The European bifurcation club Left Main Coronary Stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN)

Side Branch Late Thrombosis After Left Main Coronary Artery Crossover Stenting

Background

With the established use of crossover stenting technique in bifurcation coronary artery lesions, added clinical benefit of final kissing of the side branch remains debatable. We report a case of a stenosis and thrombus formation of an ostial side branch after crossover stenting.

Case Summary

A 38-year-old man was admitted with acute coronary syndrome complicated by acute pulmonary oedema. He was treated with stenting of the left descending artery (LAD) into the left main coronary artery (LMCA) 12 months earlier. Coronary angiography showed a filling defect in the ostial left circumflex coronary artery (LCX). Optical coherence tomography revealed neointimal growth of the LAD stent resulting in narrowing the LCX orifice and a large thrombus behind stent struts. After treatment of the lesion and optimised implantations of drug-eluting stents, the patient was transferred to the intensive care unit and monitored closely. Given his advanced ischaemic cardiomyopathy, the patient is being evaluated for heart transplantation eligibility.

Discussion

Stent struts across a bifurcated major side branch after crossover stenting could risk late stenosis and thrombus formation of the side branch. The clinical usefulness of routine imaging-guided kissing techniques even with good angiographic results in these cases should be evaluated.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40119-022-00270-w.

Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention

Background Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive. Methods and Results Extensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta-analysis produced pooled relative risk (RR) and 95% CI of 2-stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta-analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta-analysis showed no significant differences in all-cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2-stent techniques and provisional stenting. Frequentist network meta-analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38-0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39-0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39-0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28-0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2-stent techniques, including T-stent or T and protrusion, dedicated bifurcation stent, and culotte. Conclusions Double kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2-stent techniques. Superiority of 2-stent strategy over provisional stenting was observed in subgroup meta-analysis stratified to side branch lesion length ≥10 mm.

Functional comparison of different jailed balloon techniques in treating non-left main coronary bifurcation lesions

BACKGROUND

There is a paucity of data comparing functional difference between active jailed balloon technique (A-JBT) and conventional jailed balloon technique (C-JBT) in treating non-left main coronary bifurcation lesions (CBLs).

METHODS

In this retrospective cohort study, we consecutively enrolled 232 patients with non-left main CBLs who underwent percutaneous coronary intervention (PCI) using JBTs between January 2018 and March 2019. Among them, 191 patients entered the final analysis with 12-months angiographic follow-up. We stratified patients into A-JBT group (130 patients) and C-JBT group (61 patients). The functional analysis by Murray law-based quantitative flow ratio (μQFR) and Seattleanginaquestionnaire (SAQ) were performed to compare the two techniques.

RESULTS

Compared with C-JBT group, A-JBT group observed a lower abrupt (0.8% vs. 11.1%, p = 0.002) and final SB occlusion (0 vs. 7.9%, p = 0.005). Meanwhile, A-JBT group had a significantly higher μQFR of side branch (SB) both post-PCI and 12-months follow-up (median [interquartile range (IQR)]: 0.91 (0.86-0.96) vs. 0.82 (0.69-0.92), p < 0.001; median [IQR]: 0.95 (0.89-0.98) vs. 0.85 (0.74-0.93), p < 0.001) than C-JBT group. Besides, A-JBT group gained a μQFR improvement at follow-up period compared with post-PCI data (median [IQR]: 0.95 [0.89-0.98] vs. 0.91[0.86-0.96] of SB, p < 0.001) and a higher SAQ scores at 12-months follow-up compared with C-JBT group (p < 0.001).

CONCLUSIONS

Compared with C-JBT, A-JBT provided excellent SB protection during MV stenting and improved the SB functional blood flow as well as the angina relief even after 12 months.

[Myocardial revascularization : Controversy over noninvasive and invasive detection of ischemia]

With some exceptions, myocardial revascularization in patients with chronic coronary syndrome (CCS) is generally decided on the basis of the extent of myocardial ischemia. Current data indicate that a patient will benefit from revascularization if ischemia is present in more than 10% of the myocardium. Accordingly, all patients presenting with CCS should undergo a noninvasive ischemia test that can answer this question before diagnostic coronary angiography. In order to be able to make a recommendation for revascularization based on scientific data even in those patients who previously had no clear evidence of ischemia, e.g., because of discrepant findings, measurement of the hemodynamic significance of coronary stenoses with a lumen diameter reduction ≥ 50% should be performed during coronary angiography. A decision to revascularize based on hemodynamic significance was shown to be beneficial to patients in several studies.

Polymer Coating Integrity, Thrombogenicity and Computational Fluid Dynamics Analysis of Provisional Stenting Technique in the Left Main Bifurcation Setting: Insights from an In-Vitro Model

Currently, the provisional stenting technique is the gold standard in revascularization of lesions located in the left main (LM) bifurcation. The benefit of the routine kissing balloon technique (KBI) in bifurcation lesions is still debated, particularly following the single stent treatment. We compared the latest-generation drug-eluting stent (DES) with no side branch (SB) dilatation “keep it open” technique (KIO) vs. KBI technique vs. bifurcation dedicated drug-eluting stent (BD-DES) implantation. In vitro testing was performed under a static condition in bifurcation silicone vessel models. All the devices were implanted in accordance with the manufacturers’ recommendations. As a result, computational fluid dynamics (CFD) analysis demonstrated a statistically higher area of high shear rate in the KIO group when compared to KBI. Likewise, the maximal shear rate was higher in number in the KIO group. Floating strut count based on the OCT imaging was significantly higher in KIO than in KBI and BD-DES. Furthermore, according to OTC analysis, the thrombus area was numerically higher in both KIO and KBI than in the BD-DES. Scanning electron microscopy (SEM) analysis shows the highest degree of strut coating damage in the KBI group. This model demonstrated significant differences in CFD analysis at SB ostia with and without KBI optimization in the LM setting. The adoption of KBI was related to a meaningful reduction of flow disturbances in conventional DES and achieved results similar to BD-DES.

Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives

For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.

Fundamentals of percutaneous coronary bifurcation interventions

Coronary bifurcation lesions (CBLs) account for 15%-20% of all percutaneous coronary interventions. The complex nature of these lesions is responsible for poorer procedural, early and late outcomes. This complex lesion subset has received great attention in the interventional cardiac community, and multiple stenting techniques have been developed. Of these, the provisional stenting technique is most often the default strategy; however, the elective double stenting (EDS) technique is preferred in certain subsets of complex CBLs. The double kissing crush technique may be the preferred EDS technique because of its efficacy and safety in comparative trials; however, this technique consists of many steps and requires training. Many new methods have recently been added to the EDS techniques to provide better stent scaffolding and to reduce early and late adverse outcomes. Intravascular imaging is necessary to determine the interventional strategy and postinterventional results. This review discusses the basic concepts, contemporary percutaneous interventional technical approaches, new methods, and controversial treatment issues of CBLs.

Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting for Non-Protected Left Main Coronary Artery Disease: 1-Year Outcomes in a High Volume Single Center Study

Introduction: There is clear evidence of a significant reduction in all major cardiovascular adverse events (MACE) by coronary artery bypass grafting (CABG) in left main coronary artery stenosis (LMCS), but revascularization by percutaneous coronary artery intervention (PCI) shows an increasingly important role as an alternative to CABG. Several recent trials aiming to test the difference in mortality between the two types of revascularization found conflicting data. The aim of this study is to determine whether PCI is non-inferior to CABG with respect to the occurrence of MACE at 1 year in patients with significant LMCS. Material and methods: We prospectively enrolled 296 patients with chronic or acute coronary syndromes and significant LM stenosis. The angiography that recommended the revascularization procedure was used for the calculation of the Syntax II score, in order to classify the patients as low-, intermediate- or high-risk. Low- and high-risk patients were revascularized with either PCI or CABG, according to current guidelines, and were included in the subgroup S1. The second subgroup (S0) included intermediate-risk patients (Syntax II score 23–32), in whom the type of revascularization was chosen depending on the decision of the heart team or the patient preference. Patients were monitored according to the chosen mode of revascularization—PCI or CABG. LM revascularization was performed in all the patients. Clinical endpoints included cardiac death, myocardial infarction, need for revascularization and stroke. Patients were evaluated at 1 year after revascularization. Event rates were estimated using the Kaplan–Meier analysis in time to the first event. Results: At 1-year follow-up, a primary endpoint occurred in 35/95 patients in the CABG group and 37/201 in the PCI group. There were no significant differences between the 2 treatment strategies in the 1-year components of the end-point. However, a tendency to higher occurrence of cardiac death (HR = 1.48 CI (0.55–3.9), p = 0.43), necessity of repeat revascularization (HR = 1.7, CI (0.81–3.6), p = 0.16) and stroke (HR = 1.52, CI (1.15–2.93), p = 0.58) were present after CABG. Contrariwise, although without statistical significance, MI was more frequent after PCI (HR = 2, CI (0.78–5.2), p = 0.14). The Kaplan–Meier estimates in subgroups demonstrated the same tendency to higher rates for cardiac death, repeat revascularization and stroke after CABG, and higher rates of MI after PCI. Although without statistical significance, patients with an intermediate-risk showed a slightly lower risk of MACE after PCI than CABG. With the exception of dyslipidemia and gender, other cardiovascular risk factors were in favor of CABG (CKD, obesity). Conclusion: In patients with LMCS, PCI with drug-eluting stents was non-inferior to CABG with respect to the composite of cardiac death, myocardial infarction, repeat revascularization and stroke at 1 year, even in patients with intermediate Syntax II risk score.

Percutaneous Coronary Intervention Strategy for Spontaneous Coronary Artery Dissection of Left Main Coronary Artery with Extensive Intramural Hematoma in the Main Side Branch

A 46-year-old pregnant woman, presented with worsening episodes of intermittent chest pain. The patient was diagnosed with a non-ST-elevation myocardial infarction. On arrival, she had a stable hemodynamic status without chest pain. She was initially treated with conservative medical therapy. One day later, she complained of severe chest pain, and an electrocardiogram showed ST elevation in leads I, aVL, and V2-5. Emergency coronary angiography showed total occlusion of the left anterior descending artery (LAD) and intermediate stenosis of the left main coronary artery (LMCA). The intravascular ultrasound (IVUS) revealed an intramural hematoma (IMH) from the LMCA to the LAD, extending to the left circumflex artery (LCX) ostium. This finding was consistent with spontaneous coronary artery dissection (SCAD). After stent implantation from the LMCA to the LAD, severe stenosis was noted at the proximal site of the LCX. IVUS showed that the IMH extended to the LCX. The provisional crush stent technique was performed, and the final angiography revealed satisfactory results with thrombolysis in myocardial infarction flow grade 3 in the LAD and LCX. This case report highlighted that stent implantation in the SCAD lesions facilitated the extension of the IMH longitudinally and laterally into the side branch, resulting in stenosis or occlusion. Therefore, the side branch should be evaluated using IVUS before stent implantation. In cases where the IMH extends to the ostium of the side branch, two-stent techniques that do not require guidewire recrossing, such as crush stents, should be considered to avoid side branch occlusion.

Short- and Long-Term Outcomes of Left Main Coronary Artery Stenting in Patients Disqualified from Coronary Artery Bypass Graft Surgery

The study aims to evaluate the short- and long-term outcomes of left main percutaneous coronary interventions (LM PCI) in patients disqualified from coronary artery bypass graft surgery (CABG). We included 459 patients (mean age: 68.4 ± 9.4 years, 24.4% females), with at least 1-year follow-up; 396 patients in whom PCI was offered as an alternative to CABG (Group 1); and 63 patients who were disqualified from CABG by the Heart Team (Group 2). The SYNTAX score (29.1 ± 9.5 vs. 23.2 ± 9.7; p < 0.001) and Euroscore II value (2.72 ± 2.01 vs. 2.15 ± 2.16; p = 0.007) were significantly higher and ejection fraction was significantly lower (46% vs. 51.4%; p < 0.001) in Group 2. Patients in Group 2 more often required complex stenting techniques (33.3% vs. 16.2%; p = 0.001). The procedure success rates were very high and did not differ between groups (100% vs. 99.2%; p = 0.882). We observed no difference in periprocedural complication rates (12.7% vs. 7.8%; p = 0.198), but the long-term all-cause mortality rate was higher in Group 2 (26% vs. 21%; p = 0.031). LM PCI in patients disqualified from CABG is an effective and safe procedure with a low in-hospital complication rate. Long-term results are satisfactory.

Challenges and outcomes of the double kissing crush stenting technique: Insights from the PROGRESS-BIFURCATION registry

BACKGROUND

Although the double kissing (DK) crush stenting technique can provide excellent outcomes in percutaneous coronary intervention (PCI) of bifurcation lesions, it can be challenging to perform.

METHODS

We examined the clinical and angiographic characteristics, challenges encountered, and procedural outcomes of bifurcation PCI with DK crush in Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992).

RESULTS

DK crush was used in 48 of 435 bifurcation lesions (11%). Technical success was 100%, procedural success was 96%, and the incidence of in-hospital major adverse cardiovascular events was 4%. Challenges while performing DK crush were encountered in 26 lesions (54%): (1) difficulty in side branch (SB) first rewiring (38%) that was overcome with the use of a new guidewire (30%) or a microcatheter (15%); (2) inability to deliver balloon to an SB for the first kiss (54%) that was overcome with the use of a smaller balloon (86%), rewiring (29%), microcatheter (14%), and increased support 7%; (3) difficulty in SB second rewiring (19%) that was overcome with the use of a new guidewire (80%) and/or microcatheter (60%). DK crush was more often performed in left main and proximal left anterior descending artery lesions (70% vs. 50%, p = 0.014). DK crush cases required more contrast (198 ± 84 ml vs. 163 ± 70 ml, p = 0.003), fluoroscopy time (35 ± 20 min vs. 25 ± 21 min, p = 0.004), and lasted longer (137 ± 69 min vs. 99 ± 66 min, p = 0.001) compared with non-DK crush techniques.

CONCLUSIONS

While challenges are common when performing DK crush bifurcation stenting, success rates are high and complication rates are low.

The year in cardiovascular medicine 2021: interventional cardiology

Since last year's report in the European Heart Journal, we have witnessed substantial progress in all aspects of interventional cardiology. Of note, the practice of interventional cardiology took place amidst successive waves of the COVID-19 pandemic, which continues to be a major burden for all healthcare professionals around the globe. In our yearly review, we shall revisit the developments in percutaneous coronary intervention (PCI), structural heart interventions, and adjunctive pharmacotherapy.

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.

Randomized non-inferiority TrIal comParing reverse T And Protrusion versus double-kissing and crush Stenting for the treatment of complex left main bifurcation lesions

BACKGROUND

The treatment of left main bifurcation stenoses remains challenging.

AIMS

We compare the "Reverse T and Protrusion" (reverse-TAP) technique to Double-Kissing and crush (DK-crush).

METHODS

The study was designed as non-inferiority trial, the primary endpoint was percentage stent expansion in the ostial side branch at optical coherence tomography.

RESULTS

52 consecutive patients (13 females, 17 diabetics, Syntax score 25 [22-29]) with complex coronary bifurcation lesions of the left main were randomized in a 1:1 ratio to Reverse-TAP or DK-crush stenting. The intervention was performed according to protocol in all patients in both randomization groups. Side branch stent expansion was 75 [67-90]% in the DK-crush group and 86 [75-95]% in the reverse-TAP group (one-sided 97.5% lower parametric confidence interval: - 0.28%; P < 0.01 for non-inferiority; P = 0.037 for superiority). Side branch balloon pressure during final kissing was higher in the DK-crush group (14 [12-16] vs. reverse-TAP: 13 [12-14]; P = 0.043). Procedural time was shorter with reverse-TAP (DK-crush: 32 [24-44] min vs reverse-TAP: 25 [22-33] min; P = 0.044). Other procedural parameters were not different between groups. There was no difference in any of the safety endpoints up to 1 month.

CONCLUSIONS

A reverse-TAP strategy for the interventional treatment of complex coronary lesions was non-inferior and superior to DK-crush for the primary endpoint side branch expansion while requiring less time. A larger study testing long-term clinical outcomes is warranted.

TRAIL REGISTRATION

NCT: NCT03714750.

Evolution of the Crush Technique for Bifurcation Stenting

Bifurcation lesions are frequently encountered, associated with greater procedural complexity and consequently are at higher risk for restenosis and stent thrombosis. Early trials in bifurcation percutaneous coronary intervention favored a provisional stenting approach, but contemporary randomized trials have highlighted potentially superior outcomes using a double-kiss crush technique in unprotected distal left main stem bifurcation lesions. Although the evidence is greatest for double-kiss crush, many operators favor a mini-crush or nano-crush single-kiss approach. In this review, the authors describe the iterations of the crush technique and the evidence for each and review general principles for bifurcation percutaneous coronary intervention.