Customizable Angioplasty Balloon-Forming Machine: Towards Precision Medicine in Coronary Bifurcation Lesion Interventions

The ability to customize the size and shape of angioplasty balloons may be useful in many clinical and research applications of coronary and endovascular intervention. Fully customizable balloons are outside the reach of most researchers due to their prohibitive cost. A small-scale balloon-forming machine was developed to produce fully customizable balloons. This study describes the creation of this customizable balloon-forming machine and identifies the key components of manufacturing a patient-specific balloon. Using a standard balloon-shaped mold created with a novel application of 3D stereolithography-printed resin, 104 PET balloon formation tests were conducted. A statistical study was conducted in which molding temperature and inflation air pressure were independent variables ranging from 100 to 130 °C and from 3.7 to 6.8 atm, respectively. The criteria for balloon-forming success were defined; pressure and temperature combined were found to have a significant impact on the success (p = 0.011), with 120 °C and 4.76 atm resulting in the highest chance for success based on a regression model.

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

OBJECTIVES

This study aimed to determine whether side branch (SB) wire jailing before main vessel (MV) stenting could prevent SB occlusion after the 1-stent strategy for bifurcation percutaneous coronary intervention.

BACKGROUND

The benefits of SB wire jailing in the 1-stent strategy remain unclear.

METHODS

From the COBIS (Coronary Bifurcation Stenting) III registry, 1,890 patients with bifurcation lesions who underwent the 1-stent strategy using second-generation drug-eluting stents were identified and classified into 2 groups according to the use of SB wire jailing: wire jailing (n = 819) and non-wire jailing (n = 1,071). The incidence of SB occlusion (Thrombolysis In Myocardial Infarction flow grade <3) and target lesion failure (cardiac death, myocardial infarction, or target lesion revascularization) was compared.

RESULTS

The incidence of final SB occlusion was not significantly different between wire jailing (1.8%) vs non-wire jailing (2.9%; P = 0.182). However, wire jailing at the SB was a significant protective factor for SB occlusion after MV stenting on multivariate analysis and was significantly associated with a lower incidence of SB occlusion in patients with significant stenoses (≥60%) at the SB (5.1% vs 11.3%; odds ratio: 0.42; 95% CI: 0.19-0.89; P = 0.028) or MV (3.1% vs 6.2%; odds ratio: 0.49; 95% CI: 0.24-0.95; P = 0.039). During follow-up (median 52 months), the incidence of target lesion failure was not significantly different between wire jailing and non-wire jailing (7.6% vs 6.3%; P = 0.343).

CONCLUSIONS

During bifurcation percutaneous coronary intervention with the 1-stent strategy, wire jailing at the SB was associated with a lower rate of final SB occlusion following MV stenting in patients with severe stenoses at the SB or MV but not with overall bifurcation lesions. Long-term clinical outcomes were comparable between the 2 groups.

Modelling of hemodynamics in bifurcation lesions of coronary arteries before and after myocardial revascularization

Modelling of patient-specific hemodynamics for a clinical case of severe coronary artery disease with the bifurcation stenosis was carried out with allowance for standard angiographic data obtained before and after successfully performed myocardial revascularization by stenting of two arteries. Based on a non-Newtonian fluid model and an original algorithm for fluid dynamics computation operated with a limited amount of initial data, key characteristics of blood flow were determined to analyse the features of coronary disease and the consequences of its treatment. The results of hemodynamic modelling near bifurcation sites are presented with an emphasis on physical, physiological and clinical phenomena to demonstrate the feasibility of the proposed approach. The main limitations and ways to minimize them are the subjects of discussion as well. This article is part of the theme issue 'Transport phenomena in complex systems (part 2)'.

A multi-center, international, randomized, 2-year, parallel-group study to assess the superiority of IVUS-guided PCI versus qualitative angio-guided PCI in unprotected left main coronary artery (ULMCA) disease: Study protocol for OPTIMAL trial

Background

Percutaneous coronary intervention (PCI) is used increasingly for revascularization of unprotected left main coronary artery (LMCA) disease. Observational studies and subgroup analyses from clinical trials, have suggested a possible benefit from the use of intravascular ultrasound (IVUS) guidance when performing unprotected LMCA PCI. However, the value of imaging with IVUS has never been proven in an appropriately powered randomized clinical trial. The OPtimizaTIon of Left MAin PCI With IntravascuLar Ultrasound (OPTIMAL) trial has been designed to establish whether IVUS-guided PCI optimization on LMCA is associated with superior clinical outcomes when compared with standard qualitative angiography-guided PCI.

Methods

The OPTIMAL trial is a randomized, multicenter, international study designed to enroll a total of 800 patients undergoing PCI for unprotected LMCA disease. Patients will be randomized in a 1:1 fashion to IVUS-guided PCI versus angiogram-guided PCI. In patients allocated to the angiogram-guided arm, use of IVUS is discouraged, unless there are safety concerns. In patients allocated to the IVUS guidance arm, pre-procedural IVUS assessment is highly recommended, whilst post-procedural IVUS assessment is mandatory to confirm appropriate stenting result and/or to guide stent result optimization, according to predefined criteria. Patients will be followed up to 2 years after the index procedure. The primary outcome measure is the Academic Research Consortium (ARC) patient-oriented composite endpoint (PoCE) which includes all-cause death, any stroke, any myocardial infarction and any repeat revascularization at 2 years follow-up.

Discussion

The OPTIMAL trial aims to provide definitive evidence about the clinical impact of IVUS-guidance during PCI to an unprotected LMCA. It is anticipated by the investigators, that an IVUS-guided strategy will be associated with less clinical events compared to a strategy guided by angiogram alone.

Trial registration

ClinicalTrials.gov: NCT04111770. Registered on October 1, 2019.

The Predictive Effect of Negative Psychological Emotions of Anxiety and Depression on the Poor Prognosis of CHD Patients with Stent Implantation and the Improvement of Clinical Intervention Measures

OBJECTIVE

To explore the predictive effect of negative emotions such as anxiety and depression on the poor prognosis of coronary heart disease (CHD) patients with stent implantation and to seek the improvement of clinical intervention measures.

METHODS

A total of 303 patients with CHD and PCI were recruited from February 2019 to April 2021. The risk factors of CHD such as anxiety and depression, age, sex, smoking and drinking, BMI, hypertension, diabetes, dyslipidemia, and family history of CHD were collected. Meanwhile, clinical data such as laboratory examination, angiography, diseased vessels, and stent types were collected. The patients were followed up for 1 year, and the medical records, hospitalization records, or death records were checked by telephone interview once a month. Major adverse cardiovascular events (MACE) such as emergency and causes, readmission times and causes, new nonfatal myocardial infarction, stent restenosis, heart failure, arrhythmia, and death were recorded. The incidence of anxiety and depression in patients after PCI was counted, and Cox regression was applied to analyze the influence and prediction of anxiety and depression on MACE in patients with CHD stent implantation and improve clinical intervention measures.

RESULTS

Compared with those without MACE, anxiety (56.25% vs 30.63%), depression (62.5% vs 22.88%, P < 0.01), anxiety combined with depression (46.88% vs 15.50%, P < 0.01), and hypertension history (71.8% vs 39.11%, P < 0.01) were more common in patients with MACE. Uncorrected Cox proportional hazard regression found that people with anxiety had a higher risk of developing MACE than those without anxiety (HR 3.181, P < 0.01). Multiple Cox proportional hazard regression analysis of anxiety showed that anxiety was an independent predictor of cumulative MACE (P < 0.01). The risk of developing MACE in patients with anxiety was 3.742 times higher than that in patients without anxiety (P < 0.01). Uncorrected Cox hazard regression analysis showed that people with depression had a higher risk of developing MACE than those without depression (HR 5.434, P < 0.01). Furthermore, the results also uncovered that depression was an independent predictor of cumulative MACE (P < 0.01). The risk of MACE in patients with depression was 3.087 times higher than that in patients without depression (P < 0.01). Cox hazard regression showed that the risk of MACE in patients with anxiety and depression was significantly higher than that in patients without anxiety and depression (HR 4.642, P < 0.01). After screening, it was found that anxiety with depression could predict the occurrence of MACE (P < 0.01). The risk of MACE in patients with anxiety and depression was 3.702 times higher than that in patients without anxiety and depression (P < 0.01). Cox regression analysis showed that the risk of MACE with only anxiety and depression was 2.793 times higher than that without anxiety and depression (95% CI 0.914 8.526), with no statistical significance (P > 0.05), and the risk of MACE with depression without anxiety was significantly higher than that without anxiety and depression (P < 0.01). The risk of MACE in patients with anxiety and depression was 7.303 times higher than that in patients without anxiety and depression (P < 0.01).

CONCLUSION

Negative emotions such as anxiety and depression can increase the risk of poor prognosis of patients with CHD. Therefore, in clinical work, in addition to routine treatment and nursing during hospitalization, it is recommended to screen patients with depression in CHD patients. Medical staff should use simple and effective assessment tools in time and take active measures to improve the depression of patients. This trial is registered with ChiCTR2200055645.

Percutaneous coronary intervention in unprotected left main coronary artery stenosis: Mid-term outcomes of a single-center observational study

BACKGROUND

Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected left main coronary artery (ULMCA) disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG even after adequate counselling by heart team. We assessed the safety, in-hospital and mid-term outcomes of ULMCA stenting with drug-eluting stents (DES) in Indian patients.

METHODS

Our study was a retrospective analysis of patients who had undergone ULMCA PCI at a tertiary center, between March 2011 and February 2020. Clinical characteristics, procedural data, and follow-up data were analyzed. The primary outcome was a composite of major adverse cardiovascular and cerebrovascular events (MACCE) during the hospital stay and at follow-up. The median follow-up was 2.8 years (interquartile range: 1.5-4.1 years).

RESULTS

661 patients (mean age, 63.5 ± 10.9 years) had undergone ULMCA PCI. The mean SYNTAX score was 27.9 ± 10.4 and the mean LVEF was 58.0 ± 11.1%. 3-vessel disease and distal lesions were noted in 54% and 70.6% patients, respectively. The incidence of in-hospital MACCE was 1.8% and the MACCE during follow-up was 11.5% (including 48 [8.4%] cardiac deaths). The overall survival rates after one, three, five, and nine years were 94%, 88%, 84%, and 82%, respectively. The multivariate analysis revealed that age >65 years and high SYNTAX scores were independent predictors of mid to long-term mortality.

CONCLUSION

ULMCA PCI with DES is safe and has acceptable in-hospital and mid-term outcomes among patients with low-to-intermediate SYNTAX score.

Towards a common pathway for the treatment of left main disease: contemporary evidence and future directions: Left main disease treatment

There is increasing evidence to support percutaneous treatment of left main (LM) disease. Due to its major clinical impact, any procedure in the left main should be meticulously planned and performed. In this review, we aim to integrate the available evidence into a common treatment pathway, starting with understanding the distinct anatomical features of the left main. A three-level decision-making process is presented. First, in instances of angiographic ambiguity, intravascular ultrasound and fractional flow reserve can be used to decide if revascularisation could be deferred. Second, if revascularisation is indicated, the risks and benefits of percutaneous versus surgical procedures should be evaluated. Third, if percutaneous coronary intervention (PCI) is chosen, the operator should decide between the provisional single-stent versus upfront two-stent strategies. Regardless of the PCI technique selected, it should be performed according to the recommendations of a stepwise procedure utilising proximal optimisation (POT) after each instance of crossover stenting and kissing balloon inflation (KBI) where necessary. In addition to the recognised quality markers such as POT and KBI, we discuss the clinical relevance of the operator's LM PCI experience and the intracoronary imaging guidance when treating patients with left main disease.

Comparison of 2-Stenting Strategies Depending on Sequence or Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era - Analysis From the COBIS (Coronary Bifurcation Stenting) III Registry

BACKGROUND

It has not been determined which specific 2-stenting strategy is the best for bifurcation lesions. Our aim was to investigate the clinical outcomes of various 2-stenting strategies in the era of 2nd-generation drug-eluting stents (2G-DES).

METHODS AND RESULTS

We analyzed 454 patients who finally underwent 2-stenting for a bifurcation lesion, from among 2,648 patients enrolled in the COBIS III registry. The primary outcome was target lesion failure (TLF). Patients were analyzed according to stenting sequence (provisional [main vessel stenting first] vs. systemic [side branch stenting first]) and stenting technique (crush vs. T vs. culotte vs. kissing/V stenting). Overall, 4.4 years' TLF after 2-stenting treatment for bifurcation lesion was excellent: TLF 11.2% and stent thrombosis 1.3%. There was no difference in TLF according to 2-stenting strategy (11.1% vs. 10.5%, P=0.990 for provisional and systemic sequence; 8.6% vs. 14.4% vs. 12.9% vs. 12.2%, P=0.326 for crush, T, culotte, kissing/V technique, respectively). Only left main (LM) disease and a shorter duration of dual antiplatelet therapy (DAPT) were associated with TLF. The distribution of DAPT duration differed between patients with and without TLF, and the time-point of intersection was 2.5 years. Also, the side branch was the most common site of restenosis.

CONCLUSIONS

The stenting sequence or technique did not affect clinical outcomes, but LM disease and shorter DAPT were associated with TLF, in patients with bifurcation lesions undergoing 2-stenting with 2G-DES.

Side-branch expansion capacity of contemporary DES platforms

Background

Percutaneous coronary interventions (PCI) of bifurcation stenoses are both complex and challenging. Stenting strategies share that the stents’ side cells must be carefully explored and appropriately prepared using balloons or stents. So far, stent manufacturers have not provided any information regarding side-branch expansion capacity of their stent platforms.

Aims

Given that drug-eluting stent (DES) information regarding their mechanical capacity of side-branch expansion is not available, we aimed to evaluate contemporary DES (Orsiro, BIOTRONIK AG; Xience Sierra, Abbott Vascular; Resolute Integrity, Medtronic; Promus Premier Select, Boston Scientific; Supraflex Cruz, Sahajan and Medical Technologies) by their side-branch expansion behavior using in vitro bench testing.

Methods

In this in vitro study, we analyzed five commercially available DES (diameter 3.0 mm), measuring their side-branch expansion following inflation of different high-pressure non-compliant (NC) balloons (balloon diameter: 2.00–4.00 mm), thereby revealing the morphological characteristics of their side-branch expansion capacities.

Results

We demonstrated that all tested contemporary DES platforms could withstand large single-cell deformations, up to 4.0 mm. As seen in our side-branch experiments, DES designs consisting of only two connectors between strut rings did not only result in huge cell areas, but also in larger cell diameters following side-branch expansion compared with DES designs using three or more connectors. Furthermore, the stent cell diameter attained was below the balloon diameter at normal pressure.

Conclusions

We recommend that the expansion capacity of side-branches should be considered in stent selection for bifurcation interventions.

Predictive value of N-terminal pro-B-type natriuretic peptide (NT-pro BNP) combined with D-dimer for no-reflow phenomenon in patients with acute coronary syndrome after emergency of percutaneous coronary intervention

Acute coronary syndrome (ACS) is a critical illness in cardiovascular disease. The purpose of this study was to investigate the value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and D-dimer in predicting the occurrence of no reflow in emergency percutaneous coronary intervention (PCI) in patients with ACS. One hundred and sixty-eight ACS patients were recruited, including 88 patients with normal reflow and 80 patients with no reflow after emergency PCI. The levels of serum NT-proBNP and D-dimer in the patients were detected before PCI, immediately after PCI, 2 hours, and 6 months after PCI. The ROC curve was used to evaluate the predictive value of NT-proBNP and D-dimer in no-reflow phenomenon. Logistic regression model was used to analyze the independent influencing factors of no reflow phenomenon. Logistic regression analysis confirmed that NT-proBNP and D-dimer were independent predictors of the occurrence of no reflow in the total population. The ROC curve showed that the AUC value was 0.909 when NT-proBNP combined with D-dimer. The detection of NT-proBNP combined with D-dimer was helpful to predict the occurrence of no-reflow phenomenon after emergency PCI in ACS patients.

Ten-Year Trends in Coronary Bifurcation Percutaneous Coronary Intervention: Prognostic Effects of Patient and Lesion Characteristics, Devices, and Techniques

Background

Despite advances in devices and techniques, coronary bifurcation lesion remains a challenging lesion subset in the field of percutaneous coronary intervention (PCI). We evaluate 10‐year trends in bifurcation PCI and their effects on patient outcomes.

Methods and Results

We analyzed 10‐year trends in patient/lesion characteristics, devices, PCI strategy, stent optimization techniques, and clinical outcomes using data from 5498 patients who underwent bifurcation PCI from 2004 to 2015. Clinical outcomes 2 years after the index procedure were evaluated in terms of target vessel failure (a composite of cardiac death, myocardial infarction, and target vessel revascularization) and a patient‐oriented composite outcome (a composite of all‐cause death, myocardial infarction, and any revascularization). During the 10‐year study period, patient and lesion complexity, such as multivessel disease, diabetes mellitus, chronic kidney disease, and left main bifurcation, increased continuously (all P<0.001). The risk of target vessel failure or patient‐oriented composite outcome decreased continuously from 2004 to 2015 (target vessel failure: from 12.3% to 6.9%, log‐rank P<0.001; patient‐oriented composite outcome: from 13.6% to 9.3%, log‐rank P<0.001). The use of a second‐generation drug‐eluting stent and decreased target vessel failure risk in true bifurcation lesions were the major contributors to improved patient prognosis (interaction P values were <0.001 and 0.013, respectively).

Conclusions

During the past decade of bifurcation PCI, patient and lesion characteristics, devices, PCI techniques, and patient prognosis have all significantly changed. Despite increased patient and lesion complexity, clinical outcomes after bifurcation PCI have improved, mainly because of better devices and more widespread adoption of procedural optimization techniques and appropriate treatment strategies.

Registration

URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01642992 and NCT03068494.

Feasibility and efficacy of an ultra-short side branch-dedicated balloon in coronary bifurcation stenting

BACKGROUND

Side branch (SB) dilation with an ultra-short balloon after main vessel (MV) stenting may minimise stent failure in coronary bifurcation lesions.

AIMS

We sought to investigate the feasibility and efficacy of the Glider balloon (GB), a side branch (SB)-dedicated balloon 4 mm in length, in coronary bifurcation stenting.

METHODS

In bench testing, stent configuration was examined with micro-focus computed tomography after crossover stenting followed by GB dilation or kissing balloon inflation (KBI). In the clinical study we performed GB dilatation after MV stenting for 207 lesions in 194 patients. Failure of the GB dilation and additional procedures due to inducible stent failure were investigated as well as adverse cardiac events at 1-year follow-up.

RESULTS

In bench testing GB dilation maintained cross-sectional stent area without significant deformation and presented effective jailed strut removal in a high-angled bifurcation model. In the clinical study the cohort included left main, true bifurcation lesion, and two-stent treatment in 42.0%, 45.9%, and 14.0%, respectively. The proximal optimisation technique (POT) or POT-like inflation was performed in 82.1%. GB crossing failure, SB stenting due to dissection, and stent deformation requiring correction by KBI or MV dilation occurred in 8.7%, 1.4%, and 5.8%, respectively. Finally, simple GB dilation without KBI was completed in 91.8% for SB dilation. At one-year follow-up, target lesion revascularisation, cardiac death, myocardial infarction, and stent thrombosis were found in 7.2%, 2.1%, 2.1%, and 1.0%, respectively.

CONCLUSIONS

Simple GB dilation after adequate expansion of the proximal MV stent provided acceptable acute and long-term results as an alternative to KBI.

Clinical outcome after percutaneous coronary intervention with drug-eluting stent in bifurcation and nonbifurcation lesions: a meta-analysis of 23 981 patients

BACKGROUND

PCI in CBL is common and technically demanding. Whether such patients have adverse outcome during the follow-up after successful PCI is unclear. We aim to compare the clinical outcome after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation of coronary bifurcation lesions (CBL) and non-CBL.

METHODS

We performed a systematic literature search to identify studies reporting the clinical outcome of patients undergoing PCI in CBL or not. Patients with left main disease constituted a predefined subgroup. Primary study end-point was major adverse cardiac events (MACE).

RESULTS

Fifteen publications on 23 891 patients with coronary artery disease treated by DES in CBL or not were identified. Median follow-up length was 24 months (range: 12-60). MACE at the longest available follow-up were significantly higher in CBL as compared with non-CBL (19.0 vs. 12.1%, P < 0.001). Similar results were obtained in the subanalysis restricted to second-generation DES studies. The MACE rate was higher early, then decreased during the follow-up being, however, appreciable at all timings up to 36 months. In the left main (LM) subanalysis (four studies, 3210 patients), patients underwent DES implantation in distal LM, as compared with nondistal LM, had increased the MACE rate during the follow-up (27.4 vs. 17.4%, P < 0.001), which was driven by higher target vessel revascularization.

CONCLUSIONS

In the contemporary DES era, CBL represent a subset of lesions associated with increased rate of MACE after PCI. This data prompt for studies aimed at improving the clinical outcomes of patients with CAD.

Impact of lesion preparation strategies on outcomes of left main PCI: The EXCEL trial

OBJECTIVES

We examined outcomes according to lesion preparation strategy (LPS) in patients with left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in the EXCEL trial.

BACKGROUND

The optimal LPS for LMCA PCI is unclear.

METHODS

We categorized LPS hierarchically (high to low) as: (a) rotational atherectomy (RA); (b) cutting or scoring balloon (CSB); (c) balloon angioplasty (BAL); and d) direct stenting (DIR). The primary endpoint was 3-year MACE; all-cause death, stroke, or myocardial infarction.

RESULTS

Among 938 patients undergoing LMCA PCI, RA was performed in 6.0%, CSB 9.5%, BAL 71.3%, and DIR 13.2%. In patients treated with DIR, BAL, CSB, and RA, respectively, there was a progressive increase in SYNTAX score, LMCA complex bifurcation, trifurcation or calcification, number of stents, and total stent length. Any procedural complication occurred in 10.4% of cases overall, with the lowest rate in the DIR (7.4%) and highest in the RA group (16.1%) (p_trend  = .22). There were no significant differences in the 3-year rates of MACE (from RA to DIR: 17.9%, 20.2%, 14.5%, 14.7%; p = .50) or ischemia-driven revascularization (from RA to DIR: 16.8%, 10.8%, 12.3%, 14.2%; p = .65). The adjusted 3-year rates of MACE did not differ according to LPS.

CONCLUSIONS

The comparable 3-year outcomes suggest that appropriate lesion preparation may be able to overcome the increased risks of complex LMCA lesion morphology.

Left Main Disease and Bifurcation Percutaneous Coronary Intervention: Focus on Antithrombotic Therapy

Revascularization of both left main and bifurcation lesions is currently considered an important feature of complex percutaneous coronary intervention (PCI), whereas stenting distal left main bifurcation is fairly challenging. Recent evidence shows that such lesions are associated with an increased risk of ischemic events. There is no universal consensus on the optimal PCI strategy or the appropriate type and duration of antithrombotic therapy to mitigate the thrombotic risk. Prolonged dual antiplatelet therapy or use of more potent P2Y12 inhibitors have been investigated in the context of this high-risk subset of the population undergoing PCI. Thus, while complex PCI is a growing field in interventional cardiology, left main and bifurcation PCI constitutes a fair amount of the total complex procedures performed recently, and there is cumulative interest regarding antithrombotic therapy type and duration in this subset of patients, with decision-making mostly based on clinical presentation, baseline bleeding, and ischemic risk, as well as the performed stenting strategy.

One-year outcome of single-stent crossover versus accurate ostial stenting for isolated left anterior descending ostial stenosis

BACKGROUND

The optimal strategy of percutaneous coronary intervention (PCI) for isolated left anterior descending (LAD) ostial lesions remains debatable. This study aimed to compare clinical outcomes of patients with isolated LAD ostial stenosis treated by single-stent crossover versus accurate ostial stenting.

METHODS

A total of 216 eligible consecutive patients with isolated de novo LAD ostial stenosis were enrolled, and were stratified according to the stenting techniques. Clinical follow-up was performed by review of medical charts or telephone contact with the patients, and repeat angiography was made at 9-12 months after the procedure. Major adverse cardiovascular events (MACE) including cardiac death, myocardial infarction, non-fatal stroke and target vessel revascularization (TVR) were recorded.

RESULTS

Single-stent crossover and accurate ostial stenting were applied to 78 (36%) and 138 (64%) patients, respectively. During a mean of 13 ± 4.1 months of follow-up, the rate of composite MACE (19.6 vs. 8.9%; P = 0.040) was higher in LAD ostial stenosis patients treated with accurate ostial stenting than those treated with single-stent crossover technique, mainly driven by more frequent TVR (17.4 vs. 7.7%; P = 0.048). PCI strategy was an independent predictor of MACE (hazard ratio 2.561; 95% CI, 1.041-6.299; P = 0.021) in the multivariable Cox regression analysis.

CONCLUSIONS

Our retrospective study suggests that the single-stent crossover technique is associated with a better 1-year clinical outcome compared with accurate ostial stenting in patients with isolated LAD ostial stenosis.

Assessment of single and double coronary bifurcation stenting techniques using multimodal imaging and 3D modeling in reanimated swine hearts using Visible Heart® methodologies

Stent implantation in bifurcated coronary lesions is technically challenging so that procedural refinements are continuously investigated. Novel procedure modeling and intracoronary imaging techniques may offer critical insights on stent deformations and stent-wall interactions during bifurcation stenting procedures. Thus, we assessed coronary bifurcation stenting techniques using multimodal imaging and 3D modeling in reanimated swine hearts. Harvested swine hearts were reanimated using Visible Heart® methodologies and (under standard fluoroscopic guidance) used to test 1-stent (provisional and inverted provisional) and 2-stent (culotte, TAP and DK-crush) techniques on bifurcations within various coronary vessels using commercially available devices. Intracoronary angioscopy and frequency-domain optical-coherence-tomography (OCT) were obtained during the procedures. 3D OCT reconstruction and micro-computed tomography 3D modeling (post heart fixations) were used to assess stent deformations and stent-wall interactions. We conducted multiple stenting procedures and collected unique endoscopic and OCT images (and subsequent computational models from micro-CT) to assess stent deformations and device/wall interactions during different steps of bifurcation stenting procedures. Endoscopy, micro-CT and virtual reality processing documented that different 1- and 2-stent techniques, practiced according to experts’ recommended steps, achieve optimal post-intervention stent conformation. As compared with intra-procedural endoscopy, software-generated 3D OCT images accurately depicted stent deformations during 1-stent techniques. On the opposite, during more complex 2-stent techniques, some defects were appreciated at 3D OCT reconstruction despite optimal 2D OCT images. This study provided unique insights regarding both stent deformations occurring in the course of bifurcation stenting and the efficacy of OCT to visualize them.

Double kissing inflation outside the stent secures the patency of small side branch without rewiring

BACKGROUND

The jailed balloon technique is widely used for coronary bifurcation lesions, but a residual risk of SB occlusion remains, necessitating SB rewiring and further interventions, including balloon inflation or stenting, which may result in failure and SB loss. This study introduced a novel modified technique of small side branch (SB) protection, namely, double kissing inflation outside the stent (DKo) technique, for coronary bifurcations without the need for SB rewiring.

METHODS

We performed the DKo technique in consecutive patients in our center from 1/2019 to 12/2019. The procedure was as follows. We inserted a guide wire into both branches followed by proper preparation. The SB balloon was simultaneously inflated with main vessel (MV) stenting. The SB balloon remained in situ until it was kissing inflated with postdilation of the bifurcation core, which is different from traditional strategies. The proximal optimization technique was performed with a short noncompliant balloon strictly not exceeding the bifurcation. Rates of SB loss and in-hospital outcomes were evaluated.

RESULTS

The technique was successfully performed in all 117 enrolled patients without any rewiring or SB loss. The mean lesion lengths of the MV and SB were 38.3 ± 19.9 mm and 11.7 ± 7.1 mm, respectively. On average, 1.5 ± 0.6 stents were used per patient, while the mean pressure of the SB balloon was 7.4 ± 3.1 atm. DKo achieved excellent procedural success in the proximal and distal MVs: increased minimal lumen diameter (0.64 ± 0.58 mm to 3.05 ± 0.38 mm, p < 0.001; 0.57 ± 0.63 mm to 2.67 ± 0.35 mm, p < 0.001) and low residual stenosis (11.4 ± 3.4%; 7.2 ± 4.6%). DKo secured the patency of the SB without any rewiring and improved the SB stenosis with minimal lumen diameter (0.59 ± 0.48 mm to 1.20 ± 0.42 mm, p < 0.001) and stenosis (71.9 ± 19.4% to 42.2 ± 14.0%, p < 0.001). No MACE was noted in the hospital.

CONCLUSIONS

DKo for bifurcation lesions was shown to be acceptable with high procedural success and excellent SB protection.

Percutaneous coronary intervention for bifurcation coronary lesions: the 15th consensus document from the European Bifurcation Club

The 15th European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019. It facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that a provisional approach with optional side branch treatment utilising T, T and small protrusion (TAP) or culotte continues to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially those involving the LM, adoption of dedicated two-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using two-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardise clinical outcome. The development of novel technical tools and drug regimens deserves attention. In particular, intracoronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored antiplatelet therapy have been identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components has resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimising the clinical outcomes for every patient undergoing PCI on a CBL.

Online three-dimensional OFDI-guided versus angiography-guided PCI in bifurcation lesions: design and rationale of the randomised OPTIMUM trial

AIMS

The feasibility of offline optical coherence tomography (OCT) guidance in bifurcation (with either two-dimensional or three-dimensional images) and its potential benefits have been demonstrated in retrospective studies; however, these have not yet been investigated prospectively. The aim of this trial is to determine the superiority of online three-dimensional optical frequency domain imaging (3D-OFDI)-guided stenting to angiography-guided percutaneous coronary intervention (PCI) in terms of incomplete stent apposition (ISA) at the bifurcation segment.

METHODS AND RESULTS

The OPTIMUM trial is a randomised, superiority, multicentre clinical trial. The primary endpoint of this trial is the post-procedural percentage of malapposed struts assessed by OFDI in the main branch bifurcation region after final kissing balloon dilatation (FKBD). A total of 106 patients will be randomly allocated to either 3D-OFDI guidance or angiography guidance PCI. Bifurcation lesions will be treated with a provisional single-stent strategy using the Ultimaster sirolimus-eluting stent. Patients randomised to the 3D-OFDI guidance arm will undergo OFDI assessment in the main branch (MV) after rewiring into the jailed side branch following stent implantation, while in the angiography guidance arm re-crossing of a wire into the side branch will be performed using conventional fluoroscopic/angiographic guidance. In patients in the 3D-OFDI guidance arm, if the position of the wire is not located in the optimal cell, further attempts to redirect the wire to the optimal cell will be performed, with subsequent OFDI acquisitions to confirm the re-crossing position. The proximal optimisation technique and FKBD are mandatory in this trial. The study will provide a 90% power to show superiority of 3D-OFDI guidance PCI compared with angiography-guided PCI.

CONCLUSIONS

The OPTIMUM trial will be the first prospective, randomised trial to evaluate the efficacy and safety of online 3D-OFDI-guided PCI in bifurcation lesions. ClinicalTrials.gov Identifier: NCT02972489.

[Acute coronary lithotripsy in an 83-year-old man with syncope and acute coronary syndrome]

BACKGROUND

An 83-year-old male presented with syncope and acute coronary syndrome. An electrocardiogram (ECG) suggested left main (LM) coronary artery stenosis; angiography confirmed a heavily calcified tight LM stenosis.

CLINICAL COURSE

Percutaneous coronary intervention was performed using intravascular lithotripsy and implantation of drug eluting stents with an excellent angiographic result, resolution of symptoms and ECG changes.

CONCLUSION

Intravascular lithotripsy is a new and easily applicable method for heavily calcified coronary lesions. Cost-effectiveness and long-term results will define its future role.

Usability of Fantom Encore® scaffold in non-complex bifurcations-Analysis in bench models

OBJECTIVE

Present bench study aimed to evaluate whether technical characteristics of Fantom Encore® bioresorbable scaffold (BRS) allow to perform proximal optimization/side branch dilation/proximal optimization (POT-SB-POT) technique, as an adequate solution for bifurcation percutaneous coronary intervention.

METHODS

Two Fantom Encore® BRS platforms (small with 3.0 mm nominal diameter, n = 7; and large with 3.5 mm nominal diameter, n = 7) were evaluated in bench models, which were designed according to Finet-law and fitted to nominal scaffold diameter in the distal main branch (MB) and fitted to indicated maximal expansion capacity in the proximal main branch (MB). Results were evaluated by (a) fluoroscopy, (b) optical coherence tomography (OCT) and (c) micro-computed tomography (μCT).

RESULTS

All procedures were performed according to the protocol. Careful review of the fluoroscopic loops by an independent operator did not reveal any strut fracture or major deformation. By OCT the overall rate of perfectly apposed struts in the bifurcation area was 15 ± 6% after SB opening, that increased significantly but remained low with 22 ± 9% after final POT (p = .001). Compared to SB ballooning alone, significant benefit of final POT was found in rate of perfect apposition in the proximal MB (15 ± 12% vs. 26 ± 15%, respectively; p = .017) and at the abostial side of polygon of confluence (7 ± 9% vs. 16 ± 13%, respectively; p = .005). μCT analysis revealed a single strut fracture in one case with the small platform, while four cases showed single or multiple strut fractures with the large platform.

CONCLUSION

The mechanical characteristics of the device are not suitable for use of Conventional techniques for bifurcation PCI such as POT-SB-POT. The use of Fantom Encore® BRS for bifurcation PCI with relevant SB should not be encouraged.

Accuracy of the PARIS score and PCI complexity to predict ischemic events in patients treated with very thin stents in unprotected left main or coronary bifurcations

BACKGROUND

The PARIS risk score (PARIS-rs) and percutaneous coronary intervention complexity (PCI-c) predict clinical and procedural residual ischemic risk following PCI. Their accuracy in patients undergoing unprotected left main (ULM) or bifurcation PCI has not been assessed.

METHODS

The predictive performances of the PARIS-rs (categorized as low, intermediate, and high) and PCI-c (according to guideline-endorsed criteria) were evaluated in 3,002 patients undergoing ULM/bifurcation PCI with very thin strut stents.

RESULTS

After 16 (12-22) months, increasing PARIS-rs (8.8% vs. 14.1% vs. 27.4%, p < .001) and PCI-c (15.2% vs. 11%, p = .025) were associated with higher rates of major adverse cardiac events ([MACE], a composite of death, myocardial infarction [MI], and target vessel revascularization), driven by MI/death for PARIS-rs and target lesion revascularization/stent thrombosis for PCI-c (area under the curves for MACE: PARIS-rs 0.60 vs. PCI-c 0.52, p-for-difference < .001). PCI-c accuracy for MACE was higher in low-clinical-risk patients; while PARIS-rs was more accurate in low-procedural-risk patients. ≥12-month dual antiplatelet therapy (DAPT) was associated with a lower MACE rate in high PARIS-rs patients, (adjusted-hazard ratio 0.42 [95% CI: 0.22-0.83], p = .012), with no benefit in low to intermediate PARIS-rs patients. No incremental benefit with longer DAPT was observed in complex PCI.

CONCLUSIONS

In the setting of ULM/bifurcation PCI, the residual ischemic risk is better predicted by a clinical risk estimator than by PCI complexity, which rather appears to reflect stent/procedure-related events. Careful procedural risk estimation is warranted in patients at low clinical risk, where PCI complexity may substantially contribute to the overall residual ischemic risk.

Difference in basic concept of coronary bifurcation intervention between Korea and Japan. Insight from questionnaire in experts of Korean and Japanese bifurcation clubs

The coronary bifurcation intervention varies among countries due to the differences in assessment of lesion severity and treatment devices. We sought to clarify the difference in basic strategy between South Korea and Japan. A total of 19 and 32 experts from Korean (KBC) and Japanese Bifurcation Clubs (JBC), respectively, answered a survey questionnaire concerning their usual procedure of coronary bifurcation intervention. JBC experts performed less two-stent deployment in the left main (LM) bifurcation compared to KBC experts (JBC vs. KBC: median, 1–10% vs. 21–30%, p < 0.0001) instead of higher performance of side branch dilation after cross-over stenting in both LM (60% vs. 21%, p = 0.001) and non-LM bifurcations (30% vs. 5%, p = 0.037). KBC experts more frequently performed proximal optimization technique (POT) in non-LM bifurcation (41–60% vs. 81–99%, p = 0.028) and re-POT in both LM (1–20% vs. 81–99%, p = 0.017) and non-LM bifurcations (1–20% vs. 81–99%, p = 0.0003). JBC experts more frequently performed imaging-guided percutaneous coronary intervention, whereas KBC experts more often used a pressure wire to assess side branch ischemia. JBC experts used a rotablator more aggressively under the guidance of optical coherence tomography. We clarified the difference in the basic strategy of coronary bifurcation intervention between South Korea and Japan for better understanding the trend in each country.

Visually Estimated RESOLVE Score Based on Coronary Computed Tomography to Predict Side Branch Occlusion in Percutaneous Bifurcation Intervention

PURPOSE

The quantitative RESOLVE (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion) score derived from coronary computed tomography angiography (coronary CTA) was developed as a noninvasive and accurate prediction tool for side branch (SB) occlusion in coronary bifurcation intervention. We aimed to determine the ability of a visually estimated CTA-derived RESOLVE score (V-RESOLVE score) to predict SB occlusion in coronary bifurcation intervention.

MATERIALS AND METHODS

The present study included 363 patients with 400 bifurcation lesions. CTA-derived V-RESOLVE score was derived and compared with the quantitative CTA-derived RESOLVE score. The scoring systems were divided into quartiles, and classified as the high-risk and non-high-risk groups. SB occlusion was defined as any decrease in thrombolysis in myocardial infarction flow grade after main vessel stenting.

RESULTS

In total, 28 SB occlusions (7%) occurred. The concordance between visual and quantitative CTA analysis showed poor to excellent agreement (weighted κ range: 0.099 to 0.867). The area under the receiver operating curve for the prediction of SB occlusion was significantly higher for the CTA-derived V-RESOLVE score than for quantitative CTA-derived RESOLVE score (0.792 vs. 0.709, P=0.049). The total net reclassification index was 42.7% (P=0.006), and CTA-derived V-RESOLVE score showed similar capability to discriminate between high-risk group (18.6% vs. 13.8%, P=0.384) and non-high-risk group (3.8% vs. 4.9%, P=0.510) as compared with quantitative CTA-derived RESOLVE score.

CONCLUSIONS

Visually estimated CTA-derived V-RESOLVE score is an accurate and easy-to-use prediction tool for the stratification of SB occlusion in coronary bifurcation intervention.

Association of Side-Branch Treatment and Patient Factors in Left Anterior Descending Artery True Bifurcation Lesions: Analysis from the GRAND-DES Pooled Registry

Methods

Patients undergoing PCI to left anterior descending (LAD) bifurcation lesions with contemporary DES were analyzed from a nationwide registry. Baseline risk was assessed using the Age, Creatinine, and Ejection Fraction (ACEF) score. Target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, and target lesion revascularization, was assessed at 3 years.

Results

Among 1,089 patients with LAD bifurcation lesions, 548 (50.3%) patients underwent SB treatment. The SB treatment group showed a nonsignificant, but numerically lower rate of 3-year TLF (6.6% vs. 9.2%, HR 0.75, 95%CI 0.44–1.28, p = 0.29). In patients with low pretreatment risk (ACEF<1.22), SB treatment was associated with a lower rate of 3-year TLF (HR 0.43, 95%CI 0.19–0.96, p = 0.04), while no significant difference was observed in patients with high risk (ACEF≥1.22). The difference in the low risk group was mostly driven by target lesion revascularization (HR 0.24, 95%CI 0.08–0.75, p = 0.01).

Conclusions

SB treatment for LAD bifurcation lesions showed favorable long-term outcomes compared with main-branch-only intervention, especially in patients with low pretreatment risk.

A Randomized Trial Evaluating Online 3-Dimensional Optical Frequency Domain Imaging-Guided Percutaneous Coronary Intervention in Bifurcation Lesions

Supplemental Digital Content is available in the text.

Background:

Clinical implications of online 3-dimensional optical frequency domain imaging (3D-OFDI)-guided stenting for bifurcation lesions have not been investigated in the randomized controlled trials. The purpose of this study was to determine whether online 3D-OFDI-guided stenting is superior to angiography-guided percutaneous coronary intervention (PCI) in terms of incomplete stent apposition at the bifurcation segment.

Methods:

The OPTIMUM trial (Online 3-Dimensional Optical Frequency Domain Imaging to Optimize Bifurcation Stenting Using UltiMaster Stent) was a randomized, multicenter clinical trial. Eligible patients had an angiographically significant stenosis in the bifurcation lesion treated with a provisional single stent strategy using the Ultimaster sirolimus eluting stent. Patients were randomly allocated to either online 3D-OFDI-guided or angiography-guided PCI. Patients randomized to 3D-OFDI guidance underwent online 3D-OFDI assessment after rewiring into the jailed side branch after stenting and proximal optimization technique, while in the angiography guidance arm, rewiring was performed using conventional fluoroscopic/angiographic guidance. The primary end point of this trial was the postprocedural average percentage of malapposed struts per lesion assessed by OFDI in the confluence zone of the main and side branches.

Results:

Between June 8, 2017 and September 26, 2018, 110 patients with 111 bifurcation lesions were randomized at 4 Japanese centers. Of these, 56 patients with 57 lesions were treated with 3D-OFDI-guided PCI, whereas 54 patients with 54 lesions were treated with angiography-guided PCI. In the 3D-OFDI guidance arm, the feasibility of online 3D-OFDI was 98.2%. The average percentage of incomplete stent apposition per lesion at bifurcation was lower in the 3D-OFDI guidance arm than that in the angiography guidance arm (19.5±15.8% versus 27.5±14.2%, P=0.008). The superiority of the 3D-OFDI guidance arm was also confirmed in the strut level analysis (odds ratio: 0.54 [95% CI, 0.36–0.81]; P=0.003).

Conclusions:

Online 3D-OFDI-guided bifurcation PCI was superior to angiography-guided bifurcation PCI in terms of acute incomplete stent apposition at bifurcation.

Registration:

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02972489.

Comparison of overexpansion capabilities and thrombogenicity at the side branch ostia after implantation of four different drug eluting stents

Interventions in bifurcation lesions often requires aggressive overexpansion of stent diameter in the setting of long tapering vessel segment. Overhanging struts in front of the side branch (SB) ostium are thought to act as a focal point for thrombi formation and consequently possible stent thrombosis. This study aimed to evaluate the overexpansion capabilities and thrombogenicity at the SB ostia after implantation of four latest generation drug-eluting stents (DES) in an in-vitro bifurcation model. Four clinically available modern DES were utilized: one bifurcation dedicated DES (Bioss LIM C) and three conventional DES (Ultimaster, Xience Sierra, Biomime). All devices were implanted in bifurcation models with proximal optimization ensuring expansion before perfusing with porcine blood. Optical coherence tomography (OCT), immunofluorescence (IF) and scanning electron microscope analysis were done to determine thrombogenicity and polymer coating integrity at the over-expanded part of the stents. Computational fluid dynamics (CFD) was performed to study the flow disruption. OCT (p = 0.113) and IF analysis (p = 0.007) demonstrated lowest thrombus area at SB ostia in bifurcation dedicated DES with favorable biomechanical properties compared to conventional DES. The bifurcated DES also resulted in reduced area of high shear rate and maximum shear rate in the CFD analysis. This study demonstrated numerical differences in terms of mechanical properties and acute thrombogenicity at SB ostia between tested devices.

Impact of Lesion Preparation Technique on Side Branch Compromise in Calcified Coronary Bifurcations: A Subgroup Analysis of the PREPARE-CALC Trial

Objectives

To analyze the impact of different techniques of lesion preparation of severely calcified coronary bifurcation lesions.

Background

The impact of different techniques of lesion preparation of severely calcified coronary bifurcation lesions is poorly investigated.

Methods

We performed an as-treated analysis on 47 calcified bifurcation lesions treated with scoring/cutting balloons (SCB) and 68 lesions treated with rotational atherectomy (RA) in the PREPARE-CALC trial. Compromised side branch (SB) as assessed in the final angiogram was the primary outcome measure and was defined as any significant stenosis, dissection, or thrombolysis in myocardial infarction flow <3.

Results

True bifurcation lesions were present in 49% vs. 43% of cases in the SCB and RA groups, respectively. After stent implantation, SB balloon dilatation was necessary in around one-third of cases (36% vs. 38%; p = 0.82), and a two-stent technique was performed in 21.3% vs. 25% (p = 0.75). At the end of the procedure, the SB remained compromised in 15 lesions (32%) in the SCB group and 5 lesions (7%) in the RA group (p = 0.001). Large coronary dissections were more frequently observed in the SCB group (13% vs. 2%; p = 0.02). Postprocedural levels of cardiac biomarkers were significantly higher in patients with a compromised SB at the end of the procedure.

Conclusions

In the PREPARE-CALC trial, side branch compromise was more frequently observed after lesion preparation with SCB as compared with RA. Consequently, in calcified bifurcation lesions, an upfront debulking with an RA-based strategy might optimize the result in the side branch.

European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions

BACKGROUND

Defining the optimal conduction of percutaneous-coronary-intervention (PCI) to treat bifurcation lesions has been the subject of many clinical studies showing that the applied stenting technique may influence clinical outcome. Accordingly, bifurcation stenting classifications and technical sequences should be standardized to allow proper reporting and comparison.

METHODS

The European Bifurcation Club (EBC) is a multidisciplinary group dedicated to optimize the treatment of bifurcations and previously created a classification of bifurcation stenting techniques that is based on the first stent implantation site. Since some techniques have been abandoned, others have been refined and dedicated devices became available, EBC promoted an international task force aimed at updating the classification of bifurcation stenting techniques as well as at highlighting the best practices for most popular techniques. Original descriptive images obtained by drawings, bench tests and micro-computed-tomographic reconstructions have been created in order to serve as tutorials in both procedure reporting and clinical practice.

RESULTS

An updated Main-Across-Distal-Side (MADS)-2, classification of bifurcation stenting techniques has been realized and is reported in the present article allowing standardized procedure reporting in both clinical practice and scientific studies. The EBC-promoted task force deeply discussed, agreed on and described (using original drawings and bench tests) the optimal steps for the following major bifurcation stenting techniques: (a) 1-stent techniques ("provisional" and "inverted provisional") and (b) 2-stent techniques ("T/TAP," "culotte," and "DK-crush").

CONCLUSIONS

The present EBC-promoted paper is intended to facilitate technique selection, reporting and performance for PCI on bifurcated lesions during daily clinical practice.

Treatment with a dedicated bifurcation sirolimus-eluting cobalt-chromium stent for distal left main coronary artery disease: rationale and design of the POLBOS LM study

AIMS

The aim of this study is to demonstrate the non-inferiority of the BiOSS LIM C sirolimus-eluting cobalt-chromium bifurcation dedicated stent against the XIENCE stent regarding the patient-oriented composite endpoint (POCE) at 12 months among patients with left main coronary artery disease (LMCA).

METHODS AND RESULTS

The POLBOS LM study is a single-arm, prospective, multicentre study enrolling 260 patients (SYNTAX score ≤32) with a pre-specified performance goal based on the results of the EXCEL trial with contemporary percutaneous coronary intervention (PCI) for LMCA disease. Patient enrolment will comply with objective inclusion criteria of diameter stenosis ≥50% in the LMCA based on off-line quantitative coronary angiography (QCA) analysed by an independent core laboratory using dedicated bifurcation QCA software. The BiOSS LIM C is used for the treatment of LMCA disease with the same specific technical classification as for the BiOSS LIM (modified MADS classification) and the stent implantation is optimised by using pre-specified intravascular ultrasound criteria. The primary endpoint is POCE (a composite of all-cause death, stroke, any myocardial infarction, and any revascularisation) at 12 months.

CONCLUSIONS

The POLBOS LM study will indicate the efficacy of the BiOSS LIM C stent with contemporary PCI for distal left main bifurcation lesions in comparison with the XIENCE stent from the recent EXCEL trial, as a performance index.

Asia Pacific consensus document on coronary bifurcation interventions

Coronary bifurcation intervention is common but complex. Progress in this field has been made in recent years with considerable contribution from the Asia Pacific (APAC) region. However, the standard of practice varies across the APAC region due to differences in culture, socioeconomic state and healthcare set-up. Practice may also differ from the rest of the world. Hence, a panel of experts was invited to discuss topics relevant to bifurcation intervention in order to make a concerted effort to achieve consensus that is applicable within the region and in line with available evidence.

Anatomical attributes of clinically relevant diagonal branches in patients with left anterior descending coronary artery bifurcation lesions

AIMS

This study aimed to investigate the anatomical attributes determining myocardial territory of diagonal branches and to develop prediction models for clinically relevant branches using myocardial perfusion imaging (MPI) and coronary CT angiography (CCTA).

METHODS AND RESULTS

The amount of ischaemia and subtended myocardial mass of diagonal branches was quantified using MPI by percent ischaemic myocardium (%ischaemia) and CCTA by percent fractional myocardial mass (%FMM), respectively. In 49 patients with isolated diagonal branch disease, the mean %ischaemia by MPI was 6.8±4.0%, whereas in patients with total occlusion or severe disease of all diagonal branches it was 8.4±3.3%. %ischaemia was different according to the presence of non-diseased diagonal branches and dominant left circumflex artery (LCx). In the CCTA cohort (306 patients, 564 diagonal branches), mean %FMM was 5.9±4.4% and 86 branches (15.2%) had %FMM ≥10%. %FMM was different according to LCx dominance, number of branches, vessel size, and relative dominance between two diagonal branches. The diagnostic accuracy of prediction models for %FMM ≥10% based on logistic regression and decision tree was 0.92 (95% CI: 0.85-0.96) and 0.91 (95% CI: 0.84-0.96), respectively. There was no difference in the diagnostic performance of models with and without size criterion.

CONCLUSIONS

LCx dominance, number of branches, vessel size, and dominance among diagonal branches determined the myocardial territory of diagonal branches. Clinical application of prediction models based on these anatomical attributes can help to determine the clinically relevant diagonal branches in the cardiac catheterisation laboratory.

CLINICAL TRIAL REGISTRATION

NCT03935542

Provisional stenting or not provisional stenting: seven critical points for bifurcations treatment with a glimpse on left main bifurcation stenting

Stenting of coronary bifurcation lesions represents a challenge for the interventional cardiologist. A bifurcation lesion could be treated with several techniques. Therefore, it is of paramount importance to decide the strategical approach at the beginning of the procedure evaluating the patient's bifurcation anatomy, the angle between main and side branch, plaque burden at the level of the carina, and size of the side branch. Although it is clear that all bifurcation's treatment techniques have each one their advantages and disadvantages, provisional stenting remains the gold-standard technique, because it leaves the possibility to switch to other technical solutions with optimal angiographic and long-term clinical results. In this review, different tips and tricks for left main and bifurcation stenting are debated.

T and Small Protrusion (TAP) vs Double-Kissing Crush Technique: Insights From In Vitro Models

BACKGROUND

Percutaneous coronary interventions on complex bifurcation lesions may require implantation of two stents to appropriately treat diffuse side-branch (SB) disease. Comparisons among different bifurcation stenting techniques are continuously attempted by various study designs (bench tests, computer simulations, clinical studies). Among different techniques, double kissing crush (DKC) represents the last evolution for "crushing" while T and small Protrusion (TAP) represents the evolution of "T stenting". Both techniques are actually gaining popularity, but head-to-head comparisons are lacking.

METHODS AND RESULTS

Two last generation drug-eluting stents (Synergy™, Boston Scientific, MA, USA and Ultimaster™,Terumo Corp., Japan) were implanted in left main bifurcation bench models using TAP (n = 6 sets) and DKC (n = 6 sets) techniques. A peristaltic pump with fresh porcine blood was used to perfuse the blood through the silicone model at a flow rate of 200 ml/min for 4 min. Optical coherence tomography (OCT) was used to assess stent struts geometry and thrombus formation. SB cross sectional area as well as SB obstruction did not significantly differ between the two techniques. Numerical (but not statistically significant) differences were found in terms of malapposed struts (fewer with TAP) and floating struts (fewer with DKC). Thrombus formation after blood perfusion was similar between TAP and DKC technique (1.53 ± 1.12 vs. 1.20 ± 1.01 mm², p = 0.6).

CONCLUSION

The result of the present in-vitro study shows the absence of significant difference between TAP and DKC in terms of stent struts apposition and acute thrombus formation potential. Despite the completely different technical steps required, both techniques have similar performance according to such articulated pre-clinical evaluation. WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT?: Due to its limited complexity, T and Protrusion (TAP) technique is considered the to-go technique for bifurcation lesions with good long-term results. Recently, double kissing crush (DKC) technique has been gaining popularity and demonstrated promising results in randomized clinical trials. WHAT DOES THIS STUDY ADD?: This in-vitro bench test study provides a unique detailed OCT comparison and local hemodynamic environment analysis of the two techniques. HOW MIGHT THIS IMPACT ON CLINICAL PRACTICE?: New insights of acute thrombogenicity and computational flow model simulation may guide percutaneous therapeutic strategies of bifurcation lesions.

One, two, three … breakdance and twist

Wire breakage during percutaneous coronary intervention is a rare event. It occurs especially when treating complex lesions, and it should be prevented with careful planning of each procedural step. We reported a case in which wire breakage occurred when treating the left anterior descending (LAD)/first diagonal bifurcation with the T-stenting technique. After careful evaluation of all the available retrieval techniques and failure of the balloon-catheter trapping, the twin-twisting wires technique (TTWT) was applied. This technique allows the retrieval of a foreign body thanks to its entrapment in the spiral made by two twisting wires. At the first attempt, the broken wire was only withdrawn and not retrieved, while the two twisting wires went broken. The second attempt was performed using stronger wires as twisting wires. The two recently broken fragments were successfully retrieved together with a long proximal remnant of the initially broken wire, which distal tip was further withdrawn. The broken wire was successfully retrieved with the third attempt, together with the previously implanted LAD stent that was accidentally entrapped in the twist. This is the first report of TTWT implementation for the retrieval of a broken wire from a two-stent bifurcation, both proximal and distal wire remnants and a total of three broken wires. The improvements we made to the technique, tips and tricks, caveats, and suggestions for successful wire retrieval and avoidance of the complications that we experienced are described in detail.

Exploring Personal Protection During High-Risk PCI in a COVID-19 Patient: Impella CP Mechanical Support During ULMCA Bifurcation Stenting

The correct management of patients with coronavirus disease-2019 (COVID-19) and acute coronary syndrome is still uncertain. We describe the percutaneous treatment of an unprotected left main coronary artery in a patient who is positive for COVID-19 with unstable angina, dyspnea and fever. Particular attention will be dedicated to the measures adopted in the catheterization laboratory to protect the staff and to avoid further spread of the infection. (Level of Difficulty: Intermediate.).

Clinical Implications of Bifurcation Angles in Left Main Bifurcation Intervention Using a Two-Stent Technique

Objectives

The aim of this study was to assess the clinical impact of 3 bifurcation angles in left main (LM) bifurcation treated with the 2-stent technique.

Background

Data are limited regarding the impact of bifurcation angles after LM percutaneous coronary intervention (PCI).

Methods

Using patient-level 4 multicenter registries in Korea, 462 patients undergoing LM bifurcation PCI with the 2-stent technique were identified (181 crush, 167 T-stenting; 63% 1^st generation drug-eluting stent (DES), 37% 2^nd generation DES). Three bifurcation angles, between the LM and left anterior descending (LAD), the LM and left circumflex (LCX), and the LAD and LCX, were measured. The primary outcome was target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization (TLR).

Results

In patients treated with the crush technique, the best cutoff value (BCV) to predict TLF was 152° of the LM-LAD angle. In the crush group, a significantly higher TLF rate, mostly driven by TLR, was observed in the LM-LAD angle ≥152° group compared with the <152° group (35.7% vs. 14.6%; adjusted hazard ratio 3.476; 95% confidence interval 1.612–7.492). An LM-LAD angle ≥152° was an independent predictor of TLF. In the T-stenting, no bifurcation angle affected the clinical outcomes.

Conclusions

In LM bifurcation PCI using the 2-stent technique, wide LM-LAD angle (≥152°) was associated with a greater risk of TLF in the crush, whereas none of the bifurcation angles affected T-stenting outcomes.

Percutaneous management of coronary bifurcation lesions: current perspective

PURPOSE OF REVIEW

Coronary artery disease affecting bifurcations poses a challenge for percutaneous intervention. Several techniques and strategies for percutaneous management of bifurcation lesions have been described in the literature with variable data available for outcomes. In this review, we provide an overview of the strategies and techniques used for percutaneous intervention of bifurcation lesions with an update of recent technical developments and clinical evidence.

RECENT FINDINGS

The coronary bifurcation lesions of both left main and other coronary segments are best treated with a provisional stenting strategy where main branch is treated with a stent placement and side branch intervention reserved for angiographically or physiologically determined hemodynamically significant residual stenosis despite application of a proximal stent optimization technique. When a provisional stent strategy is not likely to be successful due to anatomic or morphologic lesion characteristics and a large side branch or distal left main bifurcation is involved, an upfront bifurcation stenting strategy with double kissing crush technique may provide the optimum results. Coronary imaging and fractional flow determination may guide lesion specific management, facilitate device selection and improve clinical outcomes for percutaneous therapy for bifurcation lesions.

SUMMARY

Despite advances in technology and procedural techniques, percutaneous intervention of coronary bifurcation lesions remains challenging and associated with higher adverse outcomes compared to non bifurcation lesions. Among the several bifurcation strategies, a provisional stenting approach is preferred for technical simplicity and better long term outcomes. Double kissing crush technique provides superior clinical results and should be preferred when a two stent strategy is indicated. Use of coronary imaging and physiology assessment should be incorporated in the algorithm of bifurcation interventions for greater technical and clinical success.

One- and 3-year outcomes of percutaneous bifurcation left main revascularization with modern drug-eluting stents: a systematic review and meta-analysis

AIMS

Optimal percutaneous coronary intervention (PCI) strategy for coronary left main (LM) bifurcation lesions remains controversial. We performed systematic review and meta-analysis comparing one and 3-year clinical outcomes of 1- and 2- stent strategies using modern drug eluting stents (DESs) for revascularization of LM bifurcation disease.

METHODS

We systematically identified all investigations published between January 2015 and February 2020 comparing the use of single versus double-stent strategies for the revascularization of LM bifurcation lesions. The primary endpoint was 1- and 3-years all-cause mortality. Secondary outcomes included target lesion revascularization (TLR), target lesion failure (TLF), major adverse cardiovascular vents (MACEs) and cardiovascular (CV) mortality while the tertiary outcome was overall occurrence of stent thrombosis (ST) at 1- and 3-years.

RESULTS

No significant differences were observed between the two groups in terms of all-cause mortality rate both at 1 and 3-year follow-up. Single stent strategy was associated with a significantly lower risk of TLR (OR 0.78, 95% CI 0.62- 0.97, p = 0.03, I² = 61%) as well as of MACEs (OR 0.78, 95% CI 0.63-0.97, I² = 24%) compared to 2-stent strategy. Conversely no significant differences between the two groups were observed in terms of TLF, CV mortality and ST during the same follow-up period.

CONCLUSIONS

In patients with LM bifurcation disease, single stent strategy demonstrated lower rate of MACEs and TLR but was not superior to 2-stent strategy in terms of CV mortality, TLF and ST at 1 and 3-year follow-up.

Comparison of Computed Tomography Angiography Versus Invasive Angiography to Assess Medina Classification in Coronary Bifurcations

The Medina classification is used to determine the presence of significant stenosis (≥50%) within each of the 3 arterial segments of coronary bifurcation in invasive coronary angiography (ICA). The utility of coronary computed tomography angiography (coronary CTA) for assessment of Medina classification is unknown. We aimed to compare the agreement and reproducibility of Medina classification between ICA and coronary CTA, and evaluate its ability to predict side branch (SB) occlusion following percutaneous coronary intervention (PCI). In total 363 patients with 400 bifurcations were included, and 28 (7%) SB occlusions among 26 patients were noted. Total agreement between CTA and ICA for assessment of Medina class was poor (kappa = 0.189), and discordance between both modalities was noted in 253 (63.3%) lesions. Larger diameter ratio between main vessel and SB in CTA, and larger bifurcation angle in ICA were independently associated with discordant Medina assessment. Whereas the interobserver agreement on Medina classification in CTA was moderate (kappa = 0.557), only fair agreement (kappa = 0.346) was observed for ICA. Finally, Medina class with any proximal involvement of main vessel and SB (1.X.1) on CTA or ICA was the most predictive of SB occlusion following PCI with no significant differences between both modalities (area under the curve 0.686 vs 0.663, p = 0.693, respectively). In conclusion, Medina classification was significantly affected by the imaging modality, and coronary CTA improved reproducibility of Medina classification compared with ICA. Both CTA and ICA-derived Medina class with any involvement of the proximal main vessel and SB was predictive of SB occlusion following PCI.