Role of Proximal Optimization Technique Guided by Intravascular Ultrasound on Stent Expansion, Stent Symmetry Index, and Side-Branch Hemodynamics in Patients With Coronary Bifurcation Lesions

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.

Randomized trial of an oblique versus standard fluoroscopic-guided micropuncture technique for femoral arterial access: The Micropuncture-CFA trial

BACKGROUND

The anterior-posterior fluoroscopic guidance (the AP technique) is a standard method for common femoral artery (CFA) access, but the rate of CFA access with ultrasound vs. the AP technique was not significantly different. We have shown an oblique fluoroscopic guidance (the oblique technique) with a micropuncture needle (MPN) resulted in CFA access in 100 % of patients. The outcome of the oblique vs. AP technique is unknown. We compared the utilities of the oblique vs. AP technique for CFA access with a MPN in patients undergoing coronary procedures.

METHODS

A total of 200 patients were randomized to the oblique vs. AP technique. Using the oblique technique, a MPN was advanced to the mid pubis in the 20° ipsilateral right-or left anterior oblique view with fluoroscopic guidance and the CFA was punctured. In the AP technique, a MPN was advanced to the mid femoral head in the AP view with fluoroscopic guidance and the CFA was punctured. The primary endpoint was the rate of successful access to the CFA.

RESULTS

The rates of first pass and CFA access were higher with the oblique vs. AP technique (82 % vs. 61 %, and 94 % vs. 81 %, respectively; P < 0.01). The number of needle punctures was lower with the oblique vs. AP technique (1.1 ± 0.39 vs. 1.4 ± 0.78, respectively; P < 0.01). In high CFA bifurcations, the rate of CFA access was higher with the oblique vs. AP technique (76 % vs. 52 %, respectively; P < 0.01). Vascular complications were lower with the oblique vs. AP technique (1 % vs. 7 %, respectively; P < 0.05).

CONCLUSIONS

Our data suggest that the oblique technique, compared with the AP technique, significantly increased the rates of first pass and access to the CFA, and decreased the number of punctures and vascular complication.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03955653.

"Main Vessel-Oriented" Treatment Strategy Versus "Open Side Branch" Treatment Strategy in Acute Coronary Syndrome Patients With Culprit Bifurcation Lesions

Percutaneous coronary intervention of bifurcation lesions is associated with an increased risk of complications in patients with acute coronary syndrome (ACS). The study aimed to evaluate the in-hospital outcomes of patients with ACS with culprit bifurcation lesions who were treated with either a "main vessel-oriented" (MVO) treatment strategy or an "open side branch" (OSB) treatment strategy. This retrospective study included 575 consecutive patients with ACS. "MVO" and "OSB" treatment strategies were defined as primary/urgent percutaneous coronary intervention procedures performed by either totally ignoring the side branch (SB) or trying to maintain both main vessel and SB open with thrombolysis in myocardial infarction 3 flow. Procedural success and major cardiac/cerebrovascular events during hospitalization were noted. MVO and OSB treatment strategies were performed on 384 and 191 patients, respectively. The procedural success rate was significantly higher in the OSB treatment strategy whereas major cardiac/cerebrovascular events rates were similar except for the contrast-induced nephropathy rate being slightly higher in OSB treatment strategy. Subgroup analysis revealed a significantly higher procedural success rate in OSB treatment strategy if the SB was located within the bifurcation core, especially in those where the diameter of SB was ≥2 mm. In conclusion, our results suggest a better procedural result with SB protection attempts in patients with ACS with a culprit bifurcation lesion if the SB is originating within the bifurcation core and its diameter is ≥2 mm. MVO treatment strategy may be preferred in most cases with minor SBs located distant to the bifurcation core because of the similar procedural success.

Impact of Endothelial Dysfunction on Long-Term Clinical Outcomes in Patients With Chronic Coronary Syndromes Treated With Second Generation Drug-Eluting Stent Implantation

BACKGROUND

Studies investigating clinical outcomes of patients with or without endothelial disfunction (ED) treated with percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) using second generation drug eluting stents (DES) are lacking.

METHODS

We prospectively collected data from 109 patients undergoing PCI with second generation DES due to stable CAD between December 2014 and September 2016. ED was evaluated evaluating the flow mediated dilation (FMD) at the brachial artery level and defined by an FMD < 7 %. Primary outcome were major adverse cardiovascular events (MACE), secondary outcomes were target vessel failure (TVR), myocardial infarction (MI) and all-cause death.

RESULTS

Five-year follow-up was available in all patients. Median FMD didn't significantly differ between patients who experienced the outcome and those who didn't [no TVR vs. TVR: p = 0.358; no MI vs. MI: p = 0.157; no death vs. death: p = 0.355; no MACE vs. MACE: p = 0.805]. No association between ED and an increased risk for the primary outcome as well as for the secondary ones was evident [MACE: 17.0 % vs. 14.3 %, HR 0.87 (0.33-2.26), log rank p = 0.780; TVR: 9.4 % vs. 5.4 %, HR 0.53 (0.12-2.24), log rank p = 0.384; MI: 3.7 % vs. 8.9 %, HR 2.46 (0.47-12.76), log rank p = 0.265; death: 7.5 % vs. 3.6 %, HR 0.53 (0.09-2.90), log rank p = 0.458]. These findings were confirmed using a lower threshold of FMD to define ED and at one-year landmark analysis.

CONCLUSIONS

ED is not associated with an increased risk of adverse events at long-term follow-up in a contemporary cohort of patients undergoing PCI with second generation DES.

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.

Long-term prognostic value of Murray law-based quantitative flow ratio in jailed left circumflex coronary artery after left main crossover stenting

We aimed to evaluate the impact of new Murray law-based QFR of jailed left circumflex coronary artery (LCx) on long-term clinical outcomes after left main coronary artery (LM) simple crossover stenting. 164 patients who underwent LM-to-left anterior descending coronary artery simple crossover stenting and had appropriate angiographic view of LCx for QFR computation were enrolled. The primary clinical outcome was the 5-year target lesion failure (TLF), defined as a composite of cardiac death, a target vessel myocardial infarction or target lesion repeat revascularization. The mean QFR of the LCx after LM stent implantation was 0.88 ± 0.09, and 29 patients (17.7%) had a low QFR (< 0.80), which was significantly associated with a higher 5-year rate of TLF when compared with the high QFR group (27.6% vs. 6.7%; HR: 4.235; 95% CI 1.21-14.95; p = 0.0015). The 5-year LCx ostium-related TLR rate in the low QFR group was also higher (17.2% vs. 3.0% in the high QFR group; HR: 6.07, 95% CI 1.63-22.59, p = 0.002). In a multivariate Cox regression analysis, a low QFR in the LCx after LM stenting was an independent predictor of the 5-year TLF rate (HR: 3.21, 95% CI 1.21-8.53; p = 0.019). ROC analysis showed that QFR a negative predictive value (NPV) of 89.6% ([AUC] 0.73, 95% CI 0.58-0.88, p < 0.05), the cutoff point is 0.85. The patients with a low QFR (< 0.80) in jailed LCX after LM simple crossover stenting had worse 5-year outcomes than those with a high QFR. Conversely, a QFR ≥ 0.85 of jailed LCx could serve as a good predictor of low risk of adverse outcome in LCx ostium. The QFR computation of the jailed LCx may be helpful to determine whether an additional procedure is required for the jailed side branch.

Multimodality imaging results of TAP versus novel modified TAP stenting in coronary bifurcation: From bench testing to first-in-man investigation

OBJECTIVES

We investigated the results of T and small protrusion (TAP) versus a novel modification of TAP (mTAP) stenting by multimodality imaging in bench testing and in patients with coronary bifurcation lesions (CBL).

BACKGROUND

TAP stenting is a suboptimal technique for bailout side branch (SB) stenting.

METHODS

In a bench model, optical coherence tomography (OCT), microscopic examinations (ME), and computational fluid dynamics (CFD) were performed after TAP and mTAP stenting. In 20 patients with CBL, 80 intravascular ultrasound (IVUS) examinations were performed during mTAP stenting in which the SB stent was pulled-back to indent the inflated main vessel (MV) balloon and deployed while deflating it. For TAP stenting, the tip of the SB stent was positioned in the MV and deployed.

RESULTS

In bench testing, OCT showed neocarina length (NL) was shorter and minimum stent area (MSA) was larger after mTAP versus TAP stenting (2.84 ± 0.70 vs. 4.80 ± 020 mm; 6.75 ± 1.50 vs. 4.5 ± 2.2 mm² ; respectively; p < 0.05). By ME, NL was shorter and shear rate trended lower after mTAP versus TAP stenting. In patients, IVUS showed MSA was larger after versus before mTAP stenting (6.32 ± 0.58 vs. 5.21 ± 0.56 mm² ; p < 0.01); NL was 1.43 ± 0.22 mm with SB ostium coverage. The Seattle Angina questionnaire (SAQ) score was higher at 6 months versus baseline (85 ± 4.0 vs. 48 ± 6.0, respectively; p < 0.001).

CONCLUSIONS

This multimodality imaging study showed, for the first time, mTAP stenting resulted in larger stent area and shorter neocarina than TAP stenting in bench testing. In patients with CBL, mTAP stenting led to larger stent area, short neocarina with complete SB ostium coverage, and improved the SAQ score at follow-up.

Intracoronary Electrocardiography-guided Strategy for the Treatment of Coronary Bifurcation Lesions

Introduction: Revascularization of bifurcation lesions remains an interventional challenge. Intracoronary electrocardiograms can predict the functional significance of side branch stenosis after bifurcation stenting.

Aim: This study was aimed at evaluating the effects of an intracoronary ECG electrocardiography (icECG)-guided revascularization strategy, compared with the currently accepted standard of care, on the clinical outcomes of patients after coronary bifurcation stenting.

Methods: Patients with coronary bifurcation lesions who underwent percutaneous revascularization were enrolled in a prospective all-comers’ registry. Clinical outcomes were compared between patients who underwent icECG-guided revascularization versus the current standard of care (SOC), provisional stenting.

Results: A total of 768 patients were included in the analysis: 349 were treated with an icECG-guided strategy, and 419 received SOC. The overall all-cause death rate was 23.2%, and the cardiovascular death rate was 15.9%. Patients with icECG guidance had significantly lower all-cause mortality (20.3% vs. 25.5% for icECG vs. SOC, log-rank P = 0.006) and cardiovascular mortality (12.6% vs. 18.6% for icECG vs. SOC, log-rank P = 0.004). The decrease in mortality was most pronounced in patients with no increase or a moderate increase in troponin post-PCI, or with higher-than-normal baseline troponin concentrations.

Conclusion: An icECG-guided strategy for coronary bifurcation PCI led to lower patient mortality than the provisional stenting strategy.

Impact of Reference Mismatch on Procedure Outcomes of Percutaneous Coronary Intervention

A significant mismatch between proximal and distal reference lumen diameters of the target lesion may pose challenges during percutaneous coronary intervention (PCI) and therefore influence the outcomes. We investigated total 1706 lesions underwent IVUS guided percutaneous coronary intervention, that were divided into 2 groups, including 411 lesions in Mismatch group and 1295 lesions in Non-Mismatch group. After propensity score matching, 397 lesions in each group were selected for final data set. The analysis showed that Mismatch group PCI required more frequently use of post-stenting optimization (79.6% vs 53.9%, P < .001) using higher max pressure (19.5 ± 3.9 vs 16.7 ± 3.7 atm, P < .001). Besides, Mismatch group also encountered more PCI major complications (7.8% vs 4.0%, P = .024) and lower procedure success rate (91.4% vs 95.5%, P = .022). On final angiogram, Mismatch group had smaller minimum lumen diameter (2.62 ± .45 vs 2.90 ± .57 mm, P < .001) and lower angiographic success rate (93.2% vs 96.7%, P = .023). On final IVUS, Mismatch group had higher rate of incomplete stent apposition and stent edge dissection (6.3% vs 3.0%, P = .029 and 2.5% vs .5%, P = .021, respectively). In conclusion, reference mismatch posed significant challenging during PCI that led to unfavorable procedural outcomes. These impacts may translate into long-term clinical implications that need to be addressed in future studies.

A novel technique of proximal optimization with kissing balloon inflation in bifurcation lesions

BACKGROUND

Percutaneous coronary interventions (PCI) of bifurcation lesions poses a technical challenge with a high complication rate. Kissing balloon inflation (KBI) and proximal optimization technique (POT) are used to correct bifurcation carina after stenting. However, both may still lead to uncomplete strut apposition to the side branch (SB) lateral wall. Proposed herein, is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and KBI called proximal optimization with kissing balloon inflation (POKI).

METHODS

Bench and in-vivo evaluations were performed. For the bench visualization bifurcated silicone mock vessel was used. The POKI technique was simulated using a 3.5 mm POT balloon. For the in-vivo evaluation patients with angiographic bifurcation lesions in a native coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm, SB diameter ≥ 2.0 mm, and percentage diameter stenosis (%DS) more than 50% in the main vessel (MV) were included. Provisional stenting was the default strategy.

RESULTS

In total 41 vessels were evaluated. The target vessel was left main in 9 (22.0%) patients, left anterior descending artery - in 26 (63.4%), left circumflex artery - in 4 (9.8%) and right coronary artery - in 2 (4.9%). The predominant type of bifurcation was Medina 1-1-1 (61.8%). Baseline proximal MV DS% was 60.0 ± 23.7%, distal MV DS% - 58.8 ± 28.9% and SB DS% 53.0 ± 32.0%. The application of POKI was feasible in 41 (100%) of the vessels. Post-PCI residual DS at proximal MV was 11.5 ± 15.4%, distal MV - 6.6 ± 9.3%, and SB - 22.9 ± 28.5%. Both procedural and angiographic success was 100%.

CONCLUSIONS

POKI is a novel stent-optimization technique for bifurcation lesions. It showed excellent feasibility and success rate both in bench and in-vivo evaluation.

Physiological Approach for Coronary Artery Bifurcation Disease: Position Statement by Korean, Japanese, and European Bifurcation Clubs

Coronary artery bifurcation lesions are frequently encountered in cardiac catheterization laboratories and are associated with more complex procedures and worse clinical outcomes than nonbifurcation lesions. Therefore, anatomical and physiological assessment of bifurcation lesions before, during, and after percutaneous coronary intervention is of paramount clinical importance. Physiological assessment can help interventionalists appreciate the hemodynamic significance of coronary artery disease and guide ischemia-directed revascularization. However, it is important to understand that the physiological approach for bifurcation disease is more important than simply using physiological indexes for its assessment. This joint consensus document by the Korean, Japanese, and European bifurcation clubs presents the concept of a physiological approach for coronary bifurcation lesions, as well as current knowledge, practical tips, pitfalls, and future directions of applying physiological indexes in bifurcation percutaneous coronary intervention. This document aims to guide interventionalists in performing appropriate physiology-based assessments and treatment decisions for coronary bifurcation lesions.

A Novel Strategy to Simplify the Procedures in Treating Complicated Coronary Bifurcation Lesions: From a Bench Test to Clinical Application

Background

Although provisional stenting strategy based on jailed balloon side branch (SB) protection could be useful for high-risk bifurcation lesion in certain clinical scenarios, its complexity still gives rise to procedure complications. We proposed a novel strategy, the jailed balloon proximal optimization technique (JB-POT), to simplify the procedures in treating complex coronary bifurcation lesions (CBLs). The present study was designed to verify the safety and efficacy of JB-POT under bench testing and clinical circumstances.

Methods

After a stent was deployed in main vessel (MV) with a balloon jailed in SB, POT and post-dilation of the stent were performed without retrieving the jailed balloon. A re-POT was performed 2 mm away from SB branching point to minimize proximal stent malapposition. The JB-POT procedure was performed on 10 samples of a silicone bifurcation bench model, and optical coherence tomography (OCT) was utilized to evaluate stent deployment. From December 2018 to July 2021, a total of 28 consecutive patients with true CBLs treated with JB-POT were enrolled. Immediate procedure results were observed, and clinical follow-ups were performed.

Results

The bench test showed that JB-POT did not induce significant stent malapposition, underexpansion or distortion, as indexed by the malapposition rate, minimum stent area (MSA), eccentricity index and symmetry index determined through OCT. Under clinical circumstances, JB-POT did not induce significant malapposition, underexpansion or distortion. Among the 30 lesions, there was no primary endpoint event defined as SB occlusion, need to rewire the SB with a polymer-covered guide wire, or failure to retrieve a jailed wire or balloon. One rewiring event and 0 double stenting events occurred as secondary endpoint events. One patient died of heart failure in the 8th month after discharge.

Conclusions

The JB-POT protocol, which tremendously simplifies the current standard provisional stenting procedure in complicated bifurcation lesions, shows acceptability in safety and efficacy. Hence, it might become an applicable strategy for treating high-risk bifurcation lesions, especially those with multiple risked SBs.

Effect of proximal optimization technique on coronary bifurcation stent failure: Insights from the multicenter randomized PROPOT trial

OBJECTIVE

We investigated the effect of proximal optimization technique (POT) on coronary bifurcation stent failure (BSF) in cross-over stenting by comparing with the kissing balloon technique (KBT) in a multicenter randomized PROPOT trial.

BACKGROUND

POT is recommended due to increased certainty for optimal stent expansion and side branch (SB) wiring.

METHODS

We randomized 120 patients treated with crossover stenting into the POT group, which was followed by SB dilation (SBD), and the KBT group. Finally, 52 and 57 patients were analyzed by optical coherence tomography before SBD and at the final procedure, respectively. Composite BSF was defined as a maximal malapposition distance of >400 μm, or malapposed and SB-jailed strut rates of >5.95% and >21.4%, respectively.

RESULTS

Composite BSF before SBD in the POT and KBT groups was observed in 29% and 26% of patients, respectively. In the POT group, differences in stent volumetric index between the proximal and distal bifurcation (odds ratio [OR] 60.35, 95% confidential interval [CI] 0.13-0.93, p = 0.036) and between the proximal bifurcation and bifurcation core (OR: 3.68, 95% CI: 1.01-13.40, p = 0.048) were identified as independent risk factors. Composite BSF at final in 27% and 32%, and unplanned additional procedures in 38% and 25% were observed, respectively. Composite BSF before SBD was a risk factor for the former (OR: 6.33, 95% CI: 1.10-36.50, p = 0.039) and the latter (OR: 6.43, 95% CI: 1.25-33.10, p = 0.026) in the POT group.

CONCLUSION

POT did not result in a favorable trend in BSF. Insufficient expansion of the bifurcation core after POT was associated with BSF.

Clinical outcomes of the proximal optimisation technique (POT) in bifurcation stenting

BACKGROUND

Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate.

AIMS

We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how post-implantation deployment techniques influence clinical outcomes.

METHODS

Data from the e-ULTIMASTER registry were used to perform an analysis of 4,395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at one year (follow-up rate 96.2%).

RESULTS

The global one-year TLF rate was low (5.1%). The proximal optimisation technique (POT) was used in 33.9% of cases and was associated with a reduction in the adjusted TLF rate (4.0% [95% confidence interval: 3.0-5.1%] vs 6.0% [5.1-6.9%], p<0.01) due to a reduction of all components of this composite endpoint, except for cardiac death. Stent thrombosis was also positively impacted (0.4% [0.04-0.7%] vs 1.3% [0.8-1.7%], p<0.01). POT benefit was uniform across subgroups. Conversely, the use of the kissing balloon technique (36.5%) did not influence the adjusted TLF rate.

CONCLUSIONS

Despite a low one-year failure rate in this large bifurcation stenting cohort, POT was associated with a further reduction in the event rate and a uniform benefit across subgroups, suggesting systematic use of this deployment technique regardless of the bifurcation anatomy and stenting technique.

The importance of proximal optimization technique with intravascular imaging guided for stenting unprotected left main distal bifurcation lesions: The Milan and New-Tokyo registry

OBJECTIVES

This study evaluated the 5-years outcomes of intracoronary imaging-guided proximal optimization technique (POT) for percutaneous coronary intervention (PCI) in patients with unprotected left main distal bifurcation lesions (ULMD).

BACKGROUND

The long-term effects of POT with intracoronary imaging guide in PCI for ULMD have been unclear.

METHODS

Between January 2005 and December 2015, we identified 1832 consecutive patients who underwent DES implantation for ULM distal bifurcation lesions. Of them, 780 (56.1%) patients underwent POT with intravascular imaging guidance (optimal expansion group). Residual 611 (43.9%) patients did not undergo either POT or intravascular imaging or both (suboptimal expansion group). Analysis using propensity score adjustment was performed. The primary endpoint was target lesion failure (TLF) defined as a composite of cardiac death, target lesion revascularization (TLR), and myocardial infarction.

RESULTS

TLF rate at 5 years was significantly lower in optimal expansion group than that in suboptimal expansion group [adjusted HR 0.65, 95% CI (0.48-0.87), p = 0.004]. Cardiac mortality was significantly lower in optimal expansion group than that in suboptimal expansion group [adjusted HR 0.46, 95% CI (0.27-0.79), p = 0.004]. The multivariable analysis identified POT with intravascular imaging guide [adjusted HR 0.65, 95% CI (0.48-0.87), p = 0.004] as an independent predictor of TLF.

CONCLUSIONS

Intravascular imaging guided POT was strongly associated with the reduced risk of TLF at 5 years after PCI for ULMD, mainly driven by reducing cardiac mortality.

Standardized fractal bench test evaluation of coronary stents: Performances in bifurcation lesions treated by the re-proximal optimization technique

BACKGROUND

Bifurcation lesions in coronary arteries are complex to treat with coronary stents, which are not designed for that purpose and can be unproperly deployed. Moreover, devices are constantly evolving, and so are angioplasty techniques.

OBJECTIVES

The aim of this study was to determine the performances of different stents in the treatment of bifurcation lesions using the re-proximal optimization technique (rePOT).

METHODS

Eleven stent platforms were evaluated: Xience Sierra (Abbott), Xience Alpine (Abbott), Synergy (Boston), Coroflex Isar (Bbraun), Cobra PzF (Celonova), Ultimaster (Terumo), Resolute Integrity (Medtronic), Resolute Onyx (Medtronic), Optimax (Hexacath), Orsiro (Biotronik), and Absorb (Abbott). Stents were deployed in a silicone fractal bifurcation model using the rePOT. Micro-computed tomography was performed to assess side branch ostium coverage and strut malapposition, as well as the effect of rePOT on stent cell area.

RESULTS

Our study showed significant differences between stent platforms regarding side branch ostium coverage (p = .002). The Synergy and Cobra PzF stents were the most performant devices to avoid ostium coverage. Strut malapposition varied significantly between devices (p = .008) but the percentage of malapposed struts was relatively low. Significant differences were observed between stents regarding the cell area before (p = .002) and also after rePOT (p = .003), and the increase in cell area caused by rePOT varied considerably between devices (p = .08).

CONCLUSION

This study highlighted significant differences in the performances of stent platforms deployed in a fractal bifurcation model using rePOT, with a variable impact of the procedure on stent cell area.

True caring is protecting who is at your side

The modified jailed balloon technique (MJBT) is a safe and effective tool for preserving immediate and long-term side branch (SB) patency when treating true bifurcation lesions. This technique could be routinely implemented, or selectively chosen when the risk of SB occlusion is high and a two-stent technique is not desirable. A randomized study comparing provisional stenting with the MJBT versus systematic two-stent strategy for the treatment of true bifurcation lesions is warranted.

Optimal Site for Proximal Optimization Technique in Complex Coronary Bifurcation Stenting: A Computational Fluid Dynamics Study

BACKGROUND/PURPOSE

The optimal position of the balloon distal radio-opaque marker during the post optimization technique (POT) remains debated. We analyzed three potential different balloon positions for the final POT in two different two-stenting techniques, to compare the hemodynamic effects in terms of wall shear stress (WSS) in patients with complex left main (LM) coronary bifurcation.

METHODS/MATERIALS

We reconstructed the patient-specific coronary bifurcation anatomy using the coronary computed tomography angiography (CCTA) data of 8 consecutive patients (6 males, mean age 68.2± 18.6 years) affected by complex LM bifurcation disease. Subsequently a virtual bench test was performed in each patient using two different double stenting techniques represented by the DK and Nano crush using the reconstruction of Orsiro stents (Biotronik IC, Bulack, Switzerland).

RESULTS

A significant reduction in the mean WSS values in all the lesion's sites was observed when the final POT was performed 1 mm distally the carina cut plane in both techniques. Moreover, a significant improvement in the mean WSS values of the entire SB (e.g. LCX) was obtained performing the POT 1 mm distally to the carina cut plane. The proximal POT resulted in larger area of lower WSS values at the carina using both the Nano crush and the DK crush techniques.

CONCLUSIONS

In patients with complex LM bifurcation disease the use of a final POT performed 1 mm distally to the carina cut plane might results in more favorable WSS patterns (i.e. higher WSS values) along all stented segments and, especially, along the entire LCX lesions.

An Upfront Two-Stent Strategy for True Coronary Bifurcation Lesions with A Large Side Branch in Acute Coronary Syndrome: A Two-Year Follow-Up Study

Background and Objectives: Little is known about the upfront two-stent strategy (U2SS) for true coronary bifurcation lesions (CBLs) in acute coronary syndrome (ACS). We aimed to present our two-year follow-up results on the U2SS by using different two-stent techniques for the true CBL with a large side branch (SB) in ACS patients, including unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), and to identify independent predictors of the presence of major adverse cardiac events (MACEs) after intervention. Materials and Methods: The study included 201 consecutive ACS patients with true CBLs who underwent percutaneous coronary intervention (PCI) using U2SS from October 2015 to March 2018. Clinical outcomes at follow-up were assessed. MACE was defined as a composite of cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR). Results: 31.3% of the patients had an UA, 46.3% had an NSTEMI, and 22.4% had an STEMI. CBL was most frequently located in the left anterior descending (LAD)/diagonal artery (59.2%). In total, 71.1% of the patients had a Medina classification (1,1,1). Overall, 62.2% of cases were treated with mini-crush stenting. Clopidogrel was given in 23.9% of the patients; 71.1% of the patients received everolimus eluting stent (EES); and 11.9% received a sirolimus eluting stent (SES). Final kissing balloon inflation was carried out in all patients, with an unsatisfactory rate of 5%. A proximal optimization technique sequence was successfully carried out in all patients. The MACE incidence was 16.9% with a median follow-up period of 2.1 years. There were seven cardiac deaths (3.5%). The TLR rate was 13.4% (n = 27), with PCI treatment in 16 patients, and coronary artery bypass grafting treatment in 11 patients. After multivariate penalized logistic regression analysis (Firth logistic regression), clopidogrel use (odds ratio (OR): 2.19; 95% confidence interval (CI): 0.41–2.51; p = 0.007) and SES use (OR: 1.86; 95% CI: 0.31–2.64; p = 0.014) were independent predictors of the presence of MACE. Conclusion: U2SS is feasible and safe for the true CBLs with large and diseased SB in ACS patients, and is related to a relatively low incidence of MACE. Clopidogrel use and SES use may predict the MACE development in ACS patients treated using U2SS.

Critical aspects of balloon position during final proximal optimization technique (POT) in coronary bifurcation stenting

OBJECTIVES

In a coronary bifurcation bench model, to determine the effects of side branch (SB) wire crossing position and balloon position on the stent scaffolding after the final proximal optimization technique (POT).

BACKGROUND

POT performed as a final step after SB dilatation or kissing balloon inflation (KBI) has been widely advocated despite limited evidence.

METHODS

Thirty-one stent implantations in bifurcation phantoms were performed using a one-stent provisional technique with (KBI) (n = 13), with POT-side-POT technique (n = 12) or with the two-stent culotte technique (n = 6). SB wiring was performed through either a proximal or a distal stent cell and confirmed by optical coherence tomography. Final POT was performed with the balloon positioned either across or proximal to the SB takeoff. The area of the opened stent cell in front of the SB was assessed by 3D reconstructed microcomputation tomography scans performed before and after Final POT.

RESULTS

In cases with metallic carina, final POT across the SB takeoff caused SB rejailing. Regardless of stent technique and wire position, a Final POT across the SB takeoff reduced the SB cell opening area by 43% [32%;58%] (n = 15). The largest reduction (54-70%) was found after the POT-side-POT technique in procedures with a proximal wiring. Final POT performed proximal to the SB takeoff caused limited or no SB cell opening area reduction (4% [0.6%;6%] [n = 16]).

CONCLUSION

Final POT with balloon positioned across the SB takeoff in a narrow angle bifurcation reduces largest stent cell area in front of the SB ostium and may cause SB rejailing in cases with metallic carina.

Randomised comparison of provisional side branch stenting versus a two-stent strategy for treatment of true coronary bifurcation lesions involving a large side branch: the Nordic-Baltic Bifurcation Study IV

Background

It is still uncertain whether coronary bifurcations with lesions involving a large side branch (SB) should be treated by stenting the main vessel and provisional stenting of the SB (simple) or by routine two-stent techniques (complex). We aimed to compare clinical outcome after treatment of lesions in large bifurcations by simple or complex stent implantation.

Methods

The study was a randomised, superiority trial. Enrolment required a SB≥2.75 mm, ≥50% diameter stenosis in both vessels, and allowed SB lesion length up to 15 mm. The primary endpoint was a composite of cardiac death, non-procedural myocardial infarction and target lesion revascularisation at 6 months. Two-year clinical follow-up was included in this primary reporting due to lower than expected event rates.

Results

A total of 450 patients were assigned to simple stenting (n=221) or complex stenting (n=229) in 14 Nordic and Baltic centres. Two-year follow-up was available in 218 (98.6%) and 228 (99.5%) patients, respectively. The primary endpoint of major adverse cardiac events (MACE) at 6 months was 5.5% vs 2.2% (risk differences 3.2%, 95% CI -0.2 to 6.8, p=0.07) and at 2 years 12.9% vs 8.4% (HR 0.63, 95% CI 0.35 to 1.13, p=0.12) after simple versus complex treatment. In the subgroup treated by newer generation drug-eluting stents, MACE was 12.0% vs 5.6% (HR 0.45, 95% CI 0.17 to 1.17, p=0.10) after simple versus complex treatment.

Conclusion

In the treatment of bifurcation lesions involving a large SB with ostial stenosis, routine two-stent techniques did not improve outcome significantly compared with treatment by the simpler main vessel stenting technique after 2 years.

Trial registration number

NCT01496638.

[Hot issues in bifurcation lesions PCI in 2019]

Coronary bifurcations are involved in 15-20% of all percutaneous coronary interventions (PCI) and remain one of the most challenging lesions in interventional cardiology in terms of procedural success rate as well as long-term cardiac events. The optimal management of bifurcation lesions is still debated but involves careful assessment, planning and a sequential provisional approach. The preferential strategy for PCI of bifurcation lesions remains to use main vessel (MV) stenting with a proximal optimisation technique (POT) and provisional side branch (SB) stenting as a preferred approach. Final kissing balloon inflation is not recommended in all cases. In the minority of lesions where two stents are required, careful deployment and optimal expansion are essential to achieve a long-term result. Intracoronary imaging techniques (IVUS, OCT) and FFR are useful endovascular tools to achieve optimal results.

The Proximal Optimization Technique Improves Clinical Outcomes When Treated without Kissing Ballooning in Patients with a Bifurcation Lesion

Background and Objectives

There are limited data regarding the clinical efficacy of the proximal optimization technique (POT) in the treatment of coronary bifurcation lesions. We investigated the influence of POT on the clinical outcomes of patients with coronary bifurcation lesions.

Methods

We enrolled a total of 1,191 patients with a bifurcation lesion with a side branch (SB) diameter ≥2.5 mm treated with a drug-eluting stent from 18 centers between January 2003 and December 2009. The primary outcome was major adverse cardiac events (MACEs: cardiac death, myocardial infarction or target lesion revascularization [TLR]). We performed one-to-many (1:N) propensity score matching with non-fixed matching ratio.

Results

POT was performed in 252 patients. During follow-up (median 37 months), the incidence of MACE was lower in the POT group than it was in the non-POT group (adjusted hazard ratio, 0.43; 95% confidence interval [CI], 0.24–0.79; p=0.006). After propensity score matching, these were 0.34; 95% CI, 0.17–0.69; p=0.003 for MACE and 0.37; 95% CI, 0.17–0.78; p=0.01 for TLR. The use of POT was associated with significantly lower TLR in patients treated without kissing ballooning, but was not in those who underwent kissing ballooning (p for interaction=0.03).

Conclusions

In coronary bifurcation lesions with a large SB, POT may be beneficial to improve long-term clinical outcome, particularly in patients treated without kissing ballooning during the procedure.

Trial Registration

ClinicalTrials.gov Identifier: NCT01642992

Efficacy of the proximal optimization technique on crossover stenting in coronary bifurcation lesions in the 3D-OCT bifurcation registry

AIM

We sought to investigate the efficacy of the proximal optimization technique (POT) on crossover stenting followed by side branch (SB) dilation under optical coherence tomography guidance in a multicenter registry study.

METHODS AND RESULTS

A total of 135 bifurcation lesions in 134 patients were divided into POT (n = 52) and non-POT groups (n = 83). The POT was performed before SB dilatation (pre-POT; n = 26), finally (final-POT; n = 12), at both timing (re-POT; n = 13), and uncertain (n = 1). There were no significant intergroup differences in the success rate of guide wire re-crossing (GWR) into the optimal cell (72% vs. 65%), incidence of the link-free type in the configuration of the SB jailed struts (51% vs. 49%), or incomplete strut apposition at the bifurcation (13 ± 11% vs. 10 ± 9%). However, insufficient stent expansion close to the carina in the proximal main vessel (MV) due to inappropriate POT was likely to induce greater incomplete strut apposition (ISA) around the bifurcation. Only re-POT provided more symmetric proximal MV expansion, while pre- and final-POT did not.

CONCLUSION

The POT did not provide the expected beneficial effects, such as reduction of ISA or more optimal GWR, under the OCT guidance. Wide stent expansion in the proximal MV induced by the POT increased the likelihood of achieving optimal GWR, whereas symmetric stent expansion was provided by re-POT.

Treatment strategies for coronary bifurcation lesions made easy in the current era by introduction of the BIFURCAID app

Coronary bifurcation lesions account for 15-20% of all percutaneous coronary interventions. Percutaneous revascularization of these lesions is technically challenging and results in lower success rates than nonbifurcation lesions. There are unique procedural considerations and techniques that are employed in the percutaneous revascularization of these lesions. Our objective is to define the procedural complexities of treating coronary bifurcation lesions and describe the leading provisional and dedicated two stent techniques used to optimize procedural and clinical results, as described in the BIFURCAID app.