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

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

A Pilot Study on Culottes versus Crossover Single Stenting for True Coronary Bifurcation Lesions

BACKGROUND

The purpose of our study was to compare clinical and angiographic outcomes of planned culottes technique with that of provisional crossover single stenting in the treatment of true coronary bifurcation lesions (CBL) with drug-eluting stent (DES).

METHODS

True CBL patients (n = 104) were randomly assigned to either the provisional stenting of the side branch (crossover group) or the culottes group. Additional side branch (SB) stenting in the crossover group was required if there was thrombolysis in myocardial infarction flow ≤ 1 flow). The primary end point was the occurrence of major adverse cardiac events (MACE) at nine months, including cardiac death, myocardial infarction, target lesion/vessel revascularization and in-stent thrombosis. The secondary end point was angiographic in-segment restenosis at nine months.

RESULTS

The rate of MACE at nine months was similar between the crossover and culottes groups (7.7% vs. 7.7%, p = 1.000). Additional SB stenting in the crossover group was required in 3.8% of patients. There was one procedural occlusion of SB in the crossover group. At nine months, the rate of in-segment restenosis was similar in the parent main vessel (0% vs. 1.9%, p = 1.000), main branch (1.9% vs. 7.7%, p = 0.363) and SB (17.3% vs. 9.6%, p = 0.250) between the crossover and culottes groups, respectively.

CONCLUSIONS

This study demonstrated that there is no significant difference in cumulative MACE or in-segment restenosis between crossover and culottes groups. Larger randomized clinical trials are warranted to re-evaluate the outcomes of the provisional crossover stenting versus the culottes stenting techniques utilizing DES for true CBL.

Comparison of failure rates of crossing side branch with pressure vs. coronary guidewire: a meta-analysis

OBJECTIVES

The aim of this study was to compare the failure rates of crossing side branch (SB) with pressure guidewire vs. coronary guidewire after main vessel (MV) stenting in coronary bifurcation lesions (CBL).

BACKGROUND

Percutaneous coronary intervention of CBL is technically difficult. The European Bifurcation Club recommends performing either fractional flow reserve (FFR) estimation of the SB or final kissing balloon inflation (FKBI) after the MV stenting when a significant SB ostial stenosis is present. Even though FFR is recommended in CBL, there is concern about SB crossing with pressure guidewire among interventionists.

MATERIALS AND METHODS

We undertook a comprehensive literature search to identify all relevant studies reporting the failure rates of SB crossing after MV stenting with either pressure or coronary guidewire. A random effects model was used to compare the failure rates between the two approaches.

RESULTS

Our search identified six studies that reported failure rates of SB crossing with a pressure guidewire (n = 648) and 11 studies that reported failure rates of SB crossing with a coronary guide-wire (n = 2601). Estimated pooled failure rate was 3·9% (95% CI: 1·5% to 9·6%) for inability to cross SB with pressure guidewire. Estimated pooled failure rate of SB crossing with coronary guidewire was 3·1% (95% CI: 1·5% to 6·2%). There was no significant difference between the failure rates in the two groups (P = 0·70).

CONCLUSION

The failure rates of SB crossing after MV stenting are low with both pressure and coronary guidewire procedures, with no significant difference between the two approaches.

Characteristics of drug-eluting stent platforms potentially influencing bifurcated lesion provisional stenting procedure

AIMS

We aimed to review the technical characteristics of DES platforms which have been documented to influence bifurcation stenting procedures conducted according to the provisional approach.

METHODS AND RESULTS

DES platforms have remarkable technical differences (side cell diameter, shape, deformability, etc.). We reviewed the literature data and performed original virtual bench tests to highlight the characteristics of DES platforms which influence the following phases of bifurcation stenting conducted according to the provisional approach: stent implantation in the main vessel across side-branch take-off ("crossover" stenting), proximal optimisation technique, rewiring and kissing balloon inflation. Available data show that the response of different DES platforms to the various procedural steps of provisional stenting is different.

CONCLUSIONS

When treating bifurcated lesions according to the provisional stenting approach, the search for an ideal matching between individual bifurcated anatomy and DES selection should take into account an articulated series of technical parameters.

Proximal optimization technique and kissing balloon inflations with the bioresorbable vascular scaffold for coronary bifurcation percutaneous coronary intervention

Proximal optimization technique and final kissing balloon inflations with noncompliant balloons facilitate success with coronary bifurcation intervention. The use of bioresorbable vascular scaffolds has been postulated to reduce the risk of in-stent restenosis, a particular problem with bifurcation intervention. We present a case of bifurcation intervention in a 49-year-old woman, using for the first time, proximal optimization and kissing balloon inflation within bioresorbable vascular scaffolds, using optical coherence tomography guidance.

Percutaneous coronary intervention for coronary bifurcation disease: consensus from the first 10 years of the European Bifurcation Club meetings

The European Bifurcation Club (EBC) is an independent, non-political and informal "think tank" of scientists with a particular interest in clinical, technical and fundamental aspects of the management of coronary artery bifurcation disease. Bifurcations account for 15-20% of all percutaneous coronary interventions (PCI) and remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate as well as long-term cardiac events. The optimal management is, despite a fast growing scientific literature, still the subject of considerable debate, one of the main concerns being the potential increased risk of late stent thrombosis associated with treatment complexity. The EBC was initiated in 2004 and aims to facilitate an exchange of ideas on management of bifurcation disease. The EBC hosts an annual, compact meeting dedicated to bifurcations which brings together physicians, engineers, biologists, physicists, epidemiologists and statisticians for detailed discussions. Every meeting is finalised with a consensus statement which reflects the unique opportunity of combining the opinion of interventional cardiologists with the opinion of a large variety of other scientists on bifurcation management. This year the EBC celebrates its 10-year anniversary. This consensus document represents the summary of the consensus from the last ten years of the annual EBC meetings.

Technical Aspects of Provisional Stenting in Percutaneous Treatment of Complex Bifurcation Lesions

Drug-eluting stent (DES) implantation using the 'provisional' approach is the gold standard for percutaneous treatment of patients with unselected bifurcated lesions. Nevertheless, many operators still consider the provisional approach unsuitable for coronary patients with complex bifurcation anatomies. Yet, the provisional approach may be so differently carried out that its procedural outcome is often unpredictable. Some technical refinements may help to anticipate or manage procedural difficulties, which may occur during the management of complex patients. We sought to overview the issues related with DES selection as well as some technical points, which may increase the effectiveness of provisional stenting. In particular, the DES characteristics influencing bifurcation interventions and the technical refinements, which may be considered during a provisional stenting procedure are discussed. Indeed, main vessel stent sizing, proximal optimisation, side branch protection modality, side branch rewiring, kissing balloon and side branch rescue techniques are all pivotal to increase the safety and efficacy of the provisional strategy especially in the setting of complex anatomies and patients.

Provisional side branch-stenting for coronary bifurcation lesions: evidence of improving procedural and clinical outcomes with contemporary techniques

OBJECTIVES

To determine whether recent technical modifications have improved clinical outcomes for patients undergoing contemporary bifurcation lesion percutaneous coronary intervention (PCI).

BACKGROUND

Provisional side branch (SB)-stenting has become the preferred strategy for bifurcation PCI. Newer generation drug-eluting stents (DESs), the proximal optimization technique (POT), and the use of noncompliant (NC) balloons for final kissing inflation (FKI) have the potential to optimize outcomes.

METHOD

We compared baseline characteristics, procedural and clinical outcomes in 300 consecutive patient pairs treated in 2005 and 2009. The primary outcome measure was the cumulative incidence of major adverse cardiac events (MACE) at 2-years.

RESULTS

Compared to 2005, patients undergoing PCI in 2009 were at higher risk: prior myocardial infarction (18% vs. 8%, P = 0.0004), left ventricular function (EF 54 ± 13% vs. 61 ± 12%, P < 0.0001). Cypher (53 vs. 3%, P < 0.001) and Taxus (47 vs. 11%, P < 0.0001) stents were used more frequently in 2005, and Xience V in 2009 (0 vs. 47%, P < 0.0001). In 2009, the POT was performed in 36% and NC balloons used for FKI in 81%. SB stenting was required less frequently in 2009 (9% vs. 22%, P < 0.001). Two-year MACE was significantly lower in 2009 than 2005 (5.7 vs. 11.3%, P = 0.02), a difference driven by fewer cardiac deaths (2.0 vs. 5.0%, P = 0.05). MACE was independently associated with left main bifurcation treatment [hazard ratio (HR) 1.85:95%, CI 1.04-3.29; P = 0.036], side-branch stenting (HR 2.31:95% CI 1.27-4.20; P = 0.006), and PCI in 2005 (HR 1.86:95% CI 1.03-3.37; P = 0.004).

CONCLUSIONS

Together, contemporary techniques and newer generation DES appear to improve outcomes and are both recommended for widespread uptake in patients undergoing provisional SB stenting for coronary bifurcation lesions.