Ten-Year Clinical Outcomes of Late-Acquired Stent Malapposition After Coronary Stent Implantation

Coronary Bifurcation Lesions

Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) for the treatment of coronary bifurcation lesions (CBLs) is still technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. Although provisional stenting (PS) is considered as the preferred strategy for most of the CBLs, a systematic two-stent technique (double kissing [DK] crush) should be considered in patients with complex left main (LM)-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation should be used to optimize CBLs intervention. PCI with DES for the treatment of CBLs is technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. PS is a default strategy for most of the CBLs. Double kissing (DK) crush is associated with better clinical outcomes compared with PS in patients with complex LM-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation are useful tools to guide the treatment of CBLs. The use of drug-coated balloons in CBLs needs further data to support the clinical benefits.

Multi-modality intravascular imaging for guiding coronary intervention and assessing coronary atheroma: the Novasight Hybrid IVUS-OCT system

Intravascular imaging has evolved alongside interventional cardiology as an adjunctive tool for assessing plaque pathology and for guiding and optimising percutaneous coronary intervention (PCI) in challenging lesions. The two modalities which have dominated the field are intravascular ultrasound (IVUS), which relies on sound waves and optical coherence tomography (OCT), relying on light waves. These approaches however have limited efficacy in assessing plaque morphology and vulnerability that are essential for guiding PCI in complex lesions and identifying patient at risk that will benefit from emerging therapies targeting plaque evolution. These limitations are complementary and, in this context, it has been recognised and demonstrated in multi-modality studies that the concurrent use of IVUS and OCT can help overcome these deficits enabling a more complete and accurate plaque assessment. The Conavi Novasight Hybrid IVUS-OCT catheter is the first commercially available device that is capable of invasive clinical coronary assessment with simultaneously acquired and co-registered IVUS and OCT imaging. It represents a significant evolution in the field and is expected to have broad application in clinical practice and research. In this review article we present the limitations of standalone intravascular imaging techniques, summarise the data supporting the value of multimodality imaging in clinical practice and research, describe the Novasight Hybrid IVUS-OCT system and highlight the potential utility of this technology in coronary intervention and in the study of atherosclerosis.

Long-term Clinical Outcomes of Drug-Eluting Stent Malapposition

Previous pathologic, intravascular imaging, and clinical studies have investigated the association between adverse cardiac events and stent malapposition, including acute stent malapposition (ASM, that is detected at index procedure) and late stent malapposition (LSM, that is detected during follow-up) that can be further classified into late-persistent stent malapposition (LPSM, ASM that remains at follow-up) or late-acquired stent malapposition (LASM, newly developed stent malapposition at follow-up that was not present immediately after index stent implantation). ASM has not been associated with adverse cardiac events compared with non-ASM, even in lesions with large-sized malapposition. The clinical outcomes of LSM may depend on its subtype. The recent intravascular ultrasound studies with long-term follow-up have consistently demonstrated that LASM steadily increased the risk of thrombotic events in patients with first-generation drug-eluting stents (DESs). This association has not yet been identified in LPSM. Accordingly, it is reasonable that approaches to stent malapposition should be based on its relationship with clinical outcomes. ASM may be tolerable after successful stent implantation, whereas prolonged anti-thrombotic medications and/or percutaneous interventions to modify LASM may be considered in selected patients with first-generation DESs. However, these treatments are still questionable due to lack of firm evidences.