Simultaneous kissing stent technique to treat left main stem bifurcation disease

Two-Step V-Stenting and Simultaneous Kissing Stent via 6F Guides: Simple Just Got Simpler

V-stenting (VS) and simultaneously kissing stents (SKS) upfront 2-stent strategies for treating large diameter bifurcations and especially distal left main coronary artery (LMCA) disease. Former teaching suggests that the minimal requirements for VS and SKS requires 8F guiding catheters or 7.5F sheathless guide. Presented is the "2-Step refinement" of SKS and VS that can be executed via conventional 6F guide without any additional equipment. In view of the simplicity and suitability for unstable subjects with acute coronary syndromes; "2 Step SKS and VS" should be in the armamentarium of all advanced interventionalists.

The Y-stenting technique for pulmonary artery bifurcation stenosis: Initial results and mid-term outcomes

BACKGROUND

Treatment for main or peripheral PBS is challenging. An interventional approach is generally preferred as surgical angioplasty often results in residual stenosis. However, there is limited data on the mid- and long-term results of the different interventional approaches. The aim of this study is to report on initial and mid-term results of the Y-stenting technique for pulmonary artery bifurcation stenosis (PBS).

METHODS

A single centre retrospective study of all Y-stenting procedures for main or peripheral PBS was conducted. Patient and procedural data as well as mid-term outcomes were analysed.

RESULTS

11 Y-stenting procedures were performed, 9 in the main pulmonary bifurcation and 2 in the PA periphery. In 8 patients the bifurcation stents were connected, in 3 patients there was no connection between the stents. Y-stenting creates a geometry close to the physiological PA bifurcation anatomy with complete alignment to the vessel wall without flow separation. Control angiography showed unrestricted blood flow after all procedures. Median right/left ventricle pressure ratio decreased from 0.9 to 0.5. No immediate or delayed adverse events were seen. During a median follow-up of 33.5 months, 2 patients in the non-connected group and 3 patients in the connected group needed a total of 6 re-interventions. No intima proliferation was seen in patients with connected stents.

CONCLUSIONS

Y-stenting is a safe and effective treatment for PBS. When both bifurcation stents are connected, this may result in lower rates of in-stent intima proliferation in comparison to other PBS stenting techniques.

Simultaneous kissing stents to treat unprotected left main stem coronary artery bifurcation disease; stent expansion, vessel injury, hemodynamics, tissue healing, restenosis, and repeat revascularization

Objectives

To perform detailed analysis of stent expansion, vessel wall stress, hemodynamics, re‐endothelialization, restenosis, and repeat PCI in the simultaneous kissing stents (SKS) technique of bifurcation left main stem (LMS) stenting.

Background

The SKS technique is useful to treat patients with true bifurcation disease of the LMS but remains controversial.

Methods and Results

Computational structural analysis of SKS expansion demonstrated undistorted and evenly expanded stents. Computational fluid dynamics modelling revealed largely undisturbed blood flow. 239 PCI procedures were performed on 217 patients with unprotected bifurcation LMS disease with SKS using DES (2004‐2017). We electively studied 13 stable patients from baseline to 10 years post‐SKS with repeat angiography and optical coherence tomography, and demonstrated tissue coverage of the stent struts at the carina, with no evidence of lacunae behind the stents. We studied all patients with symptomatic recurrence. Target lesion revascularization rate was 3.2% at 1 year and 4.6% at 2 years. Of all 20 patients with restenosis, the site was the LMS‐Cx stent in 7, the LMS‐LAD stent in 2 and both in 11. Two‐year recurrence rate was 7/32 (5.3%) for first, and 4/108 (3.7%) for second generation DES. Treatment with repeat kissing techniques was undertaken in 19/20, with sustained clinical results with re‐SKS.

Conclusion

The SKS technique for treating unprotected LMS bifurcation disease does not distort the stents, is associated with favorable hemodynamics, tissue coverage of the exposed struts, and a low restenosis rate when performed with contemporary stents. Re‐PCI with repeat SKS appears feasible, safe, and durable.

Bilateral bronchial stent deployment for palliative treatment of a compressive intrathoracic mass in a cat

Case summary

Bronchial stents may be useful to relieve clinical signs of extraluminal compression. Herein we describe a case which, to our knowledge, is the first cat where bilateral bronchial stents have been used clinically. Respiratory signs of principal bronchial compression were alleviated after the stent procedure. Minor complications occurred, specifically: severe hypoxia during stent deployment; a transient, self-limiting postoperative pneumothorax possibly associated with ventilation-induced lung injury; bronchopneumonia (possibly pre-existing); and transient worsening of cough postoperatively. Stents were well- tolerated long- term. The cat was euthanased at 44 weeks post-stent procedure, owing to clinical signs of regurgitation, seemingly related to oesophageal dysfunction associated with tumour invasion.

Relevance and novel information

In this case, it appeared that bronchial stents were feasible and the procedure was associated with long-term improvement in respiratory signs related to extraluminal bronchial compression.

How should I treat a coronary "traffic jam"? A triple kissing balloon in distal left main trifurcation

BACKGROUND

A 60-year-old man with relapsing unstable angina a year aftger an anterior acute myocardial infarction treated with PCI to proximal left anterior descending (LAD) and proximal intermediate branch (IB), resulting in a severely impaired LV function.

INVESTIGATION

Physical examination, laboratorytest, transthoracic echocardiogram, rest ECG, coronary angiography.

DIAGNOSIS

Severe in-stent restenosis to IB, with a bulky plaque involving distal left main, obtuse marginal and proximal circumflex.

MANAGEMENT

Percutaneous coronary intervention/coronary artery bypass grafting.

Double-barrel stenting of distal left main stenosis in a patient with acute coronary syndrome: intravascular ultrasound and optical coherence tomography follow-up at six months

A 58-year-old man presented with frequent episodes of angina at rest. A diagnosis of anterior non-ST elevation myocardial infarction was made. Coronary angiography performed on the day of admission revealed a significant stenosis (50% to 60%) of the distal left main stem (LMS) extending to the ostia of the left anterior descending and left circumflex arteries. Coronary artery bypass graft surgery was advised; however, the patient consistently declined this option. Kissing balloon predilation was performed at the LMS bifurcation, and two stents of the same diameter and length (4.0 mm × 18 mm) were simultaneously deployed at the same high pressure (18 atm) spanning the entire length of the LMS, and extending into the left anterior descending and left circumflex arteries beyond the bifurcation lesion. Six months later, intravascular ultrasound and optical coherence tomography revealed neointimal hyperplasia, especially in the artificial septum.

Long-term outcome after the V stenting technique in de novo bifurcation lesions using drug-eluting stents

AIMS

To report long-term outcome data on the V technique using drug-eluting stents.

METHODS AND RESULTS

From April 2002 to December 2006, 31 consecutive patients were successfully treated with V stenting of a de novo bifurcation lesion. The technique involves the deployment of two stents in the two branches of a bifurcation, the proximal edges of the stents just touching one another. Patients exclusively received either sirolimus- (10), paclitaxel- (20) or biolimus-eluting (one) stents. On average, 1.5 +/- 0.8 stents with a total length of 26.6 +/- 17.2 mm and 1.1 +/- 0.4 stents with a total length of 18.3 +/- 7.6 mm were deployed in the distal main vessel and side branch respectively. Mean duration of follow-up was 853 +/- 553 days. Within 30 days, three patients died; two other patients had definite stent thrombosis involving the V stents, both requiring re-PCI. Beyond 30 days and within one year, there was one death and three cases of target vessel revascularisation, including one target lesion revascularisation. There were a further three deaths (one cardiac) beyond one year. Eleven patients (35.5%) had angiographic follow-up, exhibiting a binary restenosis rate of 9.1% at 203 +/- 33 days.

CONCLUSIONS

In this real-world cohort, late clinical events stand in accord with studies on competitive techniques, but early outcome was less encouraging, probably due to the baseline risks.

Drug-eluting stents in a patient with favism: is the aspirin administration safe?

We describe the case of a 64-year-old patient with glucose-6-phosphate dehydrogenase deficiency who was referred to our hospital because of an acute inferior myocardial infarction.Given the possible risk of acute haemolytic anaemia, aspirin was not given in the acute phase, and the patient was successfully treated by balloon angioplasty of the right coronary artery.After functional and genetic testing showing the presence of the Mediterranean mutation, known to be a class II variant, the patient received oral daily aspirin (100 mg) under strict monitoring in order to promptly detect any sign of haemolysis. After 4 days, a complex percutaneous coronary intervention with an implantation of two drug-eluting stents was successfully performed on the left coronary artery. After 3 months, the patient is free from adverse events.Glucose-6-phosphate dehydrogenase deficiency is commonly considered a contraindication to aspirin intake; however, this case shows that aspirin at low, antiplatelet dosage is well tolerated and should not be denied to patients with ischaemic heart disease and complex coronary anatomy.

Long-term outcome of simultaneous kissing stenting technique with sirolimus-eluting stent for large bifurcation coronary lesions

OBJECTIVES

This study was conducted to evaluate the outcomes of simultaneous kissing stenting with sirolimus-eluting stent (SES).

BACKGROUND

Percutaneous intervention for bifurcation coronary lesions is still challenging.

METHODS

This study was designed to evaluate the long-term outcomes of 36 consecutive patients with large bifurcation coronary lesions who underwent simultaneous kissing stenting with SES.

RESULTS

Lesion location was unprotected left main in 29 patients (81%) and anterior descending artery in 7 (19%). The patients received a combination of aspirin and clopidogrel for 6 months and cilostazol for 1 month. Mean proximal reference diameter was 4.05 +/- 0.68 mm. Compared with the side branch (SB), the main vessel (MV) involved longer lesions (25.8 +/- 17.0 mm vs. 10.2 +/- 10.8 mm, P < 0.001) and smaller preprocedural minimal lumen diameters (1.02 +/- 0.53 mm vs. 1.46 +/- 0.78 mm, P = 0.006) and was treated with larger stents (3.1 +/- 0.3 mm vs. 3.0 +/- 0.3 mm, P = 0.006). Angiographic success rate was 100%. Over the follow-up of 26.7 +/- 8.6 months, no deaths, myocardial infarctions or stent thromboses occurred. Target lesion revascularization was performed in five patients (14%). Overall angiographic restenosis occurred in 5/30 patients (17%), consisting of 4 (13%) at MV and 3 (10%) at SB. At follow-up angiography, a membranous diaphragm at the carina was identified in 14 patients (47%), but only one of whom was associated with angiographic restenosis.

CONCLUSION

Simultaneous kissing stenting with SES appears a feasible stenting technique in large bifurcation coronary lesions. However, a new angiographic structure of carinal membrane developed in a half of patients at follow-up and its influence needs to be further investigated.