Sequential vs. kissing balloon angioplasty for stenting of bifurcation coronary lesions.

Coronary angioplasty of bifurcation lesions remains a technical challenge and is believed to result in low procedural success associated with the risk of side-branch occlusion. Furthermore, long-term results are associated with a high rate of reintervention. The aim of the study was to evaluate the immediate and long-term clinical and angiographic results of sequential vs. simultaneous balloon angioplasty (kissing balloon technique) for stenting of bifurcation coronary lesions. Between December 1999 and January 2001, 59 patients underwent coronary angioplasty because of symptomatic bifurcation lesions type III (i.e., side branch originates from within the target lesion of the main vessel, and both main and side branch are angiographically narrowed more than 50%). Twenty-six patients were treated with simultaneous and 33 patients with sequential balloon angioplasty. Main-vessel stent placement was mandatory; side-branch stenting and platelet IIb/IIIa antagonists were allowed at the discretion of the operator. Kissing balloon technique offered no advantage in terms of procedural success or need for repeat target vessel revascularization due to restenosis at 6-month follow-up. Using sequential balloon angioplasty, permanent or transient side-branch compromise rate (TIMI flow < 3) was significantly higher than after kissing balloon technique (33% vs. 0%, respectively; P = 0.003). Major clinical events in-hospital or at 6-month follow-up, however, showed no significant differences. Kissing balloon angioplasty reduces the rate of transient side-branch occlusion compared to sequential PTCA but does not improve immediate or long-term outcome compared to sequential PTCA for stenting of bifurcation lesions.     

改良Y支架术与reverse crush支架术治疗冠状动脉分叉病变的疗效比较

目的对比改良Y支架术与reverse crush支架术治疗冠状动脉分叉病变的临床疗效。方法将65例冠状动脉分叉病变患者随机分为两组,分别行改良Y支架术（改良组）和reverse crush支架术（对照组）治疗,观察两组疗效和随访1年主要心脏不良事件发生率。结果改良组手术时间、X线曝光时间短于对照组（P均〈0．01）;造影剂和球囊用量少于对照组（P均〈0．01）,最终球囊对吻成功率更高,但无统计学差异（P〉0．05）;6～9个月造影随访,改良组分支血管再狭窄率低于对照组（P〈0．01）。1年随访结束,对照组心脏不良事件发生率高于改良组,但无统计学差异（P〉0．05）。结论改良Y支架术较teverse crash支架术操作简单、费时少,具有更低的分支再狭窄率,有减少随访1年临床心脏不良事件的趋势,推荐临床优先选用。     

Serial intravascular ultrasound analysis comparing double kissing and classical crush stenting for coronary bifurcation lesions

Background : Compared with the classical crush, double kissing (DK) crush improved outcomes in patients with coronary bifurcation lesions. However, there is no serial intravascular ultrasound (IVUS) comparisons between these two techniques. Objectives : This study aimed to analyze the mechanisms of the two crush stenting techniques using serial IVUS imaging. Methods : A total of 54 patients with IVUS images at baseline, post‐stenting and eight‐month follow‐up were classified into classical (n = 16) and DK (n = 38) groups. All patients underwent final kissing balloon inflation (FKBI). Unsatisfactory kissing (KUS) was defined as the presence of wrist or >20% stenosis during FKBI at the side branch (SB) ostium. The vessels at bifurcation lesions were divided into the proximal main vessel (MV) stent, the crushed segment, the distal MV stent, the SB ostium and the SB stent body. Results : KUS and incomplete crushing were commonly observed in the classical group (62.5%, 81.3%), compared with DK group (18.0%, 39.5%, P < 0.001 and P = 0.004). The post‐stenting stent symmetry in the classical group was 71.85 ± 7.69% relative to 85.93 ± 6.09% in DK group (P = 0.022), resulting in significant differences in neointimal hyperplasia (NIH, 1.60 ± 0.21 mm² vs. 0.85 ± 0.23 mm², P = 0.005), late lumen loss (1.31 ± 0.81 mm² vs. 0.55 ± 0.70 mm², P = 0.013), and minimal lumen area (MLA, 3.57 ± 1.52 mm² vs. 4.52 ± 1.40 mm^2, P = 0.042) at the SB ostium between two groups. KUS was positively correlated with the incomplete crush and was the only predictor of in‐stent‐restenosis (ISR) at the SB ostium. Conclusion : DK crush was associated with improved quality of the FKBI and larger MLA. KUS predicted the occurrence of ISR. © 2011 Wiley Periodicals, Inc.     

药物涂层球囊联合切割球囊行冠状动脉分叉病变边支保护的疗效观察

目的探索切割球囊联合药物球囊行冠状动脉分叉病变分支血管保护的即刻效果及远期预后。方法回顾性选取2017年1月至2018年6月解放军总医院收治的冠状动脉分叉病变患者60例为研究对象。依据治疗方法分为2组:研究组(n=28)和对照组(n=32)。研究组和对照组分别预埋药物球囊和普通球囊。比较2组患者基线资料、即刻手术效果、围手术期并发症,以及随访9个月发生的主要不良心血管事件(MACE)、靶病变血运重建和晚期管腔丢失(LLL)。采用SPSS 24.0软件进行统计分析。依据数据类型,组间比较分别采用t检验或χ~2检验。结果 2组患者术前病变类型及影像学参数、术后主支及分支血管最小直径和残余狭窄间差异无统计学意义(P0.05)。2组患者围手术期均无并发症发生。研究组和对照组患者MACE发生率间差异具有统计学意义[25.8%(8/31)vs 3.57%(1/28),P=0.044],但2组靶病变血运重建率[3.57%(1/28)vs 9.88%(3/31),P0.05]差异无统计学意义。部分患者术后9个月完成影像学复查,研究组和对照组主支直径及主支LLL差异无统计学意义(P0.05),但分支血管最小直径[(2.50±0.48)vs(1.96±0.39)mm,P=0.013]及分支血管LLL[(0.04±0.07)vs(0.25±0.36)mm,P=0.024]间差异具有统计学意义(P0.05)。结论切割球囊联合药物球囊在冠状动脉分叉病变分支保护中安全、有效。     

Balloon crush: treatment of bifurcation lesions using the crush stenting technique as adapted for transradial approach of percutaneous coronary intervention.

The recent advent of drug-eluting stents has allowed the crush stenting technique to be adopted, thus simplifying the treatment of bifurcation coronary artery lesions. However, this can only be achieved in 7 Fr or greater guiding catheters, hence precluding most transradial percutaneous coronary interventions that are usually undertaken using 6 Fr or less guiding catheters. We assessed the feasibility of balloon stent crush as a stepwise procedure in achieving bifurcation crush stenting in 6 Fr transradial percutaneous coronary interventions. Since it is not possible to place two stents through a 6 Fr guiding catheter, we have adapted the crush stenting technique by initially placing a stent in the side branch and a balloon in the main vessel. The side branch stent is then deployed against the main vessel balloon that is later inflated, crushing the side branch stent within the main vessel. The main vessel is then stented and the side branch recrossed for kissing inflations. Seven patients (five males; age range, 47-78 years) with bifurcation lesions were treated using the above-described technique without major complications. Balloon crush of the side branch stent were successfully achieved in all cases without balloon trapping. In six cases where side branch recrossing was attempted, all were successful and kissing balloon inflations were undertaken in five cases. We have demonstrated that the modified crush stenting technique is feasible and can be safely adapted for use in a 6 Fr transradial percutaneous coronary intervention approach.     

Use of intravascular ultrasound in evaluating repeated balloon rupture during coronary stenting

Balloon rupture during coronary angioplasty is a well-recognized complication of PTCA. Coronary angiography commonly fails to elicit the cause of balloon perforation. We present a case with multiple balloon rupture during additional high-pressure inflations of a Palmaz-Schatz stent where intravascular ultrasound was useful in revealing a calcified lesion protruding through the struts of the stent. Cathet Cardiovasc Diagn 40:52–54, 1997. © 1997 Wiley-Liss, Inc.     

Trouser-like stenting: A new technique for bifurcation lesions

We report on a new technique of stenting a bifurcation lesion. A manually bent 180° hinged slotted tube stent was implanted using the kissing balloon technique (resembling two trouser legs). In addition, the proximal part of the main vessel was covered with a stent mounted on two balloons corresponding to the trousers' waist. This “trousers-like stent technique” ensures open accesses to both vessels not obstructed by stent struts and could be a promising solution for main bifurcation lesions. Cathet. Cardiovasc. Diagn. 41:192–196, 1997. © 1997 Wiley-Liss, Inc.     

New stent delivery balloon: A technical note

This study reports the first clinical application of a new noncompliant balloon composed of a middle polyurethane layer sandwiched between an inner layer of polyethylene terephtalate and an outer membrane that provides for consistent even expansion. With this balloon design, the very low compliance and high pressure resistance of polyethylene terephthalate are associated with the high elasticity of polyurethane, preventing balloon damage from stent crimping and expansion and allowing a firm embedding of the stent struts. Palmaz-Schatz stent implantation was successful in 33/35 stents (94%), and the two stents that could not be advanced up to the lesion were successfully withdrawn. High pressure expansion of the stent was obtained during deployment with no balloon ruptures at inflation pressures equal or lower than 16 atmospheres (atm). Accurate positioning of the stent was facilitated by the two markers at the balloon ends and by the optimal visualization after contrast injection, even with 6 Fr guiding catheters. This new delivery system maintains the advantages of hand-crimped stents on noncompliant balloons, reducing the risk of stent loss. Cathet Cardiovasc. Diagn. 42:452–456, 1997. © 1997 Wiley-Liss, Inc.     

Modified crush technique with double kissing balloon inflation (sleeve technique): a novel technique for coronary bifurcation lesions.

We report a modified crush technique with double kissing balloon inflation (the sleeve technique) in an attempt to increase the success rate of final kissing balloon inflation, which has been shown to improve the angiographic outcomes of side branch in bifurcation lesions. A stent was advanced across the side branch with protrusion of 3-5 mm of proximal stent segment into the main vessel. At the same time, a size-matched balloon with length long enough to cover the bifurcation as well as the protruding stent segment was placed in the main vessel. The side-branch stent is deployed first, the wire and stent balloon are removed. This is followed by balloon inflation in main vessel at high pressure to crush the protruding stent segment against vessel wall. The side branch is then rewired, two balloons are advanced to the main vessel and side branch, and the bifurcation is kissed with balloons the first time. The side branch is now like a new sleeve. The balloon and wire of the side branch are removed. Another stent was positioned and then deployed in the main vessel. The side branch is rewired the second time, two balloons are advanced to the main vessel and side branch again, followed by final (second) kissing balloon inflation of the bifurcation. The sleeve technique has been employed in six consecutive patients with 100% success rate of final kissing balloon inflation. There was no major adverse cardiac events or stent thrombosis encountered within 30 days of percutaneous coronary intervention.     

Acute and long-term outcomes of the novel side access (SLK-View) stent for bifurcation coronary lesions: a multicenter nonrandomized feasibility study.

OBJECTIVE: To evaluate technical feasibility and procedural safety of SLK-View stent for treating bifurcation lesions. BACKGROUND: Percutaneous treatment of coronary bifurcation lesions represents a technical challenge. Several stenting techniques and dedicated devices have proven unsuccessful, with high rates of side branch occlusion at index procedure and follow-up. METHODS: Eighty one patients with 84 de novo coronary artery lesions involving a major side branch underwent SLK-View (Advanced Stent Technologies, Inc., Pleasanton, CA) stent implantation with subsequent kissing balloon post dilatation. SLK-View stent is a new scaffolding device incorporating a side aperture that allows access to the side-branch of a bifurcation after deployment of the stent in main vessel. All patients underwent angiographic follow-up at 6 months. Procedural, in-hospital, and 6-month follow-up outcomes were examined. RESULTS: The lesions were located in left main (n = 11), left anterior descending (n = 50), left circumflex (n = 8), right coronary artery (n = 7), and 1 ramus intermedius. The most frequent lesions (44.1%) were true bifurcations. Successful stent delivery to bifurcation was accomplished in 82/84 of the cases (97.6%). Technical success was obtained in 99 and 94% of main vessel and side branches, respectively. Stenting in side-branch was performed in 21 lesions (25%). Side-branches were accessed effectively in 100% of bifurcations postprocedurally. Binary restenosis rate at 6-month follow-up was 28.3% and 37.7% for main vessel and side-branch, respectively. TLR rate at 6-month follow-up was 21% and CABG rate of 6%. CONCLUSION: In this consecutive multicenter series of patients with coronary bifurcation lesions, this novel side-branch access stent proved feasible, with a high procedural success rate, while maintaining side-branch access.     

Impact of three-dimensional characteristics of the left main coronary artery bifurcation on outcome of crush stenting.

BACKGROUND: Crush stenting with drug-eluting stents is used to treat left main coronary artery (LMCA) bifurcations. However, the rate of restenosis at the left circumflex (LCX) artery ostium is high. The impact of the three-dimensional (3D) structure of LMCA bifurcation on the outcome of crush stenting with respect to restenosis has not been described. Objectives: This study examined the stent expansion, deformity, overlapping, and apposition after crush stenting of LMCA bifurcations. METHODS: Bare metal stents were crushed at LMCA bifurcations in a 3D model that reproduced actual angles, such that the stent deployed from the LMCA to the left anterior descending (LAD) artery crushed the stent deployed from the LMCA to the LCX, followed by kissing balloon inflation. The stents were inspected under fluoroscopy and endoscopy. The effect of the bifurcation angle on stent expansion was also examined. RESULTS: In the 3D model, one stent overlapped the other in the distal LMCA, in contrast to the nearly parallel position of the stents observed in a separate two-dimensional model. When the LAD stent overlapped the LCX stent, the latter was crushed on the myocardial side of the vessel, and an unstented segment was observed on the nonmyocardial side, at the LCX ostium. When the overlap was reversed, the LCX stent was crushed on the nonmyocardial side and an unstented segment was observed on the myocardial side. A narrow LMCA-LCX angle was associated with less expansion of the LCX stent at the ostium than more distally, and with a higher likelihood of incomplete stent apposition. CONCLUSIONS: Overlap of the LAD stent over, as opposed to under, the LCX stent was associated with close apposition of the stent to the vessel on the myocardial side, at the ostium of the LCX artery, where atherosclerotic plaques are likely to be present. The spatial plaque burden and bifurcation angle should be closely examined before crush stenting, and segments should not be left unstented over large plaques.     

Techniques for palmaz-schatz stent deployment in lesions with a large side branch

Palmaz-Schatz coronary stent implantation in lesions with a large side branch are reported. The first case describes how to manage plaque shifting after stent implantation. The second and third cases demonstrate a kissing balloon predilatation and stent dilatation technique of a bifurcational lesion. The final case demonstrates a stent implantation technique through the stent struts of a previously deployed stent.     

Theoretical prediction of side branch compromise after main branch stenting in coronary bifurcation

One of the main problems of treatment of bifurcation lesions is side branch (SB) stenosis appearing after stent placement in the main vessel.The aim of this study was to create quantitative method for prediction of side branch compromise extent.We accepted that the main mechanism for SB ostial stenosis is flow divider (FD) displacement from stent struts after stent implantation in the main vessel.Using easily measurable parameters from coronary angiography,as SB diameter,angle α (initial angle between axes of parent vessel and SB axis) and angle α' (angle between above mentioned axes after stent placement) we can calculate percentage diameter stenosis at branch ostium (%DS):%DS = sin (α - α')/(tan α).In boundary condition of full FD displacement %DS = cos α.We tested our theoretical predictions with fluoroscopic observation of elastic wall model of bifurcation (45°distal angle between branches)permitting wall deformations with stent.There is full coincidence of values of %DS and percentage area stenosis (%AS).The regular formulas for calculations of %DS and %AS overestimate stenosis severity between 10% and 25%.Our model tests have shown full coincidence between predicted values for %DS and observed values.We demonstrate that part of the SB ostium is not visible in regular angiography and contributes to ostial lumen area.This is a method that permits quantitative prediction of side branch compromise.     

主支支架加边支预埋球囊治疗冠状动脉分叉病变的疗效及安全性观察

目的 探讨主支支架加边支预埋球囊治疗冠状动脉分叉病变的临床疗效及手术安全性.方法 以江苏省徐州市中心医院2012年10月至2013年7月收治的冠状动脉分叉病变患者86例为研究对象,采用主支支架加边支预埋球囊术进行治疗.依据研究组患者的基线资料特点,选取行单导丝边支保护的60例边支病变患者为对照组.术后,对比评价两组患者的介入治疗成功率、并发症发生率以及随访1年后的心肌梗死溶栓试验（thrombolysis in myocardial infarction,TIMI）血流分级、TIMI心肌灌注（TIMI myocardial perfusion,TMP）血流分级等.结果 术后,研究组和对照组的介入治疗成功率分别为98.84％和85.71％,并发症发生率分别为1.16％和11.11％,组间比较差异具有统计学意义（P＜0.05）.随访1年期间,研究组的主要心血管事件发生率低于对照组,差异具有统计学意义[6.98％（6/86） vs.31.75％（20/63） P＜0.05];TIMI血流分级、TMP血流分级以及右心室舒张末期内径和右心室射血分数均优于对照组,差异具有统计学意义（P＜0.05）.结论 主支支架加边支预埋球囊可提高冠状动脉分支病变患者的介入治疗成功率,降低并发症的发生率,血运重建效果良好,具有较好的远期疗效.     

Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): immediate procedure result and short-term clinical outcomes.

BACKGROUND: Sleeve technique is a modified version of crush technique. It is specifically designed to increase the success rate of final kissing balloon inflation, which used to be a major limitation of the latter. OBJECTIVES: The aim of this study was to examine the feasibility, safety, and early clinical outcomes of sleeve technique in stenting different types (de novo, in-stent restenotic or in-stent bifurcation) of coronary bifurcation lesions at different locations. METHODS: From August 2005 to May 2006, 41 consecutive patients with symptomatic, nonleft-main coronary bifurcation stenoses of diameter narrowing >or=50% were treated with two-stent strategy, using sleeve technique. RESULTS: The mean age was 63.6 +/- 11.6 years with male predominance (70.7%). High prevalence of diabetes mellitus (31.7%), total occlusion (22.0%), and multi-vessel disease (65.9%) was observed in this cohort. Intravenous abciximab was given in 35 (85.4%) patients. Final kissing balloon inflation was successfully performed in all patients. The minimal luminal diameter in main vessel and side branch was increased from 0.97 +/- 0.53 mm and 0.81 +/- 0.45 mm to 2.76 +/- 0.34 mm and 2.22 +/- 0.35 mm, respectively. The mean procedure time was only 66.6 +/- 24.6 min. There was one (2.4%) case of subacute stent thrombosis presented as non-Q-wave myocardial infarction at day 3 postprocedure. The resultant in-hospital and 30-day major adverse cardiac event rate were both 2.4%. CONCLUSIONS: Sleeve technique is a feasible and efficient approach in stenting of coronary bifurcation stenoses.     

Effect of jailed balloon technique on side branch protection in percutaneous coronary intervention for bifurcation lesions

Background Data comparing the jailed balloon technique （JBT） and conventional jailed wire technique （JWT） during percutaneous coronary intervention （PCI） for bifurcation lesions is scanty. Methods From January 2013 to June 2013, 192 consecutive patients undergoing elective PCI for de novo Medina 1,1,1 bifur- cation lesions were enrolled in this study. JBT and JWT were applied to protect the side branch （SB） at the discretion of the operator. Procedural outcomes were compared between the JBT and the JWT group. Results Seventy-four patients were treated with JBT and 118 with JWT. Proportion of patients achieving TIMI 3 flow in main branch （MB） was similar in both groups while in SB it was much lower in JWT group compared with JBT group （74.6% vs. 93.2%, P = 0.001）. In addition, patients in JWT group showed higher incidence of periprocedural myocardial infarction （MI） compared with patients in JBT group （11.9% vs. 2.7%, P = 0.008）. Similar tendency was observed in SB occlusion （18.6% vs. 5.4%, P = 0.009）. No device-related complications were observed in both groups. Conclusion JBT is an effective and safe measure to protect the SB during PCI for bifurcation lesions.     

应用切割球囊结合支架术治疗冠状动脉分叉处病变89例

目的 :评价经皮冠状动脉腔内切割球囊成形术 （PTCBA）结合支架术治疗冠脉分叉处病变的安全性及疗效。方法 :对 89例冠心病患者主支病变应用 PTCBA预扩张后置入支架、分支病变单行 PTCBA而不置入支架 ,观察其冠脉病变特点、手术过程相关因素、手术成功率、并发症和近、中期随访结果。结果 :89例患者中分叉处病变位于前降支 /对角支占 71% ,回旋支 /钝圆支占 2 5 % ,右冠脉 /后降支或后侧支占 4%。对分支血管行 PTCBA后 1例因残余狭窄 >5 0 %而植入支架 ,1例因并发轻度钙化且分支成角较大切割球囊未通过 ,改用常规 PTCA球囊扩张成功。病变 PTCBA成功率达 97.8% ;无院内死亡、急性心肌梗死 （AMI）、急性心包填塞及急诊冠脉搭桥术等严重并发症。对手术成功的 87例术后临床随访 3～ 2 6个月 ,无死亡及 AMI等心脏事件发生。临床心绞痛复发率 17.2 %。复查冠脉造影 （CAG）率 5 6.3 % ,示 49处分叉病变主支支架内再狭窄率 14.3 % ,分支血管再狭窄率 18.4%。结论 :PTCBA结合支架术治疗冠脉分叉处病变是一种安全、有效的介入治疗技术 ,其成功率高、并发症少 ,近、中期疗效满意