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Gobeil F, Lefèvre T, Guyon P, Louvard Y, Chevalier B, Dumas P, Glatt B, Loubeyre C, Royer T, Morice MC. Stenting of bifurcation lesions using the Bestent: a prospective dual-center study. Catheter Cardiovasc Interv 2002; 55:427-33. [PMID: 11948886 DOI: 10.1002/ccd.10091] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Treatment of bifurcation lesions remains a technical challenge. Among 13 stents previously tested in a bench study, the Bestent seemed of particular interest in this indication as it provided good access to the side branch after stent implantation in the main branch associated with a satisfactory coverage of the lesion after kissing balloon inflation. The use of Bestent implanted in the main branch or both branches for treatment of bifurcation lesions involving a side branch > or = 2.2 mm in diameter was prospectively evaluated in a dual-center prospective study with a prospective 6-month clinical follow-up. All angiographic documents were analyzed by an independent corelab (CORISIS). Between 11 September 1997 and 21 February 1998, 96 patients were consecutively included (mean age, 63.7 +/- 11.4 years; 81.3% male; 58.3% with unstable angina and 6.3% acute myocardial infarction). The lesion involved the left anterior descending-diagonal coronary bifurcation in 55% of cases, left circumflex-marginal 23%, posterior descending-postero-lateral 12%, distal left main 6%, and others 4%. The main branch (proximal reference diameter: 3.43 +/- 0.45 mm) was stented in 98% of cases and the side branch (2.72 +/- 0.38 mm) in 38% (both branches in 34% of cases). T-stenting or provisional T-stenting was used in 88% of cases and final kissing balloon inflation was performed in 78% of cases. Procedural success was obtained in 100% of cases in the main branch and 98% in both branches. Major cardiac and cerebral events (MACCE) during hospitalization occurred in 4.2% of cases, non-Q-wave myocardial infarction (MI) in 3.1%, Q-wave MI in 1.0%, repeat PTCA in 2.1%; there were no major access site complication, no emergency coronary artery bypass grafting operation, no death. At 6-month follow-up, total MACCE rate was 14.6% (Q-wave MI, 3.1%; non-Q-wave MI, 3.1%; target vessel revascularization, 9.4%; death, 2.1%). Patients with target vessel revascularization (TVR) had restenosis of both branches in 22.2% of cases, main branch in 22.2%, and side branch in 55.6%. This study shows that using a simple strategy of provisional T-stenting of the side branch in the majority of cases, the Bestent can be used for treating bifurcation lesions with a high rate of success and an acceptable rate of TVR at 6-month follow-up.
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Al Suwaidi J, Yeh W, Cohen HA, Detre KM, Williams DO, Holmes DR. Immediate and one-year outcome in patients with coronary bifurcation lesions in the modern era (NHLBI dynamic registry). Am J Cardiol 2001; 87:1139-44. [PMID: 11356386 DOI: 10.1016/s0002-9149(01)01482-5] [Citation(s) in RCA: 147] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Balloon angioplasty of bifurcation lesions has been associated with lower success and higher complication rates than most other lesion types. The development of alternative strategies such as debulking and stenting, either alone or in combination, are currently used relatively often. The relative role of these newer approaches in improving acute or long-term outcome, however, remains uncertain. Of the total of 2,436 patients treated between July 1997 to February 1998 in the National Heart, Lung, and Blood Institute Dynamic Registry, there were 321 patients (group 1) with bifurcation lesions and 2,115 patients without any bifurcation lesions attempted (group 2). Treatment strategies in terms of major devices used were significantly different between the 2 groups (group 1 vs 2): balloon angioplasty alone (23.1% vs 26.5%), balloon angioplasty and rotational atherectomy (6.9% vs 4.4%), balloon angioplasty and stent (55.8% vs 59.9%), and balloon angioplasty, rotational atherectomy, and stent (10.3% vs 7%) with p <0.01. There were no significant differences between the groups in terms of age, gender, and frequency of prior myocardial infarction (MI) or coronary artery bypass graft surgery (CABG). Complete angiographic success was achieved in only 86% of bifurcation lesions versus 93.5% of nonbifurcation lesions (p <0.001). In-hospital complication rates were increased in patients with bifurcation lesions compared with the nonbifurcation group: MI, 3.7% versus 2.6%; CABG, 2.2% versus 1.1%; side branch occlusion, 7.3% versus 2.3% (p <0.001); and the composite of death, MI, and any CABG, 7.2% versus 5.0%. At 1-year follow-up, major adverse cardiac events were 25% higher in group 1 than in group 2 (32.1% vs 25.7%, p <0.05). We conclude that despite the widespread use of newer percutaneous devices, treatment of bifurcation lesions remains difficult and is associated with decreased success and increased complication rates compared with nonbifurcation lesions.
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Affiliation(s)
- J Al Suwaidi
- Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Kron IL, Kern JA, Beller GA, Bergin J, Fiser SM, Gangemi JJ, McPherson JA, Powers ER. Cardiac screening before non-cardiac operations. Curr Probl Surg 2000; 37:385-454. [PMID: 10858727 DOI: 10.1016/s0011-3840(00)80008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- I L Kron
- University of Virginia, Charlottesville, USA
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Al Suwaidi J, Berger PB, Rihal CS, Garratt KN, Bell MR, Ting HH, Bresnahan JF, Grill DE, Holmes DR. Immediate and long-term outcome of intracoronary stent implantation for true bifurcation lesions. J Am Coll Cardiol 2000; 35:929-36. [PMID: 10732890 DOI: 10.1016/s0735-1097(99)00648-8] [Citation(s) in RCA: 202] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the immediate and long-term outcome of intracoronary stent implantation for the treatment of coronary artery bifurcation lesions. BACKGROUND Balloon angioplasty of true coronary bifurcation lesions is associated with a lower success and higher complication rate than most other lesion types. METHODS We treated 131 patients with bifurcation lesions with > or =1 stent. Patients were divided into two groups; Group (Gp) 1 included 77 patients treated with a stent in one branch and percutaneous transluminal coronary angioplasty (PTCA) (with or without atherectomy) in the side branch, and Gp 2 included 54 patients who underwent stent deployment in both branches. The Gp 2 patients were subsequently divided into two subgroups depending on the technique of stent deployment. The Gp 2a included 19 patients who underwent Y-stenting, and Gp 2b included 33 patients who underwent T-stenting. RESULTS There were no significant differences between the groups in terms of age, gender, frequency of prior myocardial infarction (MI) or coronary artery bypass grafting (CABG), or vessels treated. Procedural success rates were excellent (89.5 to 97.4%). After one-year follow-up, no significant differences were seen in the frequency of major adverse events (death, MI, or repeat revascularization) between Gp 1 and Gp 2. Adverse cardiac events were higher with Y-stenting compared with T-stenting (86.3% vs. 30.4%, p = 0.004). CONCLUSIONS Stenting of bifurcation lesions can be achieved with a high success rate. However, stenting of both branches offers no advantage over stenting one branch and performing balloon angioplasty of the other branch.
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Affiliation(s)
- J Al Suwaidi
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Pan M, Suárez de Lezo J, Medina A, Romero M, Hernández E, Segura J, Castroviejo JR, Pavlovic D, Melian F, Ramírez A, Castillo JC. Simple and complex stent strategies for bifurcated coronary arterial stenosis involving the side branch origin. Am J Cardiol 1999; 83:1320-5. [PMID: 10235088 DOI: 10.1016/s0002-9149(99)00093-4] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Coronary lesions located in major bifurcations constitute a challenge for the use of stents. Although the occlusion of a side branch covered by a stent is infrequent, the maintenance of a patent, stenosis-free bifurcation may result in a complex procedure. Between September 1994 and April 1998, 70 patients were treated by stent implantation for coronary bifurcation stenosis. The side branch always had a diameter >2 mm. The pairs of treated arteries were: left anterior descending (LAD)/diagonal artery in 32 patients, circumflex/obtuse marginal in 26, right coronary/posterior descending artery in 5, and LAD/circumflex in 7. We applied 2 different techniques of stent implantation: (1) deployment of 1 stent in the parent vessel covering the takeoff of the side branch and subsequent angioplasty of the side branch across the metallic structure (group A, n = 47 patients), and (2) implantation of 1 stent at the ostium of the side branch and complete reconstruction of the entire bifurcation with additional implantation of 1 or 2 stents at the parent vessel (group B, n = 23 patients). There were no significant differences between groups at baseline variables. Procedural success was similar in both groups: 42 (89%) in group A versus 21 (91%) in group B. However, major cardiac events at 18 months follow-up were higher in group B (event-free probability 44% vs 75%, p <0.05). Selected patients with coronary stenosis at major bifurcations can be treated with an acceptable rate of primary and late success. Complex techniques providing radical stent reconstruction of the bifurcation seems to provide no advantages over the simpler stent jail followed by ostial side branch balloon dilation.
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Affiliation(s)
- M Pan
- Hospital Reina Sofía, University of Córdoba, Spain
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Dauerman HL, Higgins PJ, Sparano AM, Gibson CM, Garber GR, Carrozza JP, Kuntz RE, Laham RJ, Shubrooks SJ, Baim DS, Cohen DJ. Mechanical debulking versus balloon angioplasty for the treatment of true bifurcation lesions. J Am Coll Cardiol 1998; 32:1845-52. [PMID: 9857861 DOI: 10.1016/s0735-1097(98)00488-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the immediate angiographic and long-term results of debulking versus balloon angioplasty for treatment of true bifurcation lesions. BACKGROUND Previous studies have shown true bifurcation lesions to be a high risk morphological subset for percutaneous transluminal coronary angioplasty (PTCA). Although atherectomy devices have been used to treat bifurcation lesions, no studies have compared the outcomes of these alternative treatment modalities. METHODS Between January 1992 and May 1997, we treated 70 consecutive patients with true bifurcation lesions (defined as a greater than 50% stenosis in both the parent vessel and contiguous side branch) with conventional PTCA (n = 30) or debulking (with rotational or directional atherectomy) plus adjunctive PTCA (n = 40). Paired angiograms were analyzed by quantitative angiography, and clinical follow-up was obtained in all patients. RESULTS Acute procedural success was 73% in the PTCA group and 97% in the debulking group (p = 0.01). Major in-hospital complications occurred in two patients in the PTCA group and one in the debulking group. Treatment with atherectomy plus PTCA resulted in lower postprocedure residual stenoses than PTCA alone (16+/-15% vs. 33+/-17% in the parent vessel, and 6+/-15% vs. 39+/-22% in the side branch; p < 0.001 for both comparisons). At 1 year follow-up, the incidence of target vessel revascularization (TVR) was 53% in the PTCA group as compared with 28% in the debulking group (p = 0.05). Independent predictors of the need for repeat TVR were side branch diameter >2.3 mm, longer lesion lengths, and treatment with PTCA alone. CONCLUSIONS For the treatment of true bifurcation lesions, atherectomy with adjunctive PTCA is safe, improves acute angiographic results, and decreases target vessel revascularization compared to PTCA alone. The benefits of debulking for bifurcation lesions were especially seen in lesions involving large side branches.
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Affiliation(s)
- H L Dauerman
- Cardiovascular Division, Beth Israel-Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts 02215, USA
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Chevalier B, Glatt B, Royer T, Guyon P. Placement of coronary stents in bifurcation lesions by the "culotte" technique. Am J Cardiol 1998; 82:943-9. [PMID: 9794349 DOI: 10.1016/s0002-9149(98)00510-4] [Citation(s) in RCA: 183] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Coronary angioplasty of bifurcation lesions remains a technical challenge. Balloon angioplasty induces recoil and the "snow-plow" effect with a risk of side branch occlusion. The late result is associated with a high rate of reintervention. Randomized studies in nonbifurcated lesions have demonstrated better short- and midterm results after stent placement. We propose the "culotte" technique as a new technique to place intracoronary stents in bifurcation lesions: implantation of 2 similar stents in 2 steps in the main branch and in the side branch with overlapping of the 2 stents in the main branch before bifurcation. We performed this technique in 50 patients (in the left anterior diagonal branch in 33, in the left circumflex obtuse marginal branch in 12, in the right coronary artery in 4, and in the left main coronary artery in 1). The clinical success rate was 94% with 3 non-Q-wave myocardial infarctions. Late results indicated a 24% target lesion revascularization rate, which improved when a true kissing balloon inflation was used to achieve final deployment of both stents. This culotte technique is highly feasible and provides excellent short-term results. Assessment of its midterm benefit requires further study.
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Affiliation(s)
- B Chevalier
- Centre Cardiologique du Nord, Saint-Denis, France
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Rihal CS, Garratt KN, Holmes DR. Rotational atherectomy for bifurcation lesions of the coronary circulation: technique and initial experience. Int J Cardiol 1998; 65:1-9. [PMID: 9699924 DOI: 10.1016/s0167-5273(98)00085-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Bifurcation lesions of the coronary circulation are difficult to treat with standard balloon technology and are associated with relatively low procedural success rates and high complication rates. We hypothesized that effective debulking of bifurcation lesions with rotational atherectomy would improve observed results. Fifteen patients underwent rotational atherectomy of such lesions. Both limbs of the bifurcation were rotablated in seven patients and one limb in eight; seven patients also underwent stent deployment. Successful angiographic results were obtained in all limbs (<30% residual stenoses). One patient had a non-Q-wave myocardial infarction. No other significant complications occurred. We conclude that rotablation of bifurcation coronary stenoses is feasible, safe, and associated with a high likelihood of angiographic success.
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Affiliation(s)
- C S Rihal
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55095, USA
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ANTONELLIS IOANNISP, PATSILINAKOS SOTIRIOSP, PAMBOUCAS CONSTANDINOSA, SALACHAS ANASTASIOSJ, KRANIDIS ATHANASIOSJ, MARGARIS NIKOLAOSG, IFANTIS GEORGEP, TAVERNARAKIS ANTONIOSG, ROKAS STYLIANOSG. Bare Stent Implantation Through a Side Slot of Another Stent in a Bifurcation Lesion. J Interv Cardiol 1998. [DOI: 10.1111/j.1540-8183.1998.tb00109.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
We report the treatment of a jailed side branch using the Rotablator. Initial attempts at passing various low profile balloons in the jailed branch were unsuccessful. The Rotablator allowed access to the side branch, which was stented with a single Palmaz-Schatz stent, providing excellent angiographic and 9 months follow-up results.
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Affiliation(s)
- A E Abdelmeguid
- Department of Cardiology, Henry Ford Hospital, Detroit, MI 48202, USA
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Mayeda GS, Misumi K, Matthews RV. Salvage atherectomy: using retrieved tissue to determine the etiology of acute closure. CATHETERIZATION AND CARDIOVASCULAR DIAGNOSIS 1996; 38:283-6. [PMID: 8804763 DOI: 10.1002/(sici)1097-0304(199607)38:3<283::aid-ccd15>3.0.co;2-i] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Directional coronary atherectomy was successfully performed in the mid-left anterior descending artery at the site of failed balloon angioplasty. We presumed that intracoronary thrombus had resulted in acute vessel closure following balloon angioplasty, due to the angiographic appearance of the lesion and the clinical situation. However, examination of the extracted specimen from the atherectomy device revealed predominantly atheromatous tissue with minimal thrombus.
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Affiliation(s)
- G S Mayeda
- Cardiac Catheterization and Interventional Cardiovascular Laboratories, Good Samaritan Hospital, Los Angeles, California 90017, USA
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Abstract
We report the treatment of a bifurcation stenosis using kissing stents. Three Palmaz-Schatz stents were deployed in each limb of a left anterior descending artery/diagonal bifurcation, providing excellent angiographic and 5 month clinical follow-up results.
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Affiliation(s)
- P S Teirstein
- Division of Cardiovascular Diseases, Scripps Clinic and Research Foundation, La Jolla, California 92037, USA
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Safian RD. Lesion specific approach to coronary intervention. J Interv Cardiol 1995; 8:143-80. [PMID: 10155226 DOI: 10.1111/j.1540-8183.1995.tb00528.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- R D Safian
- Division of Cardiology, William Beaumont Hospital, Royal Oak, Michigan 48073, USA
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