Percutaneous coronary intervention of bifurcation lesions

Sirolimus-coated versus paclitaxel-coated balloons for bifurcated coronary lesions in the side branch: the SPACIOUS trial

BACKGROUND

The optimal strategy to treat coronary bifurcation lesions (CBL) has been a long-debated topic. The combination of a stent in the main vessel (MV) and a drug-coated balloon (DCB) in the side branch (SB) seems promising, but the evidence is limited.

AIMS

This study aims to investigate a novel sirolimus-coated balloon in the treatment of non-left main CBL compared with a paclitaxel-coated balloon.

METHODS

The SPACIOUS trial is a prospective, non-inferiority, multicentre trial. A total of 230 patients were randomised to the sirolimus DCB or the paclitaxel DCB group in a 1:1 ratio. Angiographic and clinical follow-ups were planned at 9 months and 1 year, respectively. The primary endpoint was diameter stenosis (DS) in the SB at 9 months.

RESULTS

At 9 months, DS in the sirolimus group was 30.5±16.1% compared with 33.5±16.2% in the paclitaxel group (difference -2.94%; 95% confidence interval: -7.62% to 1.74%; p for non-inferiority<0.01). The incidence of binary restenosis was significantly lower in the sirolimus group compared to the paclitaxel group (4.4% vs 12.8%; p=0.043). Secondary angiographic endpoints, including late lumen loss and net lumen gain, and 1-year clinical outcomes were not significantly different between groups.

CONCLUSIONS

In de novo non-left main CBL treatment, MV stenting accompanied by SB dilation with the sirolimus DCB was non-inferior to the paclitaxel DCB.

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.

The impact of bifurcation angle on clinical outcomes in patients who underwent nano-crush technique: the insight from the multicenter EVOLUTE-CRUSH V study

BACKGROUND

This multicenter study aimed to retrospectively assess the relationship between bifurcation angle (BA) and major cardiovascular events (MACEs) in patients undergoing nano-crush technique (NCT) for complex bifurcation lesions (CBLs).

METHODS

A total of 122 consecutive patients [male: 85 (69.6%), mean age: 61.53 ± 9.03 years] who underwent NCT between January 2019 and January 2024 were included. The primary endpoint was a combined endpoint (MACE) including cardiac death, target vessel myocardial infarction (TVMI), or clinically driven target lesion revascularization (TLR). Patients were classified into two groups: MACE-positive and MACE-negative patients.

RESULTS

Among the study population, 22 patients (18%) had at least one MACE. The BA (46.89 ± 14.65° vs. 65.23 ± 10.40°, P = 0.001) was notably lower in the MACE-positive group than the MACE-negative group. In multivariable regression analysis, decreased BA was identified as one of the independent predictors of MACE (odds ratio = 0.908; 95% confidence interval: 0.852-0.969; P < 0.001). We divided the study cohort into two subgroups based on historical narrow and wide BAs (<70 vs. ≥70°). The incidence of MACE (25.3 vs. 6.4%, P = 0.008), clinically driven TLR (22.7 vs. 4.3%, P = 0.009), and TVMI (18.7 vs. 0%, P = 0.001) were notably higher in the BA <70° group than in the BA ≥70° group. Kaplan-Meier analysis also revealed that MACE-free survival was significantly lower in the BA <70° group than in the BA ≥70° group under mid-term follow-up (log-rank P = 0.009).

CONCLUSION

This observational multicenter study showed that the BA significantly affects mid-term outcomes in patients who underwent NCT. In addition, our findings suggest that NCT may not be a viable option in patients with narrow-angle (<70°) CBLs.

Impact of Diabetes Mellitus on Bifurcation Percutaneous Coronary Intervention: Insights from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions Registry

The impact of diabetes mellitus (DM) on the outcomes of bifurcation percutaneous coronary intervention (PCI) has received limited study. We compared the procedural characteristics and outcomes of patients with and without DM in 1,302 bifurcation PCIs (1,147 patients) performed at 5 centers between 2013 and 2024. The prevalence of DM was 33.8% (n = 388). Patients with diabetes were younger and had more cardiovascular risk factors and greater angiographic complexity, including more main vessel calcification and more frequent stenoses in the left main, proximal left anterior descending, and right coronary artery. There was no difference in technical (95.5% vs 94.9%, p = 0.613) or procedural success (90.2% vs 91.3%, p = 0.540); provisional stenting was used less frequently in patients with diabetes (64.5% vs 71.1%, p = 0.015). Patients with diabetes had higher rates of repeat in-hospital PCI and acute kidney injury. Other in-hospital outcomes were similar after adjusting for confounders. During a median follow-up of 1,095 days, diabetes was independently associated with greater incidence of major adverse cardiovascular events (hazard ratio [HR] 2.04, 95% confidence intervals [CI] 1.52 to 2.72, p <0.001), myocardial infarction (HR 1.94, 95% CI 1.05 to 3.25, p = 0.033), death (HR 2.26, 95% CI 1.46 to 3.51, p <0.001), and target (HR 1.6, 95% CI 1.01 to 2.66, p = 0.045) and nontarget (HR 2.00, CI 1.06 to 3.78, p = 0.032) vessel revascularization. Patients with DM who underwent bifurcation PCI had greater risk of in-hospital repeat-PCI and major adverse cardiac events during follow-up than did those without diabetes.

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.

Long-term efficacy of drug-coated balloon-based treatment for de novo left anterior descending artery disease

Drug-coated balloons (DCB) are increasingly utilized in percutaneous coronary intervention (PCI), but their effectiveness in coronary artery disease (CAD) needs further exploration. This study investigates the efficacy and safety of a DCB-based strategy for de novo left anterior descending artery (LAD) disease. Patients with de novo LAD lesions treated with DCB alone or combined with drug-eluting stents (DES) and were retrospectively enrolled from 2010 to 2023 (n = 268). The comparator group consisted of patients treated with second-generation DES from a Korean multicenter registry (n = 4,147). The primary endpoint was three-year major adverse cardiovascular events (MACE), including cardiac death, myocardial infarction, target vessel revascularization, target lesion thrombosis, and major bleeding. In the DCB-based group (n = 268), 218 (81.3%) received DCB-only, while 50 (18.7%) underwent a hybrid approach. After propensity score-matching of 243 paired subjects, baseline characteristics were balanced. The DCB-based PCI reduced overall stent burden by 86.7% and significantly lowered the risk of MACE at three years compared to DES-only PCI (4.5% vs. 7.6%, HR 0.50, 95% CI 0.28-0.90; p = 0.020). The most significant reduction was in major bleeding. The DCB-based approach offers an alternative to DES-only strategy for LAD PCI by reducing three-year MACE risk, supporting its use in treating de novo CAD.

Optical Coherence Tomography in Myocardial Infarction Management: Enhancing Precision in Percutaneous Coronary Intervention

In acute myocardial infarction (AMI), the urgency of coronary revascularization through percutaneous coronary intervention (PCI) is paramount, offering notable advantages over pharmacologic treatment. However, the persistent risk of adverse events, including recurrent AMI and heart failure post-revascularization, underscores the necessity for enhanced strategies in managing coronary artery disease. Traditional angiography, while widely employed, presents significant limitations by providing only two-dimensional representations of complex three-dimensional vascular structures, hampering the accurate assessment of plaque characteristics and stenosis severity. Intravascular imaging, specifically optical coherence tomography (OCT), significantly addresses these limitations with superior spatial resolution compared to intravascular ultrasound (IVUS). Within the context of AMI, OCT serves dual purposes: as a diagnostic tool to accurately identify culprit lesions in ambiguous cases and as a guide for optimizing PCI procedures. Its capacity to differentiate between various mechanisms of acute coronary syndrome, such as plaque rupture and spontaneous coronary dissection, enhances its diagnostic potential. Furthermore, OCT facilitates precise lesion preparation, optimal stent sizing, and confirms stent deployment efficacy. Recent meta-analyses indicate that OCT-guided PCI markedly improves safety and efficacy in revascularization, subsequently decreasing the risks of mortality and complications. This review emphasizes the critical role of OCT in refining patient-specific therapeutic approaches, aligning with the principles of precision medicine to enhance clinical outcomes for individuals experiencing AMI.

Advances in Technology and Technique in Percutaneous Coronary Intervention: A Clinical Review

Percutaneous coronary intervention (PCI) has become the standard procedure for patients with angina and acute coronary syndrome. From the perspective of technology and technique, PCI has advanced over the last four decades, resulting in considerably improved clinical outcomes in patients with coronary artery disease in the current era. In this review article, we summarize recent advances, promising technologies, and areas for research in the field of PCI.

Outcomes of Drug-Eluting Balloons for In-Stent Restenosis: Large Cohort Analysis and Single-Center Clinical Experience

BACKGROUND

The use of drug-eluting balloons (DEBs) remains clinically relevant in the contemporary era of drug-eluting stent percutaneous coronary interventions (DES-PCI), especially in the setting of in-stent restenosis (ISR). Our goal was to assess the outcomes of ISR patients in a large prospective registry.

METHODS

A total of 2329 consecutive patients with ISR-PCI (675 using DEB and 1654 with DES) were treated in our medical centre from 2010 to 2021. Clinical end points included mortality and major adverse cardiac events (MACE) at 1 year. Clinical outcomes were adjusted for multiple confounders.

RESULTS

Mean ages (65.9 ± 11.0 vs 66.1 ± 10.5; P = 0.73) and percentages of female patients (16.6% vs 18.2%; P = 0.353) were similar between both ISR groups. Patients treated with DEB for ISR suffered more from diabetes, hypertension, and previous myocardial infarction (P < 0.01 for all) and presented more frequently with acute coronary syndrome (40.0% vs 34.4%; P = 0.01) compared with patients treated with DES for ISR. One-year MACE was significantly higher in the DEB ISR-PCI group (23.4% vs 19.6%; P = 0.002) compared to the DES ISR-PCI group, but no significant differences in mortality were observed at 1 year between the groups. After adjustment for multiple confounders, DEB ISR-PCI was not associated with increased MACE at 1 year (P = 0.55).

CONCLUSIONS

In our large experience, patients treated with DEB for ISR-PCI have higher baseline risk and sustained increased MACE rates compared with DES ISR-PCI patients. After adjustment for confounding variables, clinical outcomes are similar between the groups at 1 year after PCI.

Successful true cavity pathfinding with balloon assisted CTO with bifurcation lesions: Two case reports

BACKGROUND

Coronary artery disease is a prevalent global cardiovascular ailment, with percutaneous coronary intervention (PCI) standing out as a crucial method for relieving symptoms and enhancing the quality of life in patients with coronary heart disease. However, the presence of concurrent chronic total occlusion (CTO) and bifurcation lesions within coronary arteries elevates the complexity and treatment risks, especially when the entry point of the CTO is ambiguous.

OBJECTIVE

This study aims to present an innovative approach for treating CTO complicated with bifurcation lesions, focusing on true cavity pathfinding assisted by a balloon.

METHODS

Two cases of CTO patients with concomitant bifurcation lesions are described. One case involves CTO of the left anterior descending artery) combined with anterior non-angle trigeminal lesions, while the other entails CTO of the posterior left artery combined with posterior angle trigeminal lesions. True lumen identification using a balloon and subsequent opening of the CTO blood vessel were performed in both cases.

RESULTS

In both cases, the true lumen was successfully located with the assistance of a balloon, leading to the successful opening of the CTO blood vessel. This approach not only simplified the procedure but also reduced procedural difficulty and associated risks of complications compared to traditional guide wire operations.

CONCLUSION

The application of true cavity pathfinding assisted by a balloon offers a novel and effective strategy for managing CTO complicated with bifurcation lesions. The method simplifies the procedure, decreases procedural difficulty, and lowers the risk of complications associated with guide wire operations. However, further studies and long-term follow-up data are warranted to validate the reliability and long-term efficacy of this innovative approach.

Research progress of drug eluting balloon in arterial circulatory system

The arterial circulatory system diseases are common in clinical practice, and their treatment options have been of great interest due to their high morbidity and mortality. Drug-eluting balloons, as a new type of endovascular interventional treatment option, can avoid the long-term implantation of metal stents and is a new type of angioplasty without stents, so drug-eluting balloons have better therapeutic effects in some arterial circulatory diseases and have been initially used in clinical practice. In this review, we first describe the development, process, and mechanism of drug-eluting balloons. Then we summarize the current studies on the application of drug-eluting balloons in coronary artery lesions, in-stent restenosis, and peripheral vascular disease. As well as the technical difficulties and complications in the application of drug-eluting balloons and possible management options, in order to provide ideas and help for future in-depth studies and provide new strategies for the treatment of more arterial system diseases.

Intrastent Restenosis: A Comprehensive Review

The primary objective of this paper is to delineate and elucidate the contemporary advancements, developments, and prevailing trajectories concerning intrastent restenosis (ISR). We aim to provide a thorough overview of the most recent developments in this area, covering various aspects such as pathophysiological insights, therapeutic approaches, and new strategies for tackling the complex challenges of ISR in modern clinical settings. The authors have undertaken a study to address a relatively new medical challenge, recognizing its significant impact on the morbidity and mortality of individuals with cardiovascular diseases. This effort is driven by the need to fully understand, analyze, and possibly improve the outcomes of this emerging medical issue within the cardiovascular disease field. We acknowledge its considerable clinical implications and the necessity for innovative methods to mitigate its effects on patient outcomes. Therefore, our emphasis was directed towards elucidating the principal facets of the condition's prevalence, expounding upon the foundational mechanisms underscoring conspicuous restenosis, and delineating the risk factors relevant in shaping the contemporary landscape of diagnostic and therapeutic modalities. This thorough examination aims to provide a comprehensive understanding of the various dimensions of the condition, including epidemiological data, pathophysiological complexities, and clinical considerations critical for evaluating and enhancing current diagnostic and treatment approaches.

Cardiovascular Outcomes After Mini-Crush or Double Kissing Crush Stenting Techniques for Complex Bifurcation Lesions: The EVOLUTE-CRUSH Registry

Comparison of clinical outcomes of double kissing crush (DKC) and mini-crush (MC) techniques in patients with complex coronary bifurcation lesions is lacking. This study sought to determine the clinical results of DKC and MC stenting techniques in mid-term follow-up. This retrospective study included a total of 269 consecutive patients with complex bifurcation lesions who underwent percutaneous coronary intervention; 132 (49%) of them were treated with MC technique, whereas 137 (51%) treated with DKC technique. The primary end point was target lesion failure (TLF), defined as the combination of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. This is the first study to compare the cardiovascular outcomes of DKC and MC stenting techniques in patients with complex bifurcation lesions. The SYNTAX scores were similar in both groups (23 [20 to 30] vs 23 [19 to 28], p = 0.631)]. The number of balloons (6.31 ± 1.80 vs 4.42 ± 0.87, p <0.001) and guidewires (3.55 ± 0.83 vs 2.86 ± 0.74, p <0.001) used, fluoroscopy time (21.55 ± 7.05 vs 16.66 ± 4.19 minutes, p <0.001), and procedure time (80.42 ± 27.95 vs 69.61 ± 18.97 minutes, p <0.001) were significantly higher in the DKC group. The rate of composite TLF was similar in complex bifurcation patients treated with MC than those treated with the DKC technique (14% vs 12%, p = 0.453). Moreover, both groups had similar rates in terms of cardiac death or all-cause death, target vessel-related myocardial infarction, clinically driven target lesion revascularization, and stent thrombosis. In conclusion, the present study showed that both techniques of bifurcation treatment met high angiographic success with low complication and similar TLF rates.

An Approach to Non-left Main Bifurcation Lesions: A Contemporary Review

Bifurcated anatomical locations in the arterial tree, such as coronary artery bifurcations, are prone to develop obstructive atherosclerotic lesions due to the pro-atherogenic low wall shear stress. The percutaneous treatment of bifurcation lesions is among the most challenging complex coronary interventions, including different multistep stenting strategies. Even though provisional side branch (SB) stenting is recommended as the primary approach in most cases, the debate continues between provisional SB and upfront two-stent strategies, particularly in complex bifurcations consisting of a significantly diseased SB that supplies a crucial myocardial territory. This review will highlight the importance of understanding the bifurcation philosophy and provide an individual algorithmic approach to find the optimal treatment strategy for each patient with a non-left main coronary bifurcation lesion. Considering the most recent scientific evidence, the advantages and disadvantages of each stenting technique and the role of intracoronary imaging to optimize bifurcation percutaneous coronary intervention outcomes will be discussed.

Double Kissing Inflation Outside the Stent Versus Jailed Balloon Technique for Coronary Bifurcation Lesions

Side branch (SB) occlusion remains challenging in bifurcation percutaneous coronary intervention. We have introduced a novel method to protect SB named double kissing inflation outside the stent (DKo), which features twice inflation of protective balloon kissing with stent and postdilation balloon. This study compared protective effects of DKo vs jailed balloon technique (JBT) for bifurcation. This retrospective, single-center study enrolled 875 consecutive bifurcation lesions receiving either DKo (n = 209) or JBT (n = 666). At the 12-month follow-up, major adverse cardiac event occurred less in DKo (6.7% vs 12.0%; P = 0.042), even in 1:2 propensity score matching analysis (6.4% vs 12.3%; P = 0.034). Rewiring and transient SB loss occurred also less in DKo (0.5% vs 13.8% [P < 0.001]; 0.5% vs 4.8% [P = 0.003]). Similar results were observed in matching analysis. This study demonstrated DKo protected SB better than JBT in bifurcation percutaneous coronary intervention.

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.