Treatment of coronary bifurcation lesions: current knowledge and future perspectives

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.

Comparative Short-Term Outcomes of Double-Kissing Culotte and Culotte Techniques in Acute Coronary Syndrome from the Lower Silesia Culotte Bifurcation Registry

Background/Objectives: The double-kissing (DK) culotte technique is a modification of the culotte technique that employs initial kissing balloon inflation after first stent implantation. The DK culotte technique may improve strut apposition and procedural outcomes; however, data on its efficacy and safety remain limited. This study aimed to investigate the short-term outcomes of bifurcation percutaneous coronary intervention (PCI) using the DK culotte technique compared with those of the culotte technique in patients with acute coronary syndrome (ACS). Methods: This two-center, observational, retrospective study included patients with ACS. Out of 12,132 screened patients, 117 and 122 underwent DK culotte and culotte PCIs, respectively, with 117 and 57 patients remaining after propensity score matching. The primary endpoint was 1-year target lesion failure (TLF), which included cardiovascular death, target vessel myocardial infarction or clinically indicated target lesion revascularization (TLR). Secondary endpoints included major adverse cardiac events (MACEs) comprising myocardial infarction, cardiac death, and TLR; contrast medium amount (mL); and cumulative radiation dose (mGy). Results: At 1 year, TLF occurred in 7% and 12% of the DK culotte and culotte groups, respectively (p = 0.17). No significant differences were observed in MACEs between the groups (13% DK culotte vs. 19% culotte; p = 0.12). Additionally, the DK culotte technique did not cause higher contrast medium usage or cumulative radiation dosage. Conclusions: No statistically significant differences were found in TLF and MACE reduction between ACS patients treated with the DK culotte technique and the culotte technique. The observed trend favoring the DK culotte needs further validation in prospective studies.

Necessity sequential intermediate kissing balloon dilation for crush stenting: Further insights from metal/polymer vessel scaffolds bench testing

Sequential intermediate kissing balloon dilation (sIKBD) is crucial for crush stenting, but it require appropriate procedure remains unclear for crush stenting. This study aims to investigate whether sIKBD is necessary and how it can be properly performed during crush stenting. Mini-crush stenting (mini-CS) and sIKBD for mini-crush stenting (sIKBD-mini-CS) using metal drug-eluting stents/polymer bioresorbable vessel scaffolds (mDES/pBVS) were emulated in bifurcation models considering the branch diameter difference, and sIKBD was added to mini-CS for pretreating side-branch (SB) stent before main-branch (MB) stenting (second figure), respectively. Micro-computed tomography was used to assess the morphological parameters of bifurcated stents including length of overlapping stent segment, residual ostial stenosis of the SB, and neocarina length using quantitative methods. Further, optical coherence tomography was to analyze the incidence of stent malapposition. Quantitative analysis demonstrated that in mDES/pBVS phantom, the neocarina length (mDES: 0.45 ± 0.10 mm vs 0.30 ± 0.09 mm, P = .005; pBVS: 0.47 ± 0.11 mm vs 0.29 ± 0.09 mm, P = .001), residual ostial stenosis at the SB (mDES: 19.37 ± 8.21% vs 12.47 ± 2.05%, P = .001; pBVS: 21.89 ± 8.54% vs 9.98 ± 3.35%, P = .035), and stent malapposition in the overlapping segment (mDES: 10.29 ± 3.31% vs 3.83 ± 0.97%, P = .001; pBVS: 12.05 ± 3.87% vs 6.40 ± 1.59%, P = .003) were lower in the sIKBD-mini-CS group than those in the mini-CS group (P < .05 for all). The results of factorial analysis showed that mDES platform tended to have better morphological indicators than the pBVS platform. Adding the sIKBD to mini-CS showed better morphologic characteristics of mDES/pBVS phantoms when compared with mini-CS. Therefore, it should be considered as a critical and proper technique for crush stenting.

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.

Three-Year Outcomes After Bifurcation Stenting With Zotarolimus-Eluting Stents: Final Results From the RESOLUTE ONYX Postapproval Study

Background

Bifurcation represents a challenging lesion subset for percutaneous coronary intervention.

Methods

In this prospective study of the Resolute Onyx zotarolimus-eluting stent (ZES), patients with a single bifurcation target lesion who underwent planned treatment using a provisional stenting technique were enrolled at 25 centers in the United States and Europe. The primary end point was target-vessel failure (TVF) at 1 year, and follow-up was performed through 3 years.

Results

A total of 205 patients were enrolled. Mean age was 66.6 ± 10.7 years, 21.5% of patients were female, and diabetes mellitus was present in 30.2%. A provisional approach with a single stent was performed in 96.6% of patients. The rate of TVF at 1 year was 7.4%, fulfilling the prespecified performance criterion (upper 1-sided 95% CI of 11.1%, compared with the performance goal of 24.5%). At 3-year follow-up, the rate of TVF was 12.1%, the rate of clinically driven target-lesion revascularization was 6.0%, and there were no episodes of stent thrombosis related to the target lesion. Event rates were consistent among the cohort of patients with angiographic core laboratory-confirmed bifurcation lesions.

Conclusions

In this prospective, multicenter study, bifurcation lesion treatment with Resolute Onyx ZES using a planned provisional stent approach was associated with favorable clinical outcomes through 3 years. These results support the longer-term safety and effectiveness of Resolute Onyx ZES to treat bifurcation lesions that are amenable to a planned provisional stenting technique.

Influence of different postballoon expansion procedures: A finite element analysis

BACKGROUND

Postballoon expansion is considered as an appropriate procedure for adequate stent expansion for coronary bifurcation lesions. Two postballoon expansion procedures are currently recommended: proximal optimization technique (POT)/side/POT and POT/kiss/POT. However, the effects of the two postballoon expansion treatments are different. There is a lack of biomechanical study to quantify the difference.

PURPOSE

It is recognized that biomechanical factors influence the occurrence of Major Cardiovascular Adverse Events (MACE), which includes recurrent angina pectoris, acute myocardial infarction and coronary heart disease death. The current paper evaluated the two postexpansion strategies and quantified biomechanical parameters to provide a basis for clinical decisions.

METHODS

Based on the CT angiography (CTA) data of a patient diagnosed with coronary bifurcation lesions, a personalized coronary bifurcation lesion model was constructed, and the surgical procedure after two expansions was simulated. The POT/side/POT and POT/kiss/POT expansion procedures were analyzed from the perspective of biomechanics through finite element analysis. The biomechanics factors, including the percentage of stent malapposition and stent occlusion at the side branch (SB) opening, the stent ellipse index of proximal main vessel (PMV) segment, the minimum lumen area of the stent vessel segment and the stress distribution of the vessel wall, were used to quantify clinician concerns about factors affecting patient outcomes. The factors include stent adhesion, SB open stent occlusion, poor stent deformation, patency effect of vessel stenosis, and vessel wall damage.

RESULTS

Both postexpansion procedures were successfully simulated. The malapposition rate during POT/side/POT was larger (1.2% vs. 0.42%) and stent occlusion at the SB opening from the cross-section perpendicular to the SB opening after the POT/side/POT procedure was 0.20%, compared with 0.00% after POT/kiss/POT. POT/kiss/POT produced a larger PMV segment stent ellipse index. Minimum lumen area after POT/side/POT was 5.6 mm² and after POT/kiss/POT 5.9 mm² . POT/kiss/POT produces an effect of greater vascular stress than POT/side/POT.

CONCLUSION

Numerical simulations provide a quantitative analysis to inform clinicians of the differences between preoperative planning and surgical procedures. Biomechanical analysis of the differences between the two postexpansion strategies found that the POT/kiss/POT procedure resulted in better stent fit, less occlusion of the SB open stent and better vascular patency but also resulted in poor stent deformation and caused greater vessel wall stress. The current study informs rationales for clinical understanding of postexpansion strategies.

Drug-Coated versus Uncoated Balloon for Side Branch Protection in Coronary Bifurcation Lesions Treated with Provisional Stenting Using Drug-Eluting Stents: A Meta-analysis

Background

Provisional stenting using drug-eluting stents (DES) has become the preferred treatment for coronary bifurcation lesions (CBLs). We performed a meta-analysis to compare the effects of side branch (SB) protection using a drug-coated balloon (DCB) versus an uncoated balloon (UCB) during the procedure.

Methods

Relevant randomized and nonrandomized studies were identified by searching the Medline, Embase, Web of Science, Wanfang, and CNKI databases. We used a random-effect model to pool the data by incorporating the heterogeneity between the included studies.

Results

Overall, 803 patients with CBLs treated with provisional stenting using DES were included from seven studies. With a follow-up duration of 6 to 12 months, SB protection with DCB was associated with a lower degree of postoperative diameter stenosis (mean difference (MD): -11.35%, 95% confidence interval (CI): -14.17 to-8.53, p < 0.001; I2 = 0%) and less late lumen loss (MD: -0.19 mm, 95% CI:-0.28 to-0.10, p < 0.001; I2 = 69%) of SB compared to those with UCB. Moreover, SB protection with DCB was associated with reduced risks of target lesion revascularization (risk ratio [RR]: 0.49, 95% CI: 0.27 to 0.88, p = 0.02; I2 = 0%) and major adverse cardiovascular events (RR: 0.42, 95% CI: 0.27 to 0.66, p < 0.01; I2 = 0%). Subgroup analysis according to the study design showed similar results.

Conclusions

For patients with CBL treated with provisional stenting using DES, SB protection with DCB was associated with better angiographic and clinical outcomes than those with UCB.

Efficacy and safety of drug-coated balloon combined with cutting balloon for side branch of true coronary bifurcation lesions: Study protocol for a multicenter, prospective, randomized controlled trial

Background

Coronary bifurcation lesions are common of percutaneous coronary intervention (PCI), and the optimal interventional therapy strategy is still a matter of debate and remains a challenge for interventional cardiologists. The provisional stenting technique is still a preferred method for most bifurcation lesions, but restenosis of the side branch (SB) occurs in approximately 17–19% of cases. Therefore, the dilemma of reducing SB restenosis still exists, and further research on strategies to reduce restenosis for SB is necessary. Drug-coated balloon (DCB) can reduce clinical events in small vessel disease and in-stent restenosis. The efficacy and safety of DCB for SB of true coronary bifurcation lesions have not been fully investigated. A randomized comparison of DCB combined with cutting balloon angioplasty vs. cutting balloon angioplasty for SB has never been published.

Methods and design

The purpose of this study is to explore the superiority of DCB combined with cutting balloon vs. cutting balloon angioplasty for SB after main vessel (MV) drug-eluting stent implantation of true coronary bifurcation lesions. This study is a multicenter, prospective, randomized controlled trial including 140 patients with true coronary bifurcation lesions. Patients will be randomized in a 1:1 manner to receive either DCB combined with cutting balloon or cutting balloon angioplasty for SB after MV drug-eluting stent implantation. The primary endpoint is the evaluation of late lumen loss (LLL) of SB at the 9-month follow-up. The secondary endpoints include procedural success during initial hospitalization, LLL of MV at the 9-month follow-up, binary angiographic restenosis in MV and SB at the 9-month follow-up, the proportion of patients with a final post-PCI quantitative flow ratio result ≤ 0.80 for SB at the 9-month follow-up, and major adverse cardiac events during the 24-month follow-up.

Conclusions

This clinical trial will provide evidence as to whether DCB combined with cutting balloon for SB of true coronary bifurcation lesions is a superior treatment approach.

Trial Registration Number

ChiCTR2000040475.

Dissemination

The results of this clinical trial will be published in a peer-reviewed journal.

Drug-coated balloon in the treatment of coronary left main true bifurcation lesion: A patient-level propensity-matched analysis

Aims

An increasing body of evidence suggests that drug-coated balloon (DCB) angioplasty represents a valuable option for revascularization in selected patients with coronary bifurcation disease. However, there remains a paucity of real-world observational evidence on the efficacy of DCB in left main (LM) true bifurcation lesion. We compared clinical and angiographic outcomes of hybrid [DCB + drug-eluting stent (DES)] versus DES-only strategy (provisional stenting or two-stent strategies) in de novo LM true bifurcated lesions.

Methods

The primary endpoint was the 2-year composite rate of target lesion failure (TLF): cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (CD-TLR). A routine 1-year angiographic follow-up was scheduled. Propensity-score matching was utilized to assemble a cohort of patients with similar baseline characteristics.

Results

Among 1077 eligible patients, 199 who received DCB treatment and 398 who were assigned to DES therapy had similar propensity scores and were included in the analysis. TLF within 2 years occurred in 13 patients (7.56%) assigned to DCB group, and 52 patients (14.36%) assigned to DES group (odds ratio: 0.487; 95% confidence interval: 0.258–0.922; P = 0.025; Log-rank P = 0.024). Compared with the DES group, the DCB group resulted in a lower rate of CD-TLR (2.91% vs. 9.42%; P = 0.007). Cardiac death, TVMI, all-cause mortality, and stent thrombosis were comparable between both groups. Patients treated with DES-only were associated with a higher late lumen loss (0.42 ± 0.62 mm vs. 0.13 ± 0.42 mm, P < 0.001) compared with the DCB group at 1 year. In sensitivity analysis, the DCB group also presented a lower incidence of TLF, CD-TLR and stent thrombosis both compared to the two-stent strategy and compared to provisional stenting (Ps < 0.05).

Conclusion

The 2-year results of PCI utilizing DCB for LM true bifurcation lesions are superior to employing DES alone in terms of safety and effectiveness.

Effect of Paclitaxel-Coated Balloon Angioplasty on Side Branch Lesion and Cardiovascular Outcomes in Patients with De Novo True Coronary Bifurcation Lesions Undergoing Percutaneous Coronary Intervention

PURPOSE

To compare the effects of paclitaxal-coated balloon (PCB) versus conventional balloon (CB) on side branch (SB) lesion and cardiovascular outcomes in patients with de novo true bifurcation lesions.

METHODS

In total, 219 patients with de novo true bifurcation lesions were enrolled and divided into PCB group (102 cases) and CB group (117 cases) according to angioplasty strategy in SB. Drug-eluting stent (DES) was implanted in main vessel (MV) for each subject. All subjects underwent a 12-month follow-up for late lumen loss (LLL), restenosis, and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI). MACEs included cardiac death, nonfatal myocardial infarction, and unstable angina requiring admission.

RESULTS

There were no differences in diameter, minimum lumen diameter (MLD), and stenosis for bifurcation lesions between the two groups before and immediately after PCI (P > 0.05). After 12-month follow-up, no differences occurred in MV-MLD and MV-LLL between the two groups (P > 0.05); SB-MLD in PCB group was higher than that in CB group (1.97 ± 0.36 mm vs. 1.80 ± 0.43 mm, P = 0.007); SB-LLL in PCB group was lower than that in CB group (0.11 ± 0.18 mm vs. 0.19 ± 0.25 mm, P = 0.024). Multivariate COX analyses indicated that PCB group had lower MACE risk than CB group (HR = 0.480, 95%CI 0.244-0.941, P = 0.033).

CONCLUSION

PCB could decrease SB-LLL and MACE risk in patients with de novo true coronary bifurcation lesion 12 months after single-DES intervention.

Drug coated balloons and their role in bifurcation coronary angioplasty: appraisal of the current evidence and future directions

INTRODUCTION

Coronary Bifurcation lesions are technically more challenging and Bifurcation percutaneous coronary intervention (PCI) remains a challenge with unpredictable and sub-optimal clinical and angiographic results. Drug-Coated Balloons (DCB) are emerging devices in the field of coronary intervention with promising results that may overcome some of drug eluting stents limitations and may have potential advantages in complex bifurcation PCI.

AREAS COVERED

We have performed a re-appraisal about the issues with current bifurcation PCI techniques and the use of DCB in the treatment of Bifurcation lesions. Several studies performed utilizing DCB are described and critically appraised. Over the recent years, there have been tremendous developments in the DCB technology, lesion preparation, clinical experience, and clinical data during bifurcation PCI. The current review describes the advances in the DCB technology, pharmacokinetics, role of excipients, and optimization of the technique. Special emphasis in lesion preparation and potential pathway of using DCB in bifurcation PCI is proposed.

EXPERT OPINION

Although different proof of concept and pilot studies have shown promising results in treatment of bifurcation lesions with DCB, larger randomized trials and/or international consensus papers are required to enable worldwide translation of this idea to clinical practice.

A Systematic Review of Jailed Balloon Technique for Coronary Bifurcation Lesion: Conventional-Jailed Balloon Technique vs Modified-Jailed Balloon Technique

BACKGROUND

In this systematic review, we aim to evaluate the latest evidence on the efficacy and safety of conventional jailed balloon technique and modified jailed balloon technique for bifurcation lesion, and also whether the former or latter is more effective for preventing side branch occlusion during main branch stenting in bifurcation lesions.

METHODS

We performed comprehensive search on studies assessing the efficacy and safety of conventional jailed balloon and modified jailed balloon technique for bifurcation lesion from several electronic databases.

RESULTS

There were 908 patients from six studies comprising of 615 in conventional jailed balloon technique group and 293 in modified jailed balloon technique group. Side branch loss was lower in modified jailed balloon technique group, however, the proportion of lesions with TIMI flow <3 in the final percutaneous coronary intervention result was somewhat higher in the modified jailed balloon technique group. The efficacy issue regarding side branch dissection was reported as high as 3.4%, especially at proximal stent edge in conventional jailed balloon technique group, but not quantitatively described in the modified jailed balloon technique group. Zero percent major adverse cardiovascular events at 9-12 months follow up was demonstrated in modified jailed balloon technique group, and 1-5% in the conventional jailed balloon group at a longer observation period up to 2.7 years.

CONCLUSION

Our study showed that modified jailed balloon technique is potentially better compared to conventional jailed balloon in terms of side branch loss, dissection, and major adverse cardiovascular events. Further controlled studies are warranted for definite conclusion.