Comparison of Everolimus- versus Sirolimus-eluting stents in the provisional Bifurcation stenting guided by intravascular ultrasound: mid-term results of the J-REVERSE registry

Assessment of fractal ratio of vessel diameters in coronary bifurcation lesions by angiography and intravascular ultrasound

Physiological coronary branching at the bifurcation has a constant fractal ratio (FR) of the diameter of the mother vessel to the sum of daughter vessels on quantitative coronary angiography (QCA). We sought to investigate the FR of diseased coronary bifurcations using QCA and intravascular ultrasound (IVUS) and its impact on late lumen loss after percutaneous coronary intervention (PCI). In multicentre prospective studies of the J-REVERSE and 3D OCT Bifurcation Registry, 402 and 109 bifurcations treated with stenting that completed QCAs and IVUS examinations, respectively were analysed. FR was investigated at the reference sites pre-PCI and the minimum lumen diameter (MLD) post-PCI. In the QCA analysis, constant FR was observed in the pre-PCI reference (0.62 ± 0.08) and in the post-PCI MLD site (0.74 ± 0.10), which was greater (p < 0.05). In the IVUS analysis, the constant FR in the post-PCI MLD site (0.67 ± 0.06) was similar to that in the pre-PCI reference (0.66 ± 0.06) and close to the physiological FR value (0.678). The fourth quintile of pre-PCI reference FR in the IVUS analysis showed numerically least late lumen loss in proximal main vessel (MV) (0.16 ± 0.22 mm) and distal MV (0.13 ± 0.32 mm) and significantly less in the side branch compared to higher FR quintile (- 0.14 ± 0.27 mm vs. 0.10 ± 0.19 mm, p = 0.004), while no relationship was found in the QCA analysis. FR in the diseased coronary bifurcation was more accurately assessed on IVUS than on QCA, and the accomplishment of physiological FR might lead to less late lumen loss after bifurcation PCI.

Effect of low-density lipoprotein cholesterol on the geometry of coronary bifurcation lesions and clinical outcomes of coronary interventions in the J-REVERSE registry

We investigated the effect of low-density lipoprotein cholesterol (LDL-C) on the geometry of coronary bifurcation lesions. A total of 300 non-left main bifurcation lesions in 298 patients from J-REVERSE registry were classified according to statin treatment status at admission (NT, non-treated; ST, statin-treated) and were further subdivided based on LDL-C levels with a cutoff of 100 mg/dL (NT-high, n = 76 lesions; NT-low, n = 46; ST-high, n = 99 and ST-low, n = 79). In addition, a group with strict control of LDL-C (< 70 mg/dL) was defined (ST-SC; n = 19). The NT-high group had higher angled bifurcations compared to that in the NT-low group (59.1° ± 21.5° vs. 50.3° ± 18.6°, p = 0.02). In the multivariate analysis, NT-high group was an independent factor contributing on generation of higher angled (> 80°) lesion (odds ratio 3.77, 95% CI 1.05-13.5, p = 0.04). The NT-low group had more men (95.6 vs. 81.6%, p = 0.03), and greater plaque volume in the distal main vessel (7.1 ± 3.2 mm³/mm vs. 5.7 ± 2.7 mm³/mm, p = 0.02), compared to those in the NT-high group. LDL-C was more likely to remain high after statin treatment in younger patients (65.3 ± 3.6 years vs. 68.6 ± 8.4 years, p = 0.02) and current smokers (36.7 vs. 16.9%, p = 0.004). The ST-SC group had limited luminal volume expansion compared to that in the ST-high group (proximal: 6.7 ± 1.4 mm³/mm vs. 7.7 ± 2.3 mm³/mm, p = 0.04; distal: 5.3 ± 1.5 mm³/mm vs. 6.5 ± 1.9 mm³/mm, p = 0.04), regardless of similar plaque volumes. Elevated LDL-C is likely to promote the generation of higher angled bifurcation lesions and multiple risk factors lead to a more progressed bifurcation lesion even in patients with lower LDL-C levels.

Mechanism of Residual Lumen Stenosis at the Side Branch Ostium After Final Kissing Balloon Inflation: A Volumetric Intracoronary Ultrasound Study of Coronary Bifurcation Lesions

OBJECTIVES

To investigate the mechanisms of residual stenosis (RS) at side branch ostium (SBO) after final kissing balloon inflation (FKI) and clarify the impact of carina- and plaque-shifts on RS.

BACKGROUND

Carina- and plaque-shift induce SBO compromise. FKI is an effective technique to treat this complication; however, RS often persist, and are associated with restenosis at SBO.

METHODS

We performed serial volumetric analysis of 91 bifurcations in which crossover-stenting with FKI and pre-/post-intravascular ultrasounds (IVUS) were completed in both branches. The plaque- and carina-shifts were defined as an increase in the plaque-volume and a decrease in the vessel-volume at the SBO, respectively. RS at the SBO, defined as area stenosis >50% on IVUS, was identified in 19 lesions.

RESULTS

After FKI, the plaque volume- significantly increased at the SBO, with its reduction in the proximal main vessel (MV). However, at the SBO, the volumetric lumen change correlated with vessel change (ρ = 0.690, P < 0.001), but not plaque change (P = 0.390), suggesting that RS at SBO was more likely associated with inadequate vessel stretch, not plaque increase after FKI. Carina-shift was more frequently found in cases with RS, compared to those without RS (37% vs. 11%, P = 0.013). Pre-procedure IVUS findings to predict RS at SBO after FKI were negative-remodeling at distal MV, plaque -burden at distal MV, and plaque-burden at the SBO.

CONCLUSIONS

Carina-shift has a greater contribution to the formation of RS at SBO after FKI. The pre-procedure IVUS provides helpful information for predicting the RS after FKI.