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

Impact of Side Branch Occlusion on Patient Outcomes After Bifurcation Percutaneous Coronary Intervention

BACKGROUND

The outcomes and characteristics of patients with side branch occlusion (SBO) after bifurcation percutaneous coronary intervention (PCI) have received limited study.

METHODS

We compared the procedural characteristics and outcomes of patients with and without SBO among 933 provisional bifurcation PCIs performed in 803 patients at six centers between 2014 and 2024.

RESULTS

The prevalence of SBO was 13% (n = 121). SBO patients had lower rates of hypertension, prior coronary artery bypass graft surgery (CABG), and prior PCI but higher angiographic complexity, with higher prevalence of left anterior descending artery stenoses, smaller side branch diameter and more severe side branch diameter stenoses. SBO patients were more likely to convert from provisional to two-stent strategies (24.8% vs 6.0%, p < 0.001), and to require plaque modification (39.7% vs 17.5%, p < 0.001) and side branch percutaneous transluminal coronary angioplasty (PTCA) (25.6% vs 12.9%, p < 0.001). SBO patients had lower technical (78.5% vs 96.2%, p < 0.001) and procedural (73.5% vs 92.2%, p < 0.001) success and similar in-hospital major adverse cardiovascular events (MACE), but higher dissection rates (7.1% vs 2.0%, p = 0.007). Patients with untreated SBO had similar in-hospital MACE with untreated SBO patients. During a median follow-up of 1,095 days patients with treated SBO (83.9%, n = 94) had lower follow-up MACE (hazard ratio [HR]: 0.29, 95% confidence intervals [CI]: 0.10, 0.84, p = 0.023) and mortality (HR: 0.22, CI: 0.065, 0.755, p = 0.016) compared with patients with untreated SBO.

CONCLUSIONS

SBO occurs in 13% of provisional PCIs. SBO patients had more complex coronary lesions and worse follow-up clinical outcomes if the SBO was left untreated.

Long-Term Evaluation of Revascularization Strategies for Medina 0.1.0 Left Main Bifurcation Lesions: The LM-CROSSOVER Registry

The present study aimed to compare long-term outcomes of patients with Medina 0.1.0 left main (LM) bifurcation lesions treated by crossover stenting (COS) versus accurate ostial stenting (AOS). A total of 229 consecutive eligible patients with Medina 0.1.0 LM bifurcation lesions were enrolled and were stratified according to the stenting techniques. The primary end-point was major cardiovascular and cerebral events (MACCE), defined as the combination of all-cause death, target vessel related-myocardial infarction (MI), clinically driven target lesion revascularization (TLR), stroke, or stent thrombosis. COS and AOS were applied to 78 (34%) and 151 (66%) patients, respectively. During a mean of 40.6 ± 21.1 months of follow-up, the rate of MACCE (27.8 vs 12.8%; P=.007) was higher in patients treated with AOS than those treated with the COS technique, mainly driven by more frequent all-cause death (13.9 vs 3.8%, P = .013) and TLR (6.4 vs 15.9%; P = .029). In multivariable Cox regression analysis, AOS strategy was one of the independent predictors of MACCE (odds ratio: 2.166; 95% confidence interval, 1.080-4.340; P = .029). The current study suggests that COS was associated with a better long-term MACCE rate and lower all-cause mortality rate than AOS in patients with Medina 0.1.0 LM bifurcation disease.

Routine intracoronary imaging-guided left main coronary intervention

Left main (LM) percutaneous coronary intervention (PCI) with routine intracoronary imaging guidance is recommended; however, its real-world effectiveness remains unclear. A total of 743 consecutive patients undergoing drug-eluting stent implantation for de novo unprotected LM lesions across 19 Japanese National Hospital Organization hospitals where routine imaging guidance was adopted were analyzed. The primary endpoint was 1-year major adverse cardiovascular and cerebrovascular events (MACCE), comprising all-cause death, cerebrovascular disorder, clinical-driven revascularization, and myocardial infarction. In this cohort, acute coronary syndrome was present in 31.2%, with 39.3% classified as Canadian Cardiovascular Society functional angina (CCS) class ≥ III. LM bifurcation lesions were observed in 78.0%, with two-stent implantation in 8.8%. MACCE occurred in 17.5%, with target lesion revascularization and cardiac death rates of 2.0% and 3.4%, respectively. Independent risk factors for MACCE included two-stent implantation (hazard ratio [HR], 2.49), mechanical cardiac support device use (HR, 2.17), CCS class ≥ III (HR, 2.07), 10% increase in left ventricular ejection fraction (HR, 0.72), and radial access (HR, 0.62). Routine imaging-guided LM-PCI is associated with favorable low rate of target lesion revascularization and cardiac death. However, severe left ventricular dysfunction and LM bifurcation treated with two-stent implantation increase risks, requiring more comprehensive management.

Twenty Years of Experience in One Thousand De-Novo Left Main Coronary Angioplasty With Angiographic Control in a High-Volume Centre Without On-Site Cardiac Surgery

INTRODUCTION

Given the widespread use of percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary artery (ULMCA) disease, real-world data are needed to understand the current practice and identify pitfalls and potential benefits, especially for an older and frail population.

METHODS

We conducted a retrospective analysis including all patients, namely 1000, who underwent PCI on ULMCA for de-novo lesions, at our high-volume Italian center without on-site cardiac surgery, from 2002 to April 2023. Cases of restenosis, stent thrombosis, and coronary artery bypass grafting (CABG) were excluded. The primary clinical endpoint is major adverse cardiovascular and cerebrovascular event (MACCE), a composite endpoint including all-cause mortality, unplanned revascularization, myocardial infarction and stroke. Secondary clinical endpoints included the individual components of MACCE. Angiographic follow-up data, derived from both elective and clinical-driven procedures, were extensively available. The primary angiographic endpoint is target lesion failure (TLF), defined as significant restenosis or stent thrombosis of the LMCA. We performed a dedicated analysis comparing patients with a protocol-driven elective angiographic follow-up to those without, to evaluate the potential impact of this strategy on clinical outcomes.

RESULTS

Our registry encompasses a real-world frail and compromised population, with most patients (75%) presenting with acute coronary syndrome. Angiographic follow-up data were available for 739 patients (73.9%), of whom 612 (82.8%) demonstrated good results of the previous PCI and 127 patients (17.2%) experienced TLF. Multivariate analysis identified insulin-dependent diabetes, moderate to severe renal impairment, and a two-stents bifurcation technique as independent predictors of TLF. Among bifurcation techniques, the highest restenosis rates were observed in the Culotte technique (33.3%), followed by T and protrusion (30%) and Minicrush (28.2%), while the single stent approach was associated with the lowest rate of TLF (12.8%, p = < 0.001). Clinical follow-up data were available for 966 patients, with a survival rate of 95% at 7 days, 86.1% at 1 year, and 70% at an average follow-up of 2033 days. Multivariate analysis identified age over 70 years, moderate to severe renal impairment, multivessel disease, ejection fraction lower than 40%, hemodynamic instability (HDI) and endotracheal intubation (ETI) as independent predictors of MACCE and all-cause mortality while intravascular imaging was found to be protective for both. A propensity score matched analysis comparing two homogenous cohorts of 131 patients with and without elective angiographic follow-up demonstrated a significant survival advantage in the elective follow-up group, highlighting the potential benefits of this strategy.

CONCLUSIONS

In the real world setting clinical outcomes of PCI for unprotected LMCA disease are good and mainly affected by age, renal impairment, lower ejection fraction, multivessel disease and by the severity of the clinical presentation (namely HDI and ETI), while intravascular imaging was found to be protective. Notably, insulin-dependent diabetes and two-stent technique are independent predictors of TLF but not of mortality, while renal impairment has a negative impact on both. An elective angiographic follow-up could provide a survival benefit in this setting.

Long-Term Outcomes of True Versus Nontrue Coronary Bifurcation Lesions Treated With Bioresorbable Polymer Sirolimus-Eluting Ultimaster Stent Under Intravascular Imaging Guidance

Limited evidence exists regarding the long-term outcomes of true versus nontrue coronary bifurcation lesions (CBLs) treated with current-generation drug-eluting stents and intravascular imaging guidance. The Sapporo Cardiovascular Clinic (SCVC) registry was a prospective, single-center, all-comers registry enrolling 1,727 consecutive patients treated with bioresorbable polymer sirolimus-eluting stent under complete imaging guidance. From this registry, 440 patients with CBLs (25.5%) were analyzed. Patients were categorized into the true and nontrue CBL groups according to the Medina classification (n = 234 and 206, respectively). The primary end point was the cumulative incidence of target vessel failure (TVF) (a composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target vessel revascularization). The 1-stent strategy was predominantly chosen for the true and nontrue CBL groups (93.9% and 96.2%, respectively). During the median follow-up of 5.4 years, the cumulative incidence of TVF did not differ between true and nontrue CBL groups after adjustment for baseline differences (5-year incidence 22.0% vs 17.7%, adjusted hazard ratio 1.27, 95% confidence interval 0.79 to 2.05, p = 0.32). Although the Medina 0.0.1 lesions were very rare (1.1%), they had the highest rate of TVF among the Medina subtypes. Final kissing balloon inflation technique was associated with a lower incidence of TVF (p = 0.036). In conclusion, imaging-guided percutaneous coronary intervention with bioresorbable polymer sirolimus-eluting stent resulted in comparable long-term clinical outcomes between true and nontrue CBLs, primarily using the 1-stent technique.

Stepwise Provisional Versus Systematic Dual-Stent Strategies for Treatment of True Left Main Coronary Bifurcation Lesions

BACKGROUND

The optimal coronary stenting technique for true left main bifurcation lesions is uncertain. EBC MAIN (European Bifurcation Club Left Main Trial) aimed to evaluate clinical outcomes of a stepwise provisional strategy compared with a systematic dual-stent approach.

METHODS

EBC MAIN was a randomized, investigator-initiated, open-label, multicenter, parallel-group trial conducted across 35 hospitals in 11 European countries. A total of 467 participants undergoing percutaneous coronary intervention for unprotected true left main bifurcation lesions were randomly assigned to the stepwise provisional strategy (n=230) or an upfront dual-stent approach (n=237). The mean (SD) age was 71 (10) years and 23% of participants were women. The primary end point was a composite of major adverse cardiac events, defined as all-cause mortality, all myocardial infarction, or clinically driven target lesion revascularization. Events were adjudicated by an independent clinical events committee and all analyses were by the intention-to-treat principle.

RESULTS

At 3 years, the primary end point occurred in 54 of 230 (23.5%) stepwise provisional and 70 of 237 (29.5%) dual-stent patients (hazard ratio, 0.75 [95% CI, 0.53-1.07]; P=0.11). There was no significant difference in all-cause mortality (10.0% versus 13.1%) or myocardial infarction (12.2% versus 11.0%). However, target lesion revascularization was significantly lower in the stepwise provisional group (8.3% versus 15.6%; hazard ratio, 0.50 [95% CI, 0.29-0.86]; P=0.013). In this population, the mean side vessel diameter by quantitative angiography was 2.9 mm, and median side vessel lesion length was 5 mm. Significant interactions were identified between the assigned bifurcation strategy and both side vessel diameter and lesion length with respect to the primary outcome (P=0.009 and P=0.005, respectively), with smaller vessels (<3.25 mm diameter) and shorter lesions (<10 mm length) favoring the provisional approach.

CONCLUSIONS

In a European population with true left main stem bifurcation coronary disease requiring intervention, there was no difference in major adverse cardiovascular events between stepwise provisional and systematic dual-stent strategies at 3 years. Target lesion revascularization was significantly less frequent with the stepwise provisional approach, which should be the default strategy for noncomplex left main bifurcation coronary intervention.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02497014.

Contemporary Use of Post-Dilatation for Stent Optimization During Percutaneous Coronary Intervention; Results From the Netherlands Heart Registration

BACKGROUNDS

Post-dilatation after stenting with a non-compliant (NC) balloon can be used to improve overall percutaneous coronary intervention (PCI) result. Due to lack of evidence on the effect of post-dilatation on adverse clinical endpoints there is no consensus whether post-dilatation should be used routinely. The aim of the current study was to determine the contemporary practice of post-dilatation.

METHODS

This study included patients from the Netherlands Heart Registration who underwent PCI between the 4th quarter of 2020 and the 3rd quarter of 2021. The primary endpoint was the rate of post-dilatation with a NC balloon. Secondary endpoints included differences in baseline and procedural characteristics of patients that received post-dilatation and patients that did not receive post-dilatation.

RESULTS

Out of 12,960 patients from 11 hospitals, 49.9% underwent post-dilatation. There was a variety in post-dilatation between hospitals ranging from 29.3% to 82.7% and among operators ranging from 15.9% to 90.5%. Post-dilatation was used less frequent in patients presenting with ST-elevation myocardial infarction or out of hospital cardiac arrest. Multivessel and left main PCI, long stent length and use of intracoronary imaging and calcium modification were associated with increased use of post-dilatation. When imaging was used, the percentage of post-dilatation was 79.4%.

CONCLUSIONS

In the Netherlands, stent optimization with post-dilatation using NC balloon is performed in only half of the patients undergoing PCI, with variations in frequency across centres and operators. Post-dilatation is more often used in cases of complex PCI and when intracoronary imaging or calcium modification techniques are used.

Double-Kissing Crush Versus Provisional Stenting for Coronary Bifurcations: A 1-Year Follow-up Study in Vietnam

Background

Coronary bifurcation lesions (CBLs) present significant challenges in interventional cardiology, especially in low and middle-income countries like Vietnam. While the double-kissing (DK) crush technique is gaining attention for its potential benefits, its efficacy and safety compared with provisional stenting (PS) in the Vietnamese population remain underexplored. This study aimed to assess the effectiveness of the DK crush technique in reducing major adverse cardiovascular events (MACE) compared with those of PS, providing essential data to inform clinical decision-making in settings with limited resources.

Methods

This prospective cohort study included 58 patients with CBL, 33 patients undergoing the DK crush technique and 25 receiving PS. Clinical follow-up at 1, 3, 9, and 12 months assessed MACE, including cardiovascular disease-related death, acute myocardial infarction, hospitalization for heart failure, and stroke.

Results

Post-percutaneous coronary intervention side branch diameter stenosis in the DK crush group was 5.64% ± 5.80%, significantly lower than the PS group (48.2% ± 28.5%; P < .001). One-year follow-up data revealed greater MACE reduction in the DK crush group (91% MACE-free vs 72% in the PS group; P = .03; hazard ratio [HR], 3.689; 95% CI, 1.034-13.160). However, the DK crush technique had longer procedural times (91.1 vs 54.6 minutes) and required higher contrast and radiation doses (P < .01).

Conclusions

Although DK crush requires longer procedure times and greater radiation exposure, it results in greater MACE reduction than does PS in patients with CBL. Clinicians should weigh the benefits and limitations of both techniques, particularly in resource-limited settings.

Comparing cross-over stenting and focal ostial stenting for ostial left anterior descending coronary artery lesions: a systematic review and meta-analysis

BACKGROUND

The ideal revascularization approach for ostial left anterior descending coronary artery (L.A.D.) lesions continues to be a matter of debate. Two primary stenting strategies are often contemplated for managing these lesions: focal ostial stenting (F.O.S.) and the provisional strategy, alternatively termed cross-over stenting (C.O.S.) from the LM to the L.A.D. artery.

AIM

Our objective is to assess the efficacy of C.O.S. vs. F.O.S. techniques in patients with ostial L.A.D. lesions who underwent percutaneous coronary intervention (P.C.I.).

METHODS

We systematically searched five electronic databases to identify relevant studies. The data was pooled as odds ratio (O.R.) with its 95% confidence interval (C.I.) using the DerSimonian-Laird random effect model in STATA 17 MP. Significance was determined by a p-value > 0.05 between intervention subgroups.

RESULTS

Nine articles with a total of 1492 patients were included in the meta-analysis. The pooled O.R. for Major Adverse Cardiovascular Events (MACE) was 0.88 (95% C.I. [0.39, 1.99], P = 0.76), indicating comparable rates between F.O.S. and C.O.S. For all-cause death, the O.R. was 1.46 (95% C.I. [0.53, 4.02], P = 0.46), with no significant differences between the compared techniques. Cardiovascular death showed no preference between treatments (O.R.=0.99, 95% C.I. [0.30, 3.31], P = 0.99), and similarly for myocardial infarction (O.R.=0.74, 95% C.I. [0.38, 1.44], P = 0.37).

CONCLUSION

Our meta-analysis comparing C.O.S. and F.O.S. for L.A.D. lesions revealed similar efficacy in clinical and angiographic outcomes.

Decoding medina 0.0.1 bifurcation: Are all codes equal? Results from a multicentric registry

OBJECTIVES

This study aimed to detail the technical management of Medina 0.0.1 lesions, assess their outcomes, and identify predictors of Major Adverse Cardiovascular Events (MACE).

BACKGROUND

Medina 0.0.1 bifurcations are rare and under-researched, with their optimal treatment strategy still debated and poorly described in daily practice.

METHODS

A multicenter international registry enrolled 273 patients (277 lesions) undergoing PCI for de novo Medina 0,0,1 lesions (2017-2022). Data were systematically collected, and clinical follow-up was performed. The primary endpoint was 3-year MACE (cardiovascular death, myocardial infarction, and target vessel revascularization). Target lesion revascularization and stent thrombosis were secondary endpoints.

RESULTS

Median follow-up was 1180 days. Most cases were treated with planned one-stent PCI (84.1 %), mainly inverted provisional and ostial stenting (53.6 % and 45.9 %, respectively). The incidence of MACE and TLR was 16.9 % and 13.4 %, respectively. Univariate analysis identified dyslipidemia, diabetes, prior PCI, and left main bifurcation as predictors of MACE. Proximal optimization technique significantly reduced 3-year MACE (HR 0.28, 95 % CI 0.10-0.80, p = 0.03). Multivariate analysis identified diabetes as the only independent predictor of 3-year MACE (adjusted HR 2.35, 95 % CI 1.23-4.49, p = 0.01). No significant difference in 3-year MACE was found between inverted provisional and ostial stenting (17.2 % vs. 12.1 %).

CONCLUSION

Medina 0.0.1 bifurcations show high levels of MACE and TLR in the long-term. Diabetes emerged as the only independent 3-year MACE predictor. While current recommendations are widely adhered to in left main bifurcation angioplasty, they are less frequently applied in smaller bifurcations and acute settings.

Differential Prognosis of True Bifurcation Lesions According to Left Main Versus Non-Left Main Location and Treatment Strategy

BACKGROUND

Although true bifurcation lesions are associated with a high risk of procedural complications, the differential prognostic implications of percutaneous coronary intervention for true bifurcations according to lesion location are unclear. This study aimed to identify whether clinical outcomes of true bifurcation lesions differed between left main coronary artery (LM) and non-LM bifurcations and to determine the optimal treatment strategy for subtypes of bifurcation lesions in the current-generation drug-eluting stent era.

METHODS

The ULTRA-BIFURCAT (Combined Insights From the Unified COBIS III, RAIN, and ULTRA Registries) was created by merging 3 bifurcation-dedicated registries from Korea and Italy. For this, 6548 patients treated with bifurcation lesions were stratified by lesion location and subtype. The primary end point was major adverse cardiac events (MACEs; composite of all-cause death, myocardial infarction, target lesion revascularization, and stent thrombosis) at 800 days.

RESULTS

In patients with an LM bifurcation, those with a true bifurcation had a significantly higher risk of a MACE than those with a nontrue bifurcation (20.2% versus 13.4%, adjusted hazard ratio [HR], 1.44 [95% CI, 1.11-1.86]; P=0.006). Conversely, there was no significant difference in the risk of a MACE according to true versus nontrue bifurcation in patients with non-LM bifurcation lesions (9.0% versus 8.8%; adjusted HR, 1.02 [95% CI, 0.82-1.27]; P=0.849). For LM true bifurcations, MACE rates were comparable between 1-stent and 2-stent strategies, whereas for LM nontrue bifurcations, the 2-stent strategy was associated with a significantly higher risk of MACEs than the 1-stent strategy. No significant differences in the risk of MACEs were observed in non-LM bifurcation lesions according to lesion subtype or treatment strategy.

CONCLUSIONS

Clinical outcomes were worse for LM true bifurcation lesions than non-LM true bifurcation lesions. A provisional 1-stent strategy should be the preferred approach for treating LM nontrue bifurcation lesions.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03068494, NCT03544294, and NCT05205148.

Percutaneous Coronary Intervention in the UK: Recommendations of the British Cardiovascular Intervention Society

Percutaneous techniques to treat obstructive coronary artery disease continue to evolve and the evidence base informing our practice is shared and summarised in international guidelines. In the UK, the British Cardiovascular Intervention Society represents and supports interventional cardiologists undertaking both coronary and structural interventions. Procedural data are collected in a national registry and these inform our understanding of UK practice and outcomes. These recommendations, pertaining to coronary intervention alone, are an update of those published in 2015 and describe the provision of percutaneous coronary intervention in the UK intended to provide optimal patient care.

Complex Left Main Trifurcation: A Case Study of Successful Treatment

Objectives: True trifurcation disease of the left main coronary artery is a rare situation encountered in clinical practice. To date, there is no evidence for a standardized strategy of percutaneous coronary intervention in this type of lesion. Methods: This article describes a novel three-stent strategy using a combination of Triple-Kissing Balloon Crush in both of the side branches. This technique is based on a well-established bifurcation stenting technique, namely, the Double-Kissing Crush technique. Results: This strategy was implemented successfully, demonstrating technical feasibility and optimal stent apposition in the trifurcation lesion, ensuring the preservation of all three branches. Conclusions: Although more data and clinical trials are needed to develop proper evidence-based guidelines, three-stent implantation with Double-Trissing Crush should be taken into consideration as a viable strategy for LM trifurcation lesions in the proper set of patients.

Drug-Coated Balloon Angioplasty of the Side Branch During Provisional Stenting: The Multicenter Randomized DCB-BIF Trial

BACKGROUND

Side branch stenting is often required during provisional stenting, leading to suboptimal results. Drug-coated balloons (DCB) for the compromised side branch have emerged as an attractive strategy. However, the benefit of DCB for coronary bifurcations remains unclear.

OBJECTIVES

This study aimed to investigate whether DCB, compared with a noncompliant balloon (NCB), for the pinched side branch improves the outcomes of provisional stenting in patients with simple, true coronary bifurcations.

METHODS

In this multicenter, randomized controlled trial, patients with true coronary bifurcations who had side branch diameter stenosis of ≥70% after main vessel stenting at 22 centers in China, Indonesia, Italy, and Korea were randomly assigned to either DCB or NCB intervention. The primary endpoint was major adverse cardiac events, a composite of cardiac death, target vessel myocardial infarction, or clinically driven target-lesion revascularization at the 1-year follow-up.

RESULTS

Between September 8, 2020, and June 2, 2023, 784 patients with true coronary bifurcation lesions undergoing main vessel stenting and having a severely compromised side branch were randomly assigned to the DCB (n = 391) or NCB (n = 393) group. One-year follow-up was completed in all patients. The primary endpoint occurred in 28 patients in the DCB group and 49 patients in the NCB group (Kaplan-Meier rate: 7.2% vs 12.5%; HR: 0.56; 95% CI: 0.35-0.88; P = 0.013), driven by a reduction in myocardial infarction. There were no significant differences between groups in procedural success, crossover to a 2-stent approach, all-cause death, revascularization, or stent thrombosis.

CONCLUSIONS

In patients with simple and true coronary bifurcation lesions undergoing provisional stenting, main vessel stenting with a DCB for the compromised side branch resulted in a lower 1-year rate of the composite outcome compared with an NCB intervention for the side branch. The high rates of periprocedural myocardial infarction, which occurred early and did not lead to revascularization, are of unclear clinical significance.

Impact of Bifurcation Lesions on Outcomes After FFR-Guided PCI or CABG

BACKGROUND

In the era of first-generation drug-eluting stents and angiography-guided percutaneous coronary intervention (PCI), the presence of a bifurcation lesion was associated with adverse outcomes after PCI. In contrast, the presence of a bifurcation lesion had no impact on outcomes following coronary artery bypass grafting (CABG). Therefore, the presence of a coronary bifurcation lesion requires special attention when choosing between CABG and PCI. The aim of this study is to assess whether the presence of a bifurcation lesion still influences clinical outcomes after contemporary PCI using second-generation drug-eluting stent and fractional flow reserve (FFR) guidance versus CABG.

METHODS

The randomized FAME 3 trial (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) compared FFR-guided PCI using current drug-eluting stents with CABG in patients with 3-vessel coronary artery disease. The prespecified key end point at 3-year follow-up was the composite of death, myocardial infarction, or stroke. In this substudy, the impact of bifurcation lesions on outcomes after FFR-guided PCI and CABG was investigated.

RESULTS

The FAME 3 trial enrolled 1500 patients and 653 (45.2%) patients had at least 1 true bifurcation lesion. There was no difference in the composite of death, myocardial infarction, or stroke at the 3-year follow-up between patients with or without at least 1 true bifurcation lesion (11.6% versus 10.0%; hazard ratio, 1.17 [95% CI, 0.86-1.61]; P=0.32), regardless of revascularization strategy. The composite end point was not statistically different between FFR-guided PCI and CABG in patients with at least 1 true bifurcation lesion (hazard ratio, 1.27 [95% CI, 0.80-2.00]) or without a true bifurcation lesion (hazard ratio, 1.36 [95% CI, 0.87-2.12]), with no significant interaction (Pinteraction=0.81).

CONCLUSIONS

In patients with 3-vessel coronary artery disease, the presence of a true bifurcation lesion was not associated with a different treatment effect after FFR-guided PCI with contemporary drug-eluting stent versus CABG.

Multimodal Imaging of Coronary Bifurcation TAP Procedures Utilizing Visible Heart® Methodologies: EBC Recommended Steps and Bailout Procedures

In some cases it is critical to clinically perform coronary bifurcation stenting to minimize the potential risk for restenosis and/or stent thrombosis. The European Bifurcation Club (EBC) has provided guidelines for optimally performing such procedures. Yet, sometimes such procedures do not go as planned, and in some cases bailout procedures are required. Here we utilized Visible Heart® (VH) methodologies and multimodal visualizations to better understand each step for optimally performed T and small protrusion (TAP) procedures, as well as those in which complications occurred. These studies were performed within reanimated swine hearts in which endoscopes, fluoroscopy, and optical coherence tomography (OCT) could readily be used. Additionally, because these procedures were performed in reanimated hearts, one could intentionally cause complications, so to perform bailout procedures. Finally, following these procedures each specimen was micro CT scanned, and high resolution computational models (~40 microns) were reconstructed of the final outcomes.

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.

Unprotected distal left main percutaneous intervention

Revascularization has been demonstrated to be clearly superior to medical therapy for significant unprotected left main coronary artery (LMCA) disease. Coronary artery bypass graft surgery (CABG) has a class 1 indication in both the American and European society guidelines for the treatment of LMCA disease. However, for the population of patients who are declined CABG after a heart team evaluation, percutaneous coronary interventional (PCI) may be an efficacious alternative. This review summarizes the data on percutaneous coronary intervention of distal left main coronary artery disease including the various contemporary techniques and associated challenges.

Long-term cardiovascular outcomes after mini-crush or T and minimal protrusion techniques in complex bifurcation lesions: the EVOLUTE-CRUSH III study

BACKGROUND

Mini-crush (MC) and T-stenting and small protrusion (TAP) techniques are frequently used, but the long-term comparison of both techniques in patients with complex bifurcation lesions (CBLs) is still a debatable issue. This study sought to retrospectively evaluate the long-term outcomes of MC and TAP techniques in patients with CBLs.

METHODS

A total of 271 patients [male: 202 (78.9%), mean age: 58.90 ± 10.11 years] patients in whom complex bifurcation intervention was performed between 2014 and 2023 were involved. The primary endpoint was major cardiovascular events (MACE) as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization. The Cox proportional hazard models were adjusted by the inverse probability weighting approach to reduce treatment selection bias.

RESULTS

The initial management strategy was MC in 146 patients and TAP in 125 cases. MACE occurred in 52 patients (19.2%) during a mean follow-up period of 32.43 ± 16 months. The incidence of MACE (13 vs. 26.4%, P  = 0.005) and major cardiovascular and cerebral events (15.1 vs. 28.8%, P  = 0.006) were significantly lower in the MC group than in the TAP group. Additionally, the incidence of definite or probable stent thrombosis was numerically lower in the MC group compared with the TAP group but did not differ significantly (2.7 vs. 8%, P  = 0.059). The long-term MACE was notably higher in the TAP group than the MC group [adjusted hazard ratio (inverse probability weighted): 1.936 (95% confidence interval: 1.053-3.561), P  = 0.033].

CONCLUSION

In this study involving patients with CBLs, percutaneous coronary intervention with the MC technique had better long-term outcomes than the TAP technique.

The feasibility of double stent strategy in left main true bifurcation with small and large angle change between diastole and systole: The Milan and New-Tokyo (MITO) registry

BACKGROUND

Provisional single stenting strategy (PSS) is a default strategy for percutaneous coronary intervention (PCI) of unprotected left main distal bifurcation lesions (ULMD). Previous study reported that a bifurcation angle change (BAC) between end diastole and systole was associated with outcomes after PCI with double stent strategy (DSS) for ULMD. However, there are no data comparing outcomes after PCI with PSS versus DSS according the degree of BAC.

OBJECTIVES

We evaluated outcomes after PCI with PSS versus DSS for true ULMD with small and large BAC.

METHODS

We identified 566 patients with true ULMD underwent PCI in three high-volume centers. We calculated the BAC in ULMD between end-diastole and systole before stenting with 2-dimensional quantitative coronary angiographic assessment. We defined small (BAC < 7.0°) and large BAC (≥7.0°) group. We compared clinical outcomes after PCI with PSS versus DSS in each cohort after propensity score adjustment. The primary endpoint was target-lesion failure (TLF), which was defined as a composite of cardiac death, target lesion revascularization, and myocardial infarction.

RESULTS

In small BAC cohort, TLF rate was significantly lower in DSS group than in PSS group (12.5% vs. 20.1%, adjusted HR 0.45; 95% CI, 0.26-0.79; p = 0.006). In contrast, in large BAC cohort, TLF rate was significantly higher in DSS group than in PSS group (54.9% vs. 29.0%, adjusted HR 2.25; 95% CI, 1.50-3.38; p < 0.001).

CONCLUSIONS

The TLF rate after PCI with DSS was significantly lower in true ULMD with small BAC compared to PSS even after propensity score adjustment. In contrast, it was significantly higher in those with large BAC.

Evaluation of Small Vessel Bifurcation Stenting Using the Double-Kissing Culotte and Culotte Technique in Acute Coronary Syndrome: 12-Month Clinical Outcomes

INTRODUCTION

Patients with small vessels who undergo percutaneous coronary intervention (PCI) with subsequent multiple implantation of drug-eluting stents remain at a higher risk of unfavorable outcomes. In complex cases where maintaining flow to all side branches is part of contemporary practice, using two-stent techniques may be appropriate. This study aims to evaluate the efficacy of double-kissing (DK) culotte technique in comparison to culotte technique in the context of small-vessel therapy in patients with acute coronary syndrome (ACS).

METHODS

This substudy of the Lower Silesia culotte Bifurcation Registry retrospectively analyzed patients who underwent ACS-PCI using DK culotte or culotte technique for bifurcation lesions in small vessels, defined as having at least one branch with a diameter of 2.75 mm or less. The primary endpoint was target lesion failure (TLF), a composite of cardiovascular death, target vessel myocardial infarction, or clinically driven target lesion revascularization (TLR) at 1-year follow-up. The secondary endpoint included major adverse cardiac events (MACE).

RESULTS

The DK culotte group (n = 49) and the culotte group (n = 52) were compared, with 12-month follow-up showing lower TLF in the DK culotte group (8.2% vs. 19.2%, p = 0.082). Similar results were observed for TLR (6.1% vs. 13.5%; p = 0.161), stent restenosis (4.1% vs. 9.6%; p = 0.203), and MACE (18.4% vs. 25%; p = 0.344).

CONCLUSION

For bifurcation lesions with a small-diameter artery, the DK culotte technique may reduce TLF and MACE compared to the culotte technique. However, given the limited sample size and the absence of statistical significance, these findings remain preliminary and require further investigation.

Contemporary State-of-the-Art PCI of Left Main Coronary Artery Disease

The left main coronary artery (LMCA) supplies over 70% of the myocardium, and significant LMCA disease is associated with high morbidity and mortality. With remarkable advances in percutaneous coronary intervention (PCI), including stent technology, antithrombotic agents, and evolving procedural techniques, PCI has become an important treatment option in clinical practice guidelines for the revascularization of LMCA disease. In contemporary clinical practice, a heart-team approach to shared decision-making, considering clinical/anatomic factors along with patient preferences, is emphasized for patients with significant LMCA disease requiring myocardial revascularization. Furthermore, recent progress in PCI procedures combined with intravascular imaging or functional guidance has resulted in significant improvements in PCI outcomes, especially for complex lesions, including LMCA disease. Nevertheless, owing to inherent anatomic complexities and frequent multivessel involvement, several unmet issues remain regarding the determination of the appropriate treatment approach for significant LMCA disease, for which further clinical research is required. This contemporary review article provides a comprehensive overview of left main PCI based on current guidelines and underlying trial data, addresses important unresolved diagnostic and therapeutic issues, and identifies future perspectives likely to advance progress in this field.

Double Kissing Mini-Culotte Stenting in Unprotected Distal Left Main Bifurcation Under Optical Coherence Tomography Guidance: Immediate and Short-Term Outcomes

Culotte stenting is an effective strategy for left main coronary artery bifurcation lesions. Increased side branch ostial restenosis is the main drawback of culotte stenting. This is due to a napkin ring or potential gap produced at the ostium of the side branch. A bench study by Toth et al11 has shown that additional sequential kissing balloon dilation before main vessel stenting can prevent this deformity. We report immediate and short-term results of double kissing (DK) mini-culotte stenting with a 1-year angiographic follow-up. Between March 2020 and December 2022, 45 patients with distal left main (LM) disease underwent DK mini-culotte stenting at our center under optical coherence tomography guidance. Of 45 patients (male: 35 (77.77%); mean age: 63.67 ± 4.94 years), chronic coronary artery syndrome was present in 26 (57.8%) and unstable angina in the remainder. All lesions were Medina (1,1,1), (0,1,1), or (1,0,1), with a median Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score of 28 (interquartile range 23 to 29). All procedures were technically successful with no adverse clinical events (death, myocardial infarction, or stent thrombosis). Under optical coherence tomography guidance, adequate minimal stent area of 13.28 ± 0.77 mm2, 8.25 ± 0.29 mm2, and 7.54 ± 0.45 mm2 was achieved in LM, left anterior descending, and left circumflex, respectively. Adequate stent expansion of >80% was achieved in all cases. At the end of 1 year, the incidence of major adverse cardiovascular events was 2.2%. Furthermore, restenosis of the side branch developed in 1 patient (2.2%), which was managed conservatively. DK mini-culotte stenting in the distal LM bifurcation has shown promising results and is effective in preventing side branch stent deformation and its sequelae of in-stent restenosis.

In-hospital outcomes of ad hoc versus planned PCI for unprotected left-main disease: An analysis of 8574 cases from British Cardiovascular Intervention Society database 2006-2018

BACKGROUND

Although data suggests ad hoc percutaneous coronary intervention (PCI) results in similar patient outcomes compared to planned PCI in nonselected patients, data for ad hoc unprotected left main stem PCI (uLMS-PCI) are lacking.

AIM

To determine if in-hospital outcomes of uLMS-PCI vary by ad hoc versus planned basis.

METHODS

Data were analyzed from all patients undergoing uLMS-PCI in the United Kingdom 2006-2018, and patients grouped into uLMS-PCI undertaken on an ad hoc or a planned basis. Patients who presented with ST-segment elevation, cardiogenic shock, or with an emergency PCI indication were excluded.

RESULTS

In total, 8574 uLMS-PCI procedures were undertaken with 2837 (33.1%) of procedures performed on an ad hoc basis. There was a lower likelihood of intervention for stable angina (28.8% vs. 53.8%, p < 0.001) and a higher rate of potent P2Y12 inhibitor use (16.4% vs. 12.1%, p < 0.001) in the ad hoc PCI group compared to the planned PCI group. Patients undergoing uLMS-PCI on an ad hoc basis tended to undergo less complex procedures. Acute procedural complications including slow flow (odds ratio [OR]: 1.70, 95% confidence interval [CI]: 1.01-2.86), coronary dissection (OR: 1.41, 95% CI: 1.12-1.77) and shock induction (OR: 2.80, 95% CI: 1.64-4.78) were more likely in the ad hoc PCI group. In-hospital death (OR: 1.65, 95% CI: 1.19-2.27) and in-hospital major adverse cardiac or cerebrovascular events (OR: 1.50, 95% CI: 1.13-1.98) occurred more frequently in the ad hoc group. In sensitivity analyses, these observations did not differ when several subgroups were separately examined.

CONCLUSIONS

Ad hoc PCI for uLMS disease is associated with adverse outcomes compared to planned PCI. These data should inform uLMS-PCI procedural planning.

State-of-the-art percutaneous coronary intervention for left main coronary artery disease in Japan

Percutaneous coronary intervention for left main coronary artery disease (LM-PCI) represents a high-risk yet life-saving procedure that has evolved significantly over the years. This review outlines the current state-of-the-art practices for LM-PCI in Japan in detail, emphasizing the integration of coronary physiology and intracoronary imaging alongside with evidence-based standardized technique using latest drug-eluting stents. These advancements enable precise lesion assessment, stent sizing, and optimal deployment, thereby enhancing procedural safety and efficacy. Despite discrepancies between current guidelines favoring coronary artery bypass grafting and real-world practice trends towards increased LM-PCI adoption, particularly in elderly populations with multiple comorbidities, careful patient selection and procedural planning are critical. Future perspectives include further refining LM-PCI through conducting randomized controlled trials integrating advanced techniques and addressing the issue of ostial left circumflex lesions and nationwide standardization of medical care for LM disease.

Hybrid strategy of drug-eluting stent and drug-coated balloon in the treatment of de novo coronary artery disease: 1-year clinical outcomes

Background

The hybrid strategy of drug-eluting stent (DES) and drug-coated balloon (DCB) has been increasingly accepted for the treatment of de novo coronary artery disease. However, data regarding the clinical outcome of this practice in a Southeast Asian population are limited.

Aims

We aimed to investigate the safety and clinical outcome of this hybrid strategy (DES and DCB) in the treatment of de novo coronary artery disease. The primary endpoint was target lesion failure (TLF) in the DES/DCB-treated segment at 12 months. TLF is defined as the composite of cardiac death, target vessel myocardial infarction (TVMI) and ischaemia-driven target lesion revascularisation (ID-TLR) in the DES- and/or DCB-treated segment.

Methods

A total of 401 patients with 458 lesions were treated with the hybrid strategy at the National Heart Institute (IJN), Kuala Lumpur, Malaysia, from 1 July 2021 to 30 June 2022, were retrospectively enrolled in the study. A total of 38 patients (9.5%) were lost to subsequent follow-up, and the remaining 363 patients (90.5%) were included in the outcome analysis. Clinical outcomes at 1 year were analysed.

Results

In all, 219 lesions (47.8%) involved the left anterior descending artery, 146 lesions (31.9%) involved the right coronary artery, and 57 lesions (12.4%) involved the left circumflex artery. In all, 87 lesions (19%) were bifurcation lesions. A total of 8 patients (2.2%) had TLF, of whom 3 patients (0.83%) had TVMI, 3 patients (0.83%) had ID-TLR, and 2 patients (0.6%) experienced cardiac death. Four patients died of a non-cardiac cause at 1-year follow-up.

Conclusions

A hybrid strategy of DES and DCB for the treatment of de novo coronary artery lesions appears to be feasible and clinically safe according to the 1-year outcomes.

[How to solve difficult side branch access: case report and literature review]

We present the case of a 53-year-old patient with history of hypertension and dyslipidemia, admitted for effort-induced angina. Coronary angiography revealed two-vessel disease with severe stenosis of the LAD- Diagonal bifurcation (MEDINA 1-1-1). This lesion was considered complex regarding the severe stenosis of the bifurcation core, the angulation <45°, and the severity and length of the diagonal lesion. The procedure was planned according to a TAP technique. The flow in the diagonal was however lost after stenting the main vessel causing an ST elevation with chest pain. It was subsequently recovered using the rescue jailed balloon technique before re-crossing the stent struts of the LAD using a Gaia First® (Asahi) guidewire. The aim of this case report is to illustrate some pitfalls that can be encountered in bifurcation percutaneous interventions and to present technical solutions to solve difficult side branch access issues through a literature review.

A New Scoring System Predicting Side-Branch Occlusion in Patients Undergoing Left Main Bifurcation Intervention: The LM V-RESOLVE Score

BACKGROUND

The risk of side-branch (SB) occlusion is pivotal for decision making of stenting strategies during unprotected left main (LM) bifurcation percutaneous coronary intervention (PCI). Accordingly, this study aimed to develop a scoring system for predicting SB occlusion during unprotected LM bifurcation PCI.

METHODS

A total of 855 consecutive patients undergoing unprotected LM bifurcation PCI with provisional strategy at Fuwai Hospital from January 2014 to December 2016 were recruited. A prediction model was selected by means of all-subsets logistic regression, and a multivariable risk score (Left Main Visual Estimation for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention [LM V-RESOLVE]) was then established with incremental weights attributed to each component variable based on its estimate coefficients. SB occlusion was defined as any decrease in Thrombolysis in Myocardial Infarction (TIMI) flow grade or absence of flow in SB after main vessel (MV) stenting.

RESULTS

SB occlusion occurred in 19 LM bifurcation lesions (2.22%). In multivariable model, 3 variables, including MV/SB diameter ratio, MV plaque ipsilateral to SB, and baseline diameter stenosis of SB, were independent predictors for SB occlusion (model C-statistic 0.829, 95% confidence interval [CI] 0.735-0.923, with good calibration). The risk score had a C-statistics of 0.830 (95% CI 0.738-0.923) with good calibration. Satisfactory discriminative ability of the risk score was also preserved in external validation (C-statistic 0.794, 95% CI 0.691-0.896).

CONCLUSIONS

The LM bifurcation-specific novel scoring system, LM V-RESOLVE, based on 3 simple baseline angiographic findings, could help to rapidly discriminate lesions at risk of SB occlusion during LM bifurcation PCI.

Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club

The 2023 European Bifurcation Club (EBC) meeting took place in Warsaw in October, and the latest evidence for the use of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to optimise percutaneous coronary interventions (PCI) on coronary bifurcation lesions (CBLs) was a major focus. The topic generated deep discussions and general appraisal on the potential benefits of IVUS and OCT in PCI procedures. Nevertheless, despite an increasing recognition of IVUS and OCT capabilities and their recognised central role for guidance in complex CBL and left main PCI, it is expected that angiography will continue to be the primary guidance modality for CBL PCI, principally due to educational and economic barriers. Mindful of the restricted access/adoption of intracoronary imaging for CBL PCI, the EBC board decided to review and describe a series of tips and tricks which can help to optimise angiography-guided PCI for CBLs. The identified key points for achieving an optimal angiography-guided PCI include a thorough analysis of pre-PCI images (computed tomography angiography, multiple angiographic views, quantitative coronary angiography vessel estimation), a systematic application of the technical steps suggested for a given selected technique, an intraprocedural or post-PCI use of stent enhancement and a low threshold for bailout use of intravascular imaging.

Comparison between provisional and dual systematic stenting approach for left main bifurcation disease: A systematic review and meta-analysis

Despite recent advancements, challenges persist in determining the optimal stenting strategy for LM bifurcation disease. Hence, this systematic review aims to compare single provisional and systematic dual stenting for managing LM bifurcation disease. A systematic search was performed until January 14, 2024. For the effect measure, risk ratios (RRs) was calculated. This study included 22 studies with 10776 participants. The all-cause mortality and cardiovascular mortality revealed comparable outcomes between provisional and dual-systematic stenting (RR 1.13, CI95 %: 0.87-1.47, p 0.36, I2 59 %; RR 1.16, CI95 %: 0.73-1.84, p 0.63, I2 80 %). In addition, MACE, MI, TLR, TVR, and in stent thrombosis also showed similar findings. Subgroup analysis revealed that cohort studies was the source of heterogeneity in all-cause mortality, stent thrombosis, and TLR. This meta-analysis suggests comparable outcomes between provisional and dual-systematic stenting in managing LM bifurcation disease. Further study is needed to validate the outcomes of novel techniques.

Optimal Percutaneous Treatment Approach to Unprotected Ostial Left Anterior Descending Artery Disease: A Meta-Analysis and Systematic Review

BACKGROUND

The optimal management strategy for significant unprotected ostial left anterior descending artery (LAD) disease remains undefined. Merits of the two most common percutaneous approaches are considered in this quantitative synthesis.

METHOD

A meta-analysis was performed to compare ostial stenting (OS) and crossover stenting (CS) in the treatment of unprotected ostial LAD stenosis. The primary outcome is the disparity in target lesion revascularisation (TLR). The Mantel-Haenszel method was employed with random effect model, chosen a priori to account for heterogeneity among the included studies.

RESULTS

Seven studies comprising 1,181 patients were included in the analyses. Of these, 482 (40.8%) patients underwent CS. Overall, there was a statistically significant trend in favour of CS (odds ratio 0.51, 95% confidence interval 0.30-0.86, p=0.01) with respect to the rate of TLR at follow-up. This remained true when TLR involving the left circumflex artery (LCx) was considered, even when there was a greater need for unintended intervention to the LCx during the index procedure (odds ratio 6.68, 95% confidence interval: 1.69-26.49, p=0.007). Final kissing balloon inflation may reduce the need for acute LCx intervention. Imaging guidance appeared to improve clinical outcomes irrespective of approach chosen.

CONCLUSIONS

In the percutaneous management of unprotected ostial LAD disease, CS into the left main coronary artery (LMCA) appeared to reduce future TLR. Integration of intracoronary imaging was pivotal to procedural success. The higher incidence of unintended LCx intervention in the CS arm may be mitigated by routine final kissing balloon inflation, although the long-term implication of this remains unclear. In the absence of randomised trials, clinicians' discretion remains critical.

Platinum chromium everolimus-eluting stents for the treatment of (complex) coronary artery disease; from SYNERGY™ to the MEGATRON™

INTRODUCTION

The introduction of drug-eluting coronary stents (DES) into clinical practice in 2002 represented a major milestone in the treatment of obstructive coronary artery disease. Over the years, significant advances in polymer coating and in antiproliferative agent technology have further improved the safety and clinical performance of newer-generation DES.

AREAS COVERED

Development of platinum chromium (PtCr) alloys with high radial strength and high radiopacity have enabled the design of new, thin-strut, flexible, and highly trackable stent platforms, while simultaneously improving stent visibility. These advances have facilitated complex percutaneous treatment of a diverse population of patients in clinical practice. This review will provide an overview of the evolution in PtCr everolimus-eluting stents from PROMUS Element™ to SYNERGY™ to the recently introduced SYNERGY MEGATRON™. The clinical data will be summarized and put into perspective, especially focusing on the role of the SYNERGY™ and MEGATRON™ platforms in the treatment of complex coronary artery disease and high-risk patients.

EXPERT OPINION

The SYNERGY™ stent demonstrates favorable clinical efficacy and safety outcome data, and whilst the clinical data on MEGATRON™ are sparse, early experience is promising. The specific overexpansion capabilities, visibility, and radial strength of the MEGATRON™ are attractive features for complex coronary interventions.

Fracture and plastering of distal left main stent during double-kissing Culotte technique: a case report

Background

Acute fracture of a left main (LM) stent during angioplasty is a rare complication. Cardiologists should be aware of the risk of stent fracture (SF) following kissing balloon inflation (KBI) even if the effective diameter of the balloons does not exceed the recommended expansion limits of stents.

Case summary

A 64-year-old female with hypertension and dyslipidaemia presented with crescendo angina since three months in spite of optimal medical therapy. Coronary angiogram showed a distal LM bifurcation lesion. The patient was admitted for LM bifurcation stenting by upfront two-stent technique (inverted double-kissing Culotte technique). Following first KBI of the stent placed from left circumflex artery (LCX) to LM, there was stent deformation in the LM shaft. As we had planned the Culotte technique, we decided to exclude the fractured segment by stenting from left anterior descending artery (LAD) to LM. The stent from LAD-LM successfully excluded the fractured part of the first stent from the lumen of LM. Optical coherence tomography done after final KBI from LCX-LM revealed successful exclusion of the deformed segment of the LCX stent with mild malapposition at the site of the deformed stent. A follow-up angiogram after six months showed normal in-stent flow with no evidence of restenosis or pseudoaneurysm.

Discussion

Acute LM SF during coronary intervention can occur even if the effective cumulative diameter of the inflated balloons does not exceed the mentioned expansion limit of stents. Intravascular imaging is a helpful modality to define type of SF and its management.

A Bayesian meta-analysis of double kissing (DK) crush or provisional stenting for coronary artery bifurcation lesions

OBJECTIVE

Despite the development of dedicated, two-stent strategies, including the double kissing (DK) crush technique, the ideal technique for coronary artery bifurcation stenting has not been identified. We aimed to compare and determine the absolute risk difference (ARD) of the DK crush technique alone versus provisional stenting approaches for coronary bifurcation lesions, using the Bayesian technique.

METHOD

We queried PubMed/MEDLINE to identify randomized controlled trials (RCTs) that compared DK crush technique with provisional stenting for bifurcation lesions, published till January 2023. We used Bayesian methods to calculate the ARD and 95% credible interval (CrI).

RESULTS

We included three RCTs, with 916 patients, in the final analysis. The ARD of cardiac death was centered at -0.01 (95% CrI: -0.04 to 0.02; Tau: 0.02, 85% probability of ARD of DK crush vs. provisional stenting <0). ARD for myocardial infarction was centered at -0.03 (95%CrI: -0.9 to 0.03; Tau: 0.05, 87% probability of ARD of DK crush vs. provisional stenting <0). ARD for stent thrombosis was centered at 0.00 (95% CrI: -0.04 to 0.03, Tau: 0.03, 51% probability of ARD for DK crush vs. provisional stenting <0). Finally, ARD for target lesion revascularization was centered at -0.05 (95% CrI: -0.08 to -0.03, Tau: 0.02, 99.97% probability of ARD for DK crush vs. provisional stenting <0).

CONCLUSIONS

Bayesian analysis demonstrated a lower probability of cardiac death, myocardial infarction and target lesion revascularization, with DK crush compared with provisional stenting techniques, and a minimal probability of difference in stent thrombosis.

Comparison of long-term outcomes of double kissing crush versus T and minimal protrusion techniques in complex bifurcation lesions: The EVOLUTE-CRUSH II registry

BACKGROUND

Double kissing (DK)-crush and T-stenting and small protrusion (TAP) techniques are gaining popularity, but the comparison for both techniques is still lacking. This study sought to retrospectively evaluate the long-term outcomes of DK-crush and TAP techniques in patients with complex bifurcation lesions.

METHODS

A total of 255 (male: 205 [80.3%], mean age: 59.56 ± 10.13 years) patients who underwent coronary bifurcation intervention at a single-center between January 2014 and May 2021 were included. Angiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary endpoint was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven-target lesion revascularization (TLR). The regression models were adjusted applying by the inverse probability weighted (IPW) approach to reduce treatment selection bias.

RESULTS

The initial management strategy was DK-crush in 152 (59.6%) patients and TAP in 103 (40.4%) cases. The SYNTAX scores (24.58 ± 7.4 vs. 24.26 ± 6.39, p = 0.846) were similar in both groups. The number of balloon (6.32 ± 1.82 vs. 3.92 ± 1.19, p < 0.001) usage was significantly higher in the DK-crush group than in the TAP group. The rates of TLF (11.8 vs. 22.3%, p = 0.025) and clinically driven TLR (6.6 vs. 15.5%, p = 0.020) were significantly lower in the DK-crush group compared to the TAP group. The long-term TLF was significantly higher in the TAP group compared to the DK-crush group (unadjusted HR: 1.974, [95% CI: 1.044-3.732], p = 0.035 and adjusted HR [IPW]: 2.498 [95% CI: 1.232-5.061], p = 0.011).

CONCLUSION

The present study showed that the DK-crush technique of bifurcation treatment was associated with lower long-term TLF and TLR rates compared to the TAP technique.

One year results of coronary bifurcation revascularization with the re-POT provisional sequential technique. The CABRIOLET registry

BACKGROUND

Re-POT (proximal optimization technique (POT)) is a simple provisional sequential technique for percutaneous coronary bifurcation revascularization with better arterial geometry respect compared to classical techniques. Re-POT has demonstrated excellent mechanical and short-term clinical results. The multicenter CABRIOLET registry (NCT03550196) evaluate the long-term clinical benefit of the re-POT sequence in non-selected patients.

METHODS

All consecutive patients presenting a coronary bifurcation lesion for which provisional stenting was indicated were included in 5 european centers. Re-POT strategy was systematically attempted. The primary endpoint was target lesion failure (TLF), comprising cardiac death, myocardial infarction, stent thrombosis and target lesion revascularization (TLR) at 12 months' follow-up. The secondary endpoints were the individual components of the primary endpoint, all-cause death, target vessel failure (TVF) and target vessel revascularization (TVR). Complex bifurcation was defined as Medina 0.1.1 or 1.1.1.

RESULTS

A total of 500 patients aged 67.7 ± 11.7 years, 78.4% male, were included from 2015 to 2019, 174 of whom (34.8%) were considered having complex bifurcation lesions. Bifurcations involved the left main in 35.2% of cases. The full re-POT sequence was systematically performed in all cases. At 1 year, TLF was 2.0% (1.7% in complex vs. 2.1% in non-complex bifurcation; p = NS), and TLR was 1.6%, (1.1% vs. 1.8% respectively; p = NS). TVF and TVR rates were 3.2% and 2.8%. On multivariate analysis, only multivessel disease was predictive of TLF at 1 year (OR = 1.66 (1.09-2.53), p = 0.02).

CONCLUSIONS

In this large prospective all-comer registry, provisional stenting with re-POT technique appeared safe and effective at 1 year, without anatomical bifurcation restriction.

The role of optical coherence tomography in guiding percutaneous coronary interventions: is left main the final challenge?

Left main (LM) coronary artery disease is a high-risk lesion subset, with important prognostic implications for the patients. Recent advances in the field of interventional cardiology have narrowed the gap between surgical and percutaneous approach of this complex lesion setting. However, the rate of repeat revascularization remains higher in the case of percutaneous coronary intervention (PCI) on long-term follow-up. As such, the need for better stent optimization strategies has led to the development of intravascular imaging techniques, represented mainly by intravascular ultrasound (IVUS) and optical coherence tomography (OCT). These techniques are both able to provide excellent pre- and post-PCI guidance. While IVUS is an established modality in optimizing LM PCI, and is recommended by international revascularization guidelines, data and experience on the use of OCT are still limited. This review paper deeply analyzes the current role of OCT imaging in the setting of LM disease, particularly focusing on its utility in assessing plaque morphology and distribution, vessel dimensions and proper stent sizing, analyzing mechanisms of stent failure such as malapposition and underexpansion, guiding bifurcation stenting, as well as offering a direct comparison with IVUS in this critical clinical scenario, based on the most recent available data.

Proximal optimization technique and percutaneous coronary intervention for left main disease: POTENTIAL-LM

BACKGROUND

Optimal stent deployment in left main (LM) bifurcation is paramount, and incomplete stent apposition may cause major adverse cardiac events (MACE). Bench studies show that the proximal optimization technique (POT) provides the best stent apposition.

AIMS

We aimed to investigate the impact of POT on clinical outcomes in patients treated for unprotected LM (ULM) disease at our institution.

METHODS

We identified 162 patients who underwent percutaneous coronary intervention (PCI) for ULM coronary disease in the Cardio-FR database. Out of these, 99 (61%) had undergone POT, while 63 patients were treated without POT. The primary outcome was the bifurcation-oriented composite endpoint (BOCE) of cardiac death, target-bifurcation myocardial infarction and target-bifurcation revascularization at maximal follow-up.

RESULTS

Mean age was 76 years, and 69% presented with acute coronary syndrome. Mean follow-up was 2.25 years (822 days). The BOCE occurred in 43 (27%) of which 20 (20%) in the POT group and 23 (37%) in the no-POT group (p = 0.009). Cardiac death occurred in 15 (15%) patients in the POT- and 17 (27%) in no-POT group (p = 0.26). Target bifurcation revascularization occurred in 4 (4%) patients in the POT- and 6 (10%) patients in the no-POT group (p = 0.19). POT In the multivariate analysis, POT was the strongest parameter and was associated with BOCE, cardiac death, occurrence of any revascularization and all-cause mortality.

CONCLUSION

The POT improves clinical outcomes. These findings strongly support the systematic use of POT in patients undergoing ULM-PCI.

Clinical outcomes of a dedicated bifurcation stent system

INTRODUCTION

Percutaneous coronary intervention (PCI) of bifurcation lesions is technically challenging and associated with higher rates of complications such as stent thrombosis or in-stent restenosis. In this paper, we present the clinical outcomes of BiOSS LIM C (Balton, Poland), a dedicated bifurcation stent.

METHODS

In this retrospective single-center study we analyzed the outcome of patients with bifurcation coronary artery disease treated with the BiOSS LIM C stent system. The primary endpoint was the cumulative rate of major adverse cardiac events (MACE) including cardiac death, myocardial infarction (MI) and target lesion revascularisation (TLR) at the longest available follow-up.

RESULTS

The study population consisted of 25 patients (mean age 73.6 ± 9.7 years, 25 % females). In 80 % of the cases (n = 20) BiOSS LIM C stent was implanted in the left main coronary artery. Intravascular imaging was used in 70 % of the cases and an additional regular drug-eluting stent (DES) was deployed in the side branch in 24 % of the cases. The device success rate was 100 % and we observed no in-hospital adverse events. At a median follow-up of 15 ± 6 months, the MACE rate was 56 %, cardiac death was 4 %, and clinically driven TLR was 55 %. One patient died in the LM subgroup, 5 months after the index PCI, due to NSTEMI complicated by cardiogenic shock. Two patients died due to non-cardiac causes.

CONCLUSIONS

In this consecutive series of patients treated with BiOSS LIM C in major coronary bifurcation lesions, mostly in the left main stem, the mid-term clinical outcomes demonstrated a high incidence of major adverse events, mainly caused by TLR, despite an adequate implantation technique.

Cost-effectiveness of stepwise provisional versus systematic dual stenting strategies in patients with distal bifurcation left main stem lesions: economic analysis of the EBC MAIN trial

BACKGROUND

In patients with distal bifurcation left main stem lesions requiring intervention, the European Bifurcation Club Left Main Coronary Stent Study trial found a non-significant difference in major adverse cardiac events (MACEs, composite of all-cause death, non-fatal myocardial infarction and target lesion revascularisation) favouring the stepwise provisional strategy, compared with the systematic dual stenting.

AIMS

To estimate the 1-year cost-effectiveness of stepwise provisional versus systematic dual stenting strategies.

METHODS

Costs in France and the UK, and MACE were calculated in both groups to estimate the incremental cost-effectiveness ratio (ICER). Uncertainty was explored by probabilistic bootstrapping. The analysis was conducted from the perspective of the healthcare provider with a time horizon of 1 year.

RESULTS

The cost difference between the two groups was €-755 (€5700 in the stepwise provisional group and €6455 in the systematic dual stenting group, p value<0.01) in France and €-647 (€6728 and €7375, respectively, p value=0.08) in the UK. The point estimates for the ICERs found that stepwise provisional strategy was cost saving and improved outcomes with a probabilistic sensitivity analysis confirming dominance with an 80% probability.

CONCLUSION

The stepwise provisional strategy at 1 year is dominant compared with the systematic dual stenting strategy on both economic and clinical outcomes.

Optimal Minimal Stent Area and Impact of Stent Underexpansion in Left Main Up-Front 2-Stent Strategy

BACKGROUND

We previously reported the use of minimal stent area to predict angiographic in-stent restenosis after drug-eluting stent implantation for unprotected left main (LM) disease. We aimed to evaluate the optimal minimal stent area criteria for up-front LM 2-stenting based on long-term clinical outcomes.

METHODS

We identified 292 consecutive patients with LM bifurcation stenosis who were treated using the crush technique. The final minimal stent area was measured in the ostial left anterior descending artery (LAD), ostial left circumflex artery (LCX), and distal LM. The primary outcome was 5-year major adverse cardiac events, including all-cause death, myocardial infarction, and target lesion revascularization.

RESULTS

The minimal stent area cutoff values that best predicted the 5-year major adverse cardiac events were 11.8 mm2 for distal LM (area under the curve, 0.57; P=0.15), 8.3 mm2 for LAD ostium (area under the curve, 0.62; P=0.02), and 5.7 mm2 for LCX ostium (area under the curve, 0.64; P=0.01). Using these criteria, the risk of 5-year major adverse cardiac events was significantly associated with stent underexpansion in the LAD ostium (hazard ratio, 3.14; [95% CI, 1.23-8.06]; P=0.02) and LCX ostium (hazard ratio, 2.60 [95% CI, 1.11-6.07]; P=0.03) but not in the distal LM (hazard ratio, 0.81 [95% CI, 0.34-1.91]; P=0.63). Patients with stent underexpansion in both ostial LAD and LCX had a significantly higher rate of 5-year major adverse cardiac events than those with no or 1 underexpanded stent of either ostium (P<0.01).

CONCLUSIONS

Stent underexpansion in the LAD and LCX ostium was significantly associated with long-term outcomes in patients who underwent up-front 2-stenting for LM bifurcation stenosis.

Evidence-based Management of Left Main Coronary Artery Disease

Left main coronary artery disease (LMCAD) is associated with high morbidity and mortality due to the large myocardial mass at risk. Although medical treatment may be an option in selected low-risk patients, revascularisation is recommended to improve survival in the majority of patients presenting with a significant left main stenosis. In the past decade, multiple randomised clinical trials and meta-analyses have compared coronary artery bypass grafting surgery (CABG) versus percutaneous coronary intervention (PCI), finding controversial results. The strategy for LMCAD revascularisation is still challenging. Coronary anatomy complexity, clinical features and patient preferences are key elements to be considered by the heart team. The current guidelines define CABG as standard therapy, but the continuous improvements in PCI techniques, the use of intracoronary imaging and functional assessment make PCI a feasible alternative in selected patients, particularly in those with comorbidities and contraindications to CABG. This review analyses the most important studies comparing CABG versus PCI in patients with LMCAD.

Definitions and Standardized Endpoints for Treatment of Coronary Bifurcations

The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

The everolimus eluting Synergy MegatronTM drug-eluting stent platform: Early outcomes from the European Synergy MegatronTM Implanters' Registry

BACKGROUND

The Synergy MegatronTM is an everolimus-drug eluting stent that may offer advantages in the treatment of aorto-ostial disease and large proximal vessels.

AIMS

To report the short- to medium-term clinical outcomes from the European Synergy MegatronTM Implanters' Registry.

METHODS

This registry was an investigator-initiated study conducted at 14 European centers. The primary outcome was target lesion failure (TLF), defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularisation.

RESULTS

Five hundred seventy-five patients underwent PCI with MegatronTM between 2019 and 2021. Patients were 69 ± 12 years old, 26% had diabetes mellitus, 24% had moderate-severe left ventricular impairment and 59% presented with an acute coronary syndrome. 15% were deemed prohibitively high risk for surgical revascularisation. The target vessel involved the left main stem in 55%, the ostium of the RCA in 13% and was a true bifurcation (Medina 1,1,1) in 50%.  At 1 year, TLF was observed in 40 patients, with 26 (65%) occurring within the first 30 days. The cumulative incidence of TLF was 4.5% at 30 days and 8.6% (95% CI 6.3-11.7) at 1 year. The incidence of stent thrombosis was 0.5% with no late stent thromboses. By multivariate analysis, the strongest independent predictors of TLF were severe left ventricular impairment (HR 3.43, 95% CI: 1.67-6.76, p < 0.001) and a target vessel involving the left main (HR 4.00 95% CI 1.81-10.15 p = 0.001).

CONCLUSIONS

Use of the Synergy MegatronTM everolimus eluting stent in a 'real-world' setting shows favorable outcomes at 30 days and 1 year.