chavez
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Mario Gössl
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Paul Sorajja
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Michael Mooney
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Anil Poulose
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Yader Sandoval
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Jay Traverse
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Bavana V Rangan
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Emmanouil S Brilakis
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
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42
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Albiero R, Burzotta F, Lassen JF, Lefèvre T, Banning AP, Chatzizisis YS, Johnson TW, Ferenc M, Pan M, Daremont O, Hildick-Smith D, Chieffo A, Louvard Y, Stankovic G. 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. EUROINTERVENTION 2022; 18:e362-e376. [PMID: 35570748 PMCID: PMC10259243 DOI: 10.4244/eij-d-22-00165] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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 16th 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.
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Affiliation(s)
- Remo Albiero
- Interventional Cardiology Unit, Ospedale Civile di Sondrio, Sondrio, Italy
| | - Francesco Burzotta
- Institute of Cardiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jens Flensted Lassen
- Department of Cardiology B, Odense Universitates Hospital & University of Southern Denmark, Odense C, Denmark
| | - Thierry Lefèvre
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Adrian P Banning
- Cardiovascular Medicine Division, Radcliffe Department of Medicine, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Thomas W Johnson
- Department of Cardiology, Bristol Heart Institute, University Hospitals Bristol and Weston NHSFT & University of Bristol, Bristol, United Kingdom
| | - Miroslaw Ferenc
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Manuel Pan
- Department of Cardiology, Reina Sofia Hospital. University of Cordoba (IMIBIC), Cordoba, Spain
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Alaide Chieffo
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Yves Louvard
- Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France
| | - Goran Stankovic
- Department of Cardiology, Clinical Center of Serbia, and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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