Stent Enhancement during Percutaneous Coronary Intervention: Current Role, Technical Tips and Case Examples

Ultra-Low-Contrast PCI: A Structured Approach to Reducing Dependence on Contrast Vessel Opacification in PCI

Since its inception, percutaneous coronary intervention (PCI) has relied upon vessel opacification with iodinated contrast to plan, guide, and assess the results of the procedure. Yet revisiting this fundamental concept is important in contemporary PCI practice, especially in patients with high-risk clinical or anatomical profiles. In addition to decreasing the probability of acute kidney injury during PCI, limiting the volume of iodinated contrast allows the operator to perform more thorough interventions by relying on intracoronary imaging and physiology, ultimately contributing to more complete revascularization and improving the efficacy and durability of the intervention. Ultra-low-contrast PCI (ULCPCI) may thus be useful in performing PCI not only in patients with chronic renal dysfunction but also in those with multivessel coronary artery disease, impaired left ventricular function, and many other scenarios. The aim of this review is to highlight contemporary PCI scenarios in which a ULCPCI approach may be beneficial. The authors provide a structured approach to address the challenges faced by operators in transitioning from conventional contrast-based interventions to ULCPCI, with practical solutions that are accessible to most interventionalists. The reader will learn that ULCPCI is feasible in contemporary practice as a result of technological innovation, the implementation of dedicated skills, and redefining the role of angiography as the cornerstone of contemporary PCI.

Enhanced Stent Imaging System Guided Percutaneous Coronary Intervention Is Linked to Optimize Stent Placement

Stent under-expansion is a predictor of restenosis and stent thrombosis. It remains uncertain whether enhanced stent imaging (ESI) (CLEARstent) guidance can improve stent under-expansion. Our aim was to assess the effect of using ESI on stent under-expansion, after percutaneous coronary intervention (PCI) in a single center, cross-sectional observational study. Participants attending our cardiology clinic with stable angina or acute coronary syndrome, from March to September 2020 were recruited. A total of 164 patients who underwent post-PCI ESI (CLEARstent) were compared with 77 age- and sex-matched control patients. Post-procedural minimal lumen diameter (MLD) was calculated. The patients in the ESI-guided PCI group, had a median age of 61 (54-69 IQR 25-75) years and 76.8% (n = 126) were males. The patients in ESI-guided PCI group had a greater minimal lumen diameter compared with the X-ray guided PCI group (βeta coefficient:2.88 (95% CI:2.58-2.99) vs βeta coefficient 2.55 (95% CI 2.34-2.63), P < .001). Our finding supports the use of the ESI system to optimize stent placement as expressed by the MLD.

The Degree of Stent Apposition Measured by Stent Enhancement at the Level of the Side Branch as a Novel Predictor of Procedural Success in Left Main PCI

BACKGROUND

Stent enhancement techniques allow adequate visualization of stent deformation or incomplete stent expansion at the ostium of the side branch. Measuring the stent enhancement side branch length (SESBL) could reflect procedural success in terms of optimal stent expansion and apposition with better long-term outcomes. A longer SESBL may reflect a better stent apposition at the polygon of confluence and at the side branch (SB) ostium.

METHODS

We evaluated 162 patients receiving the left main (LM) provisional one-stent technique and measured the SESBL, dividing them into two groups: SESBL≤ 2.0 mm and SESBL > 2.0 mm.

RESULTS

The mean SESBL was 2.0 ± 1.2 mm. More than half of the bifurcations had both main and side branch lesions (Medina 1-1-1) (84 patients, 51.9%) and the length of the SB disease was 5.2 ±1.8 mm. Kissing balloon inflation (KBI) was performed in 49 patients (30.2%). During follow-up (12 months), there was a significantly higher rate of cardiac death in the SESBL ≤ 2.0 mm group (p = 0.02) but no significant difference in all major adverse cardiovascular events (MACEs) (p = 0.7). KBI did not influence the outcomes (p = 0.3).

CONCLUSION

Suboptimal SESBL is positively correlated with worse outcomes and SB compromise. This novel sign could aid the LM operator to assess the level of stent expansion at the ostium of the SB in the absence of intracoronary imaging.

Clinical Characteristics and Outcomes following Percutaneous Coronary Intervention in Unprotected Left Main Disease: A Single-Center Study

Background: Hemodynamically significant unprotected left main (LM) coronary artery disease is a high-risk clinical condition because of the large area of myocardium at risk, and it requires prompt revascularization. Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected LM disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG after adequate counseling by the heart team. Methods: We retrospectively evaluated 201 patients receiving left main (LM) provisional one-stent or two-stent procedures, and we assessed the clinical characteristics and outcomes of patients undergoing unprotected LM PCI. Results: The mean age was 66.5 ± 9.9 years, and 72% were male. The majority of the subjects presented several cardiovascular risk factors, among which arterial hypertension (179 patients, 89.5%) and dyslipidemia (173 patients, 86.5%) were the most frequent. Out of all patients, 162 (81.8%) underwent revascularization by using the one-stent technique, while the two-stent technique was used in 36 patients (18.2%). The median value of fractional flow reserve (FFR) of the side branch was 0.9 [0.85–0.95], and 135 patients (67.1%) showed a value of FFR > 0.8. One hundred nine patients (54.2%) had a stent enhancement side branch length (SESBL) > 2, with median values of 2.5 mm2 [2.1–3]. Regarding angiographic parameters, the LM area as assessed by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and the grade of stenosis as assessed by quantitative coronary angiography (QCA) were similar between groups. However, patients who required revascularization by using the two-stent technique presented more frequently with intermediate rather than low SYNTAX scores (69.4% vs. 28.4%, p < 0.0001). Also, the same group required kissing balloon inflation (KBI) more frequently (69.4% vs. 30%, p < 0.001). There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique. FFR was able to predict a SESBL > 2 mm. The cut-off value for FFR to afford the highest degree of sensitivity (74.5%) and specificity (47%) for a SESBL > 2 was >0.86, indicating a moderate accuracy (AUC = 0.61, 95% CI 0.525–0.690, p = 0.036). Conclusions: Unprotected left main PCI is a safe and effective revascularization option amongst a complex and morbid population. There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique, and there was no significant impact of KBI on side branch FFR measurements but lower side branch FFR values were correlated with angiographic side branch compromise.

Robotics, imaging, and artificial intelligence in the catheterisation laboratory

The catheterisation laboratory today combines diagnosis and therapeutics, through various imaging modalities and a prolific list of interventional tools, led by balloons and stents. In this review, we focus primarily on advances in image-based coronary interventions. The X-ray images that are the primary modality for diagnosis and interventions are combined with novel tools for visualisation and display, including multi-imaging co-registration modalities with three- and four-dimensional presentations. Interpretation of the physiologic significance of coronary stenosis based on prior angiographic images is being explored and implemented. Major efforts to reduce X-ray exposure to the staff and the patients, using computer-based algorithms for image processing, and novel methods to limit the radiation spread are being explored. The use of artificial intelligence (AI) and machine learning for better patient care requires attention to universal methods for sharing and combining large data sets and for allowing interpretation and analysis of large cohorts of patients. Barriers to data sharing using integrated and universal protocols should be overcome to allow these methods to become widely applicable. Robotic catheterisation takes the physician away from the ionising radiation spot, enables coronary angioplasty and stenting without compromising safety, and may allow increased precision. Remote coronary procedures over the internet, that have been explored in virtual and animal studies and already applied to patients in a small pilot study, open possibilities for sharing experience across the world without travelling. Application of those technologies to neurovascular, and particularly stroke interventions, may be very timely in view of the need for expert neuro-interventionalists located mostly in central areas.