The glider balloon: A useful device for the treatment of bifurcation lesions

Background

Final kissing balloon dilatation (FKBD) is a recommended final step in case of treatment of bifurcation lesions by two stents approaches. Furthermore, dilatation of the side branch (SB) may be necessary following main vessel (MV) stenting. Occasionally, recrossing the stent struts with a balloon is hampered because the tip hits a stent strut.

Methods

The Glider (TriReme Medical, Pleasanton, CA) is a dedicated balloon designed for crossing through struts of deployed stents toward a SB. From October 2010 to January 2012, FKBD was attempted in 236 consecutive bifurcation lesions treated in our Institution. FKBD was successfully performed by conventional balloon catheters in 221 (93.5%) lesions (Conventional group). In the remaining 15 (6.5%) lesions, where a conventional balloon failed to cross the stent strut, the Glider balloon was attempted (Glider group).

Results

The angle beta (between the axis of the MV after the branch point and the SB axis at the point of divergence) was wider in the Glider group (83 ± 17° versus 65 ± 27°; p = 0.032). A trend toward an higher rate of the true bifurcation lesions was observed in the Glider group (93% versus 70.5%; p = 0.07). The Glider balloon successfully crossed through MV stent struts toward a SB in 12 patients (80%), whereas failed in the remaining 3 patients.

Conclusions

The Glider balloon represents an unique bail-out device which offers an effective rescue strategy for recrossing stent struts during complex bifurcation stenting.     

Estrategia óptima para el tratamiento de lesiones en bifurcación del tronco coronario izquierdo

Introduction and objectivesThere are no guidelines regarding the most appropriate approach for provisional side branch (SB) intervention in left main (LM) bifurcation lesions.MethodsThe present prospective, randomized, open-label, multicenter trial compared conservative vs aggressive strategies for provisional SB intervention during LM bifurcation treatment. Although the trial was designed to enroll 700 patients, it was prematurely terminated due to slow enrollment. For 160 non-true bifurcation lesions, a 1-stent technique without kissing balloon inflation was applied in the conservative strategy, whereas a 1-stent technique with mandatory kissing balloon inflation was applied in the aggressive strategy. For 46 true bifurcation lesions, a stepwise approach was applied in the conservative strategy (after main vessel stenting, SB ballooning when residual stenosis > 75%; then, SB stenting if residual stenosis > 50% or there was a dissection). An elective 2-stent technique was applied in the aggressive strategy. The primary outcome was a 1-year target lesion failure (TLF) composite of cardiac death, myocardial infarction, or target lesion revascularization.ResultsAmong non-true bifurcation lesions, the conservative strategy group used a smaller amount of contrast dye than the aggressive strategy group. There were no significant differences in 1-year TLF between the 2 strategies among non-true bifurcation lesions (6.5% vs 4.9%; HR, 1.31; 95%CI, 0.35-4.88; P = .687) and true bifurcation lesions (17.6% vs 21.7%; HR, 0.76; 95%CI, 0.20-2.83; P = .683).ConclusionsIn patients with a LM bifurcation lesion, conservative and aggressive strategies for a provisional SB approach have similar 1-year TLF rates.     

Randomized Comparisons Between Different Stenting Approaches for Bifurcation Coronary Lesions With or Without Side Branch Stenosis

ObjectivesThis study sought to evaluate the optimal percutaneous coronary intervention techniques using drug-eluting stents for bifurcation coronary lesions.BackgroundThe optimal bifurcation stenting technique needs to be evaluated.MethodsThe trial included 2 randomization studies separated by the presence of side branch (SB) stenosis for patients having non–left main bifurcation lesions. For 306 patients without SB stenosis, the routine final kissing balloon or leave-alone approaches were compared. Another randomization study compared the crush or single-stent approaches for 419 patients with SB stenosis.ResultsBetween the routine final kissing balloon and leave-alone groups for nondiseased SB lesions, angiographic restenosis occurred in 17.9% versus 9.3% (p = 0.064), comprising 15.1% versus 3.7% for the main branch (p = 0.004) and 2.8% versus 5.6% for the SB (p = 0.50) from 214 patients (69.9%) receiving 8-month angiographic follow-up. Incidence of major adverse cardiac events including death, myocardial infarction, or target vessel revascularization over 1 year was 14.0% versus 11.6% between the routine final kissing balloon and leave-alone groups (p = 0.57). In another randomization study for diseased SB lesions, 28.2% in the single-stent group received SB stents. From 300 patients (71.6%) receiving angiographic follow-up, between the crush and single-stent groups, angiographic restenosis rate was 8.4% versus 11.0% (p = 0.44), comprising 5.2% versus 4.8% for the main branch (p = 0.90) and 3.9% versus 8.3% for the SB (p = 0.12). One-year major adverse cardiac events rate between the crush and single-stent groups was 17.9% versus 18.5% (p = 0.84).ConclusionsAngiographic and clinical outcomes were excellent after percutaneous coronary intervention using drug-eluting stents with any stent technique for non–left main bifurcation lesions once the procedure was performed successfully.     

Contemporary stent treatment of coronary bifurcations.

Treatment of coronary bifurcation lesions represents a challenging area in interventional cardiology. The introduction of drug-eluting stents (DES) reduced restenosis in the main branch (MB). However, restenosis at the ostium of the side branch (SB) remains a problem. Although stenting the MB with provisional SB stenting seems to be the prevailing approach, in the era of DES various two-stent techniques emerged (crush) or were re-introduced (V or simultaneous kissing stents, crush, T, culottes, Y, skirt) to allow stenting in the SB when needed. This review describes in detail various techniques used for implantation of two stents by intention to treat.     

No reflow : quels facteurs prédictifs ?

Introduction

During the past 20 years, significant progress has been made in the recanalization of ACS with ST elevation. It is now accepted that the reopening of the large coronary vessels in the acute phase of infarction by thrombolysis or angioplasty is necessary but not sufficient, because in 20–50% of cases, the coronary recanalization is an illusion of reperfusion. This phenomenon is called “no reflow”.

Objective

The main objective of our study was to identify predictors of poor perfusion or “no reflow” in the acute phase of myocardial infarction.

Methods

Observational prospective study, in the department of cardiology and internal medicine, university hospital of Blida, over a period of 28 months from 1st September 2010 to 31st January 2013. We identified all patients hospitalized for myocardial infarction in acute phase, who underwent primary angioplasty or thrombolysis with angiographic control during a good TIMI flow. The endpoint was regression of ST segment (regression < 50% ST-segment defined no reflow).

Results

Three hundred and seventy-nine patients were included. The mean age was 56.3 ± 2.1, 87.8% of patients were male. In total, 35.9% hypertensive, 27.1% diabetic type 2, 50.1% and 10.8% dyslipidemia, smoking. One hundred and forty-seven (38.8%) developed a no reflow. Mortality was 3.9%, strongly correlated with no reflow (P = 0.001). Predictors of no reflow after multivariate analysis were: age (OR 98, 0.961–0.996 95%, P = 0.02), heart rate (1.01, 95% CI 0.998–1.02, P = 0.035), the type 2 diabetes (odds ratio 1.87, CI 1.2–3.0, P = 0.08), reaching the core (OR 7, 95% CI 1.2–18.4, P = 0.027), direct stenting (OR 0.48, 95% CI 0.31–0.78, P = 0.003). An interesting subgroup of patients was identified namely the subgroup strategy deferred primary angioplasty with stenting best reperfusion (OR 3.7, 95% CI 1.5–8.8, P = 0.04), a lower rate of reocclusion of culprit artery and a lower rate of stenting with 23/51 (45.1%) versus 136/136 (100%) of immediate stenting group with a P < 0.001.

Conclusion

No reflow is a common phenomenon, strongly correlated with mortality predictors are age, heart rate, diabetes, achieving the core and direct stenting. The distal embolization in primary angioplasty is an important phenomenon, a delayed stenting strategy appears to limit this phenomenon.     

Contemporary stent treatment of coronary bifurcations

Treatment of coronary bifurcation lesions represents a challenging area in interventional cardiology. The introduction of drug-eluting stents (DES) reduced restenosis in the main branch (MB). However, restenosis at the ostium of the side branch (SB) remains a problem. Although stenting the MB with provisional SB stenting seems to be the prevailing approach, in the era of DES various two-stent techniques emerged (crush) or were re-introduced (V or simultaneous kissing stents, crush, T, culottes, Y, skirt) to allow stenting in the SB when needed. This review describes in detail various techniques used for implantation of two stents by intention to treat.     

Randomized Comparison of FFR-Guided and Angiography-Guided Provisional Stenting of True Coronary Bifurcation Lesions: The DKCRUSH-VI Trial (Double Kissing Crush Versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions VI)

ObjectivesThis study sought to compare the outcomes of fractional flow reserve (FFR)–guided and angiography (Angio)–guided provisional side-branch (SB) stenting for true coronary bifurcation lesions.BackgroundAngio-guided provisional SB stenting after stenting of the main vessel provides favorable outcomes for the majority of coronary bifurcation lesions. Whether an FFR-guided provisional stenting approach is superior has not been studied.MethodsA total of 320 patients with single Medina 1,1,1 and 0,1,1 coronary bifurcation lesions undergoing stenting with a provisional SB approach were randomly assigned 1:1 to Angio-guided and FFR-guided groups. SB stenting was performed for Thrombolysis In Myocardial Infarction flow grade <3, ostial SB stenosis >70%, or greater than type A dissection after main vessel stenting in the Angio-guided group and for SB-FFR <0.80 in the FFR-guided group. The primary endpoint was the 1-year composite rate of major adverse cardiac events (cardiac death, myocardial infarction, and clinically driven target vessel revascularization).ResultsComparing the Angio-guided and FFR-guided groups, treatment of the SB (balloon or stenting) was performed in 63.1% and 56.3% of lesions respectively (p = 0.07); stenting of the SB was attempted in 38.1% and 25.9%, respectively (p = 0.01); and, when attempted, stenting was successful in 83.6% and 73.3% of SBs, respectively (p = 0.01). The 1-year composite major adverse cardiac event rate was 18.1% in both groups (hazard ratio: 0.91, 95% confidence interval: 0.48 to 1.88; p = 1.00). The 1-year target vessel revascularization and stent thrombosis rates were 6.9% and 5.6% (p = 0.82) and 1.3% and 0.6% (p = 0.56) in the Angio-guided and FFR-guided groups, respectively.ConclusionsIn this multicenter, randomized trial, angiographic and FFR guidance of provisional SB stenting of true coronary bifurcation lesions provided similar 1-year clinical outcomes. (Randomized Study on DK Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions; ChiCTR-TRC-07000015)     

Long‐term outcome of provisional side‐branch T‐stenting for the treatment of unprotected distal left main coronary artery disease

Percutaneous coronary intervention (PCI) on distal left main (LM) remains an independent predictor of poor outcome. The strategy of implanting one stent on the main branch (MB), with provisional stenting on the side‐branch (SB) only when required (provisional T‐stenting), has become the default approach to most bifurcation lesions. This prospective registry sought to investigate the long‐term safety and efficacy of provisional SB T‐stenting for the treatment of unprotected distal LM disease in patients undergoing PCI. From January 2006 to May 2009, 107 consecutive patients affected by unprotected distal LM disease underwent PCI at our center with the intent to use a provisional SB‐stenting technique. We evaluated the rate of major adverse cardiac events (MACE) at long‐term follow‐up (up to 12–41 months). Procedural success was obtained in 98% of patients. A final kissing balloon inflation was performed in 95% and intravascular ultrasound in 83% of patients. Additional stenting on the SB after provisional stenting on MB was required in 29% of lesions. Long‐term follow‐up (3.5 years; 25–75th percentile and 1.1–4.5 years) was completed in 97% of patients. The cumulative incidence of MACE was 32.7%: all‐cause death was 15.8%, nonfatal myocardial infarction 8.4%, and target vessel revascularization 21.5%. At multivariable analysis, age (hazard ratio, 2.08; 95% confidence interval: 2.01–3.32, P = 0.03), European System for Cardiac Operative Risk Evaluation (HR 1.20, 95% CI: 1.04–1.33, P = 0.02), and diabetes mellitus (HR 3.48, 95% CI: 1.12–6.87, P = 0.01) were identified as independent predictors of MACE. In patients with unprotected distal LM disease undergoing PCI, a provisional strategy of stenting the MB only is associated with good long‐term clinical outcomes. © 2011 Wiley‐Liss, Inc.     

Effect of Wire Jailing at Side Branch in 1-Stent Strategy for Coronary Bifurcation Lesions

ObjectivesThis study aimed to determine whether side branch (SB) wire jailing before main vessel (MV) stenting could prevent SB occlusion after the 1-stent strategy for bifurcation percutaneous coronary intervention.BackgroundThe benefits of SB wire jailing in the 1-stent strategy remain unclear.MethodsFrom the COBIS (Coronary Bifurcation Stenting) III registry, 1,890 patients with bifurcation lesions who underwent the 1-stent strategy using second-generation drug-eluting stents were identified and classified into 2 groups according to the use of SB wire jailing: wire jailing (n = 819) and non–wire jailing (n = 1,071). The incidence of SB occlusion (Thrombolysis In Myocardial Infarction flow grade <3) and target lesion failure (cardiac death, myocardial infarction, or target lesion revascularization) was compared.ResultsThe incidence of final SB occlusion was not significantly different between wire jailing (1.8%) vs non–wire jailing (2.9%; P = 0.182). However, wire jailing at the SB was a significant protective factor for SB occlusion after MV stenting on multivariate analysis and was significantly associated with a lower incidence of SB occlusion in patients with significant stenoses (≥60%) at the SB (5.1% vs 11.3%; odds ratio: 0.42; 95% CI: 0.19-0.89; P = 0.028) or MV (3.1% vs 6.2%; odds ratio: 0.49; 95% CI: 0.24-0.95; P = 0.039). During follow-up (median 52 months), the incidence of target lesion failure was not significantly different between wire jailing and non–wire jailing (7.6% vs 6.3%; P = 0.343).ConclusionsDuring bifurcation percutaneous coronary intervention with the 1-stent strategy, wire jailing at the SB was associated with a lower rate of final SB occlusion following MV stenting in patients with severe stenoses at the SB or MV but not with overall bifurcation lesions. Long-term clinical outcomes were comparable between the 2 groups.     

Clinical outcome and quality of life in octogenarians following transcatheter aortic valve implantation (TAVI) for symptomatic aortic stenosis

Objective

TAVI is the alternative option in pts with AS deemed ineligible for surgery. Although mortality and morbidity are measures to assess the effectiveness of treatments, quality of life (QOL) should be an additional target. We assessed clinical outcome and QOL in octogenarians following TAVI.

Design

All octogenarians with a risk profile considered by the Heart Team to be unacceptable for surgery entered in this registry. QOL was assessed by questionnaires concerning physical and psychic performance.

Patients

A hundred forty-five octogenarians (age: 84.7 ± 3.4 years; male: 48.3%) underwent TAVI for AS (97.2%) or isolated AR (2.8%). NYHA class: 2.8 ± 0.6; Logistic EuroScore: 26.1 ± 16.7; STS score: 9.2 ± 7.7.Echocardiographic assessments included AVA (0.77 ± 0.21 cm2), mean/peak gradients (54.5 ± 12.2/88 ± 19.5 mmHg), LVEF (21% = EF ≤ 40%), sPAP (43.1 ± 11.6 mmHg).

Interventions

All pts underwent successful TAVI using Edward-SAPIEN valve (71.2%) or Medtronic CoreValve (28.8%).

Main outcome measures

Rates of mortality at 30 days, 6 months and 1 year were 2.8%, 11.2% and 17.5%.

Results

At 16-month follow up, 85.5% survived showing improved NYHA class (2.8 ± 0.6 vs 1.5 ± 0.7; p < 0.001), decreased sPAP (43.1 ± 11.6 mmHg vs 37.1 ± 7.7 mmHg; p < 0.001) and increased LVEF in those with EF ≤ 40% (34.9 ± 6% vs 43.5 ± 14.4%; p = 0.006). Concerning QOL, 49% walked unassisted, 79% (39.5% among pts ≥ 85 years) reported self-awareness improvement; QOL was reported as “good” in 58% (31.4% among pts ≥ 85 years), “acceptable according to age” in 34% (16% among pts ≥ 85 years) and “bad” in 8%.

Conclusion

TAVI procedures improve clinical outcome and subjective health-related QOL in very elderly patients with symptomatic AS.     

L’utilisation du cathéter Heartrail II « 5-in-6 » dans l’angioplastie coronaire complexe : expérience multicentrique

Background

The mother and child “5-in-6” technique using the Heartrail II catheter is a novel tool allowing stent delivery in challenging lesions, when conventional techniques have failed.

Methods

A total of 147 consecutive patients underwent percutaneous coronary intervention (PCI) using the “5-in-6” Heartrail II catheter was restrospectively identified in the Institut Cardiovasculaire Paris Sud, (Jacques-cartier hospital), Institut hospitalier Claude-Galien (Claude-Galien hospital) and European hospital of Paris between July 2009 and September 2012.

Results

Ten interventional cardiologists treated 147 patients with the new device. The patients mean age was 68.5 ± 21.5 years, 78% were men. Radial access was used in 128 cases (87.9%). The treated vessels were the right coronary artery in 82%, left anterior descending in 22%, left circumflex in 18%, marginal branch in 9%, the posterior descending artery in three patients, retroventricular artery in one patient and a saphenous graft in two patients. Most lesions (70%) had American Heart Association/American College of Cardiology (AHA/ACC) type B2 or C, and greater than 50% were located in distal vessel segments. Mean lesion length was 16 ± 4 mm, which is indicative of long lesion. Most (62%) lesions were moderately to heavily calcified and 22 (14%) were chronic total occlusions. Problems with stent delivery were due to poor guide catheter support or excessive calcification. Introduction of the “Heartrail II” catheter allowed successful stent delivery in 139 cases (94%).

Conclusion

The “5 in 6” Heartrail II catheter is a simple and easy-to-use device that can improve the success of stent delivery in challenging coronary interventions.     

Ultrasound study of the prevalence of plaque at the carina in lesions that affect the coronary bifurcation. Implications for treatment with provisional stent

Introduction and objectives

The plaque distribution patterns in coronary bifurcation lesions are not well understood. It has been speculated that carina is free of plaque partly because of high wall shear stress providing an atheroprotective effect. To study plaque distribution with intravascular ultrasound (IVUS) in the coronary bifurcation and the prevalence of carina involvement.

Methods

IVUS study was performed on 195 coronary bifurcation lesions in the main vessel (MV) and on 91 in the side branch (SB). Plaque at the carina was considered when its thickness was > 0.3 mm. Plaque burden was measured at different levels: proximal reference, distal, carina and at the point of minimal lumen area (MLA).

Results

The prevalence of plaque at the carina was 32%. Its thickness was 0.8 (0.36) mm, less than that observed at the counter-carina [1.22 (0.54) mm; P < .01]. The prevalence was higher (52%) when the MLA point was distal to the carina. The plaque at the carina was associated with a lower incidence of damage at the SB ostium after stenting the MV (32% vs 54%; P < .04).

Conclusions

The carina is not immune to atherosclerosis, showing plaque at this level in one third of the bifurcations. The incidence of plaque is higher in those bifurcations with the MLA point distal to the carina and seems to be associated with a lower incidence of damage to the SB ostium.Full English text available from: www.revespcardiol.org     

Location of side branch access critically affects results in bifurcation stenting: Insights from bench modeling and computational flow simulation

Background

The aim of this study was to evaluate the impact of stent design and side branch access on final strut apposition during bifurcation stenting.

Methods and results

A series of 6 different commercially available Drug Eluting Stents (DES) (n = 42) were deployed in an identical model of a coronary bifurcation. Kissing Balloon (KB) optimization was performed after either proximal or distal recrossing of the guidewire and results were analyzed by micro-Computed-Tomography.Stent design only had a minor impact on side branch lumen area free of stent struts. Similar rate of strut malapposition was observed within the bifurcation when a consistent KB optimization protocol and an optimal distal recrossing of the wire to reaccess the side branch (SB) are followed.Conversely, proximal instead of distal cell recrossing toward the side branch produced a significant lower area of the side branch lumen free of struts than an optimal distal recrossing (60.3 ± 7.1% versus 81.1 ± 8.0%, p < 0.0001), as well as a higher rate of strut malapposed toward the SB ostium (40.6 ± 6.0% versus 26.0 ± 5.7%, p = 0.0005).

Conclusions

Optimal cell recrossing of the guidewire may be critical to ensure successful stent optimization in bifurcation PCI.     

Single String Technique for Coronary Bifurcation Stenting: Detailed Technical Evaluation and Feasibility Analysis

ObjectivesThe study aimed to evaluate the adequacy and feasibility of the single string bifurcation stenting technique.BackgroundDouble-stent techniques may be required for complex bifurcations. Currently applied methods all have their morphological or structural limitations with respect to wall coverage, multiple strut layers, and apposition rate.MethodsSingle string is a novel method in which, first, the side branch (SB) stent is deployed with a single stent cell protruding into the main branch (MB). Second, the MB stent is deployed across this protruding stent cell. The procedure is completed by final kissing balloon dilation. The single string technique was first tested in vitro (n = 20) and next applied in patients (n = 11) with complex bifurcation stenoses.ResultsAll procedures were performed successfully, crossing a single stent cell in 100%. Procedure duration was 23.0 ± 7.9 min, and the fluoroscopy time was 9.4 ± 3.5 min. The results were evaluated by optical coherence tomography, showing fully apposed struts in 83.0 ± 9.2% in the bifurcation area. Residual area obstruction in the MB was 6.4 ± 5.6% and 25.0 ± 16.9% in the SB, as evaluated by micro computed tomography. All the human cases were performed successfully with excellent angiographic results: the residual area stenosis was 27 ± 8% and 29 ± 10% in the MB and in the SB, respectively, by 3-dimensional quantitative coronary angiography. No relevant periprocedural enzyme increase was observed. During follow-up (6 ± 4 months), no adverse clinical events (death, myocardial infarction, target vessel revascularization) were noted.ConclusionsThe single string technique for complex bifurcation dilation was shown to be adequate in vitro and feasible in humans, with favorable results in terms of stent overlap, malapposition rate, and low residual obstruction in both the MB and SB.     

« Paradoxe des fumeurs » et stratégie de reperfusion à la phase aiguë de l’infarctus du myocarde

Previous studies have shown that smokers with acute myocardial infarction (AMI) treated by thrombolysis have lower mortality rates than nonsmokers, a phenomenon often termed “smoker's paradox”. This “smoker's paradox” has been rarely studied in case of primary angioplasty.

Aim of the study

To evaluate the impact of smoking status on the early mortality of patients admitted with AMI with regard to the strategy of reperfusion (intravenous thrombolysis versus primary angioplasty).

Patients and methods

Study undertaken from the Monsatir registry of ST elevation MI including 688 patients having had either a hospital or a prehospital thrombolysis (n = 397) or a primary angioplasty (n = 291). Among those patients, 482 (70.1%) were active smokers.

Results

In the thrombolysis group, the prevalence of hypertension, diabetes and anterior location of MI was significantly less among smokers. In the group primary angioplasty, only diabetes and hypertension were less frequent. The immediate mortality was significantly less among smokers in case of thrombolysis comparatively to non-smokers (5.3 vs 13%; p = 0.008). By multivariate analysis, cardiogenic shock (p < 0.0001), anterior MI (p = 0.03) and active smoking (p = 0.03) were independent predictive factors of mortality in case of thrombolysis. A trend toward a lower mortality among smokers was observed in the primary angioplasty group (10 vs 17.6%; p = 0.07).

Conclusion

“The smoker's paradox” seems to be observed mainly among patients having had thrombolysis.     

T and Small Protrusion (TAP) vs Double-Kissing Crush Technique: Insights From In Vitro Models

BackgroundPercutaneous coronary interventions on complex bifurcation lesions may require implantation of two stents to appropriately treat diffuse side-branch (SB) disease. Comparisons among different bifurcation stenting techniques are continuously attempted by various study designs (bench tests, computer simulations, clinical studies). Among different techniques, double kissing crush (DKC) represents the last evolution for “crushing” while T and small Protrusion (TAP) represents the evolution of “T stenting”. Both techniques are actually gaining popularity, but head-to-head comparisons are lacking.Methods and resultsTwo last generation drug-eluting stents (Synergy™, Boston Scientific, MA, USA and Ultimaster™,Terumo Corp., Japan) were implanted in left main bifurcation bench models using TAP (n = 6 sets) and DKC (n = 6 sets) techniques. A peristaltic pump with fresh porcine blood was used to perfuse the blood through the silicone model at a flow rate of 200 ml/min for 4 min. Optical coherence tomography (OCT) was used to assess stent struts geometry and thrombus formation. SB cross sectional area as well as SB obstruction did not significantly differ between the two techniques. Numerical (but not statistically significant) differences were found in terms of malapposed struts (fewer with TAP) and floating struts (fewer with DKC). Thrombus formation after blood perfusion was similar between TAP and DKC technique (1.53 ± 1.12 vs. 1.20 ± 1.01 mm², p = 0.6).ConclusionThe result of the present in-vitro study shows the absence of significant difference between TAP and DKC in terms of stent struts apposition and acute thrombus formation potential. Despite the completely different technical steps required, both techniques have similar performance according to such articulated pre-clinical evaluation.What is already known about this subject?Due to its limited complexity, T and Protrusion (TAP) technique is considered the to-go technique for bifurcation lesions with good long-term results. Recently, double kissing crush (DKC) technique has been gaining popularity and demonstrated promising results in randomized clinical trials.What does this study add?This in-vitro bench test study provides a unique detailed OCT comparison and local hemodynamic environment analysis of the two techniques.How might this impact on clinical practice?New insights of acute thrombogenicity and computational flow model simulation may guide percutaneous therapeutic strategies of bifurcation lesions.     

Proximal Side-Branch Optimization in Crush Stenting: A Step-by-Step Technical Approach in a Silicone Phantom Model

Provisional single drug-eluting stent (DES) strategy remains the standard of care in simple bifurcation lesions which comprise the vast majority of coronary bifurcations. Nevertheless, the presence of complex bifurcations which are defined based on the 1) Side Branch (SB) lesion length of >10 mm and 2) SB ostial diameter stenosis of >70% are approached with a 2-DES strategy upfront. The bifurcation angle will further define the most appropriate technique, with T-stenting more suitable in angulations close to 90°, Culotte and the family of Crush techniques more appropriate for acute angles of <75°. The Crush techniques which are composed of the classic Crush, mini-Crush and double kissing Crush (DK-Crush) share the core principle of protruding the SB DES within the Main Branch (MB) to minimize the risk of ostial SB restenosis, which remains the most prevalent etiology of stent failure during 2-stent approach in bifurcations. Proximal Side Optimization (PSO) is an additional technical consideration to further optimize the protruding SB struts enabling 1) optimal SB strut accommodation to the larger MB vessel diameter, 2) strut enlargement that will further facilitate effortless rewiring for kissing balloon inflation (KBI) avoiding unfavorable guide wire advancement in the peri-ostial SB area.     

Dénervation rénale dans le traitement de l’hypertension artérielle résistante : expérience du CHU de Lyon

Aim

We report the first experience of Lyon's university hospital regarding renal denervation to treat patients with resistant essential hypertension.

Patients and methods

Over a one-year period, 17 patients were treated (12 men, 5 women) with renal denervation. Baseline characteristics were as follows: age 56.5 ± 11.5 years, BMI 33 ± 5 kg/m² and ambulatory blood pressure 157 ± 16/87 ± 13 mmHg with 4.2 ± 1.5 anti-hypertensive treatment.

Results

We did not observe per procedural and early complications. After a median follow-up of 3 months and with the same anti-hypertensive treatment, office systolic blood pressure (SBP) and diastolic blood pressure (DBP) decrease respectively of 20 ± 15 (P < 0.001) and 10 ± 13 mmHg (P = 0.014) (n = 17). After six months of follow-up, ambulatory blood pressure (ABPM) decrease of 17.5 ± 14.9 mmHg (P = 0.027) for SBP and of 10.5 ± 9.6 mmHg (P = 0.029) for DBP (n = 6). Among these patients, five of them were controlled (ABPM inferior to 130/80 mmHg) and electrical left ventricular hypertrophy indexes decreased: R wave in aVL lead of 4 ± 3 mm (P = 0.031), Sokolow index of 3 ± 3 mm (P = 0.205), Cornell voltage criterion of 9 ± 7 mm (P = 0.027) and Cornell product of 1310 ± 1104 (P = 0.027).

Conclusion

Our results are in accordance with data from other centers. On average blood pressure decreases significantly but important inter individual variations are observed. The procedure seems safe.     

Preintervention angiographic and intravascular ultrasound predictors for side branch compromise after a single-stent crossover technique

A single stent crossover technique is the most common approach to treating bifurcation lesions. In 90 bifurcation lesions with side branch (SB) angiographic diameter stenosis <75%, we assessed preintervention intravascular ultrasound (IVUS; of main branch [MB] and SB) predictors for SB compromise (fractional flow reserve [FFR] <0.80) after a single stent crossover. Minimal lumen area (MLA) was measured within each of 4 segments (MB just distal to the carina, polygon of confluence, MB just proximal to polygon of confluence, and SB ostium). All lesions showed Thrombolysis In Myocardial Infarction grade 3 flow in the SB after MB stenting. Although angiographic diameter stenosis at the SB ostium increased from 26 ± 15% before the procedure to 36 ± 21% after stenting (p = 0.001), FFR <0.80 was observed in only 16 patients (18%). Negative remodeling (remodeling index <1) was seen in 83 (92%) lesions but did not correlate with FFR after stenting. Independent predictors for FFR after stenting were maximal balloon pressure (p = 0.002) and MLA of SB ostium before percutaneous coronary intervention (p <0.001), MLA within the MB just distal to the carina (p = 0.025), and plaque burden at the SB ostium before percutaneous coronary intervention (p = 0.005), but not angiographic poststenting diameter stenosis or minimal lumen diameter. For prediction of FFR <0.80 after percutaneous coronary intervention, the best cutoff of MLA within the SB ostium before percutaneous coronary intervention was 2.4 mm(2) (sensitivity 94%, specificity 69%). Also, the cutoff of plaque burden within the SB ostium before percutaneous coronary intervention was ≥51% (sensitivity 75%, specificity 71%). In 67 lesions with an MLA ≥2.4 mm(2) or plaque burden <50% before percutaneous coronary intervention, 63 (94%) showed FFR ≥0.80. However, FFR <0.80 was seen in only 12 (52%) of 23 lesions with an MLA <2.4 mm(2) and plaque burden ≥50%. In conclusion, there do not appear to be reliable IVUS predictors of functional SB compromise after crossover stenting.     

糖尿病合并分叉病变患者单双支架介入策略的比较

目的 探讨糖尿病合并冠状动脉分叉病变人群采用单双支架策略的预后差异.方法 回顾性研究了入选DK-Crush Ⅰ-Ⅳ系列试验的糖尿病合并冠状动脉真性分叉病变患者211例.其中,单支架策略组(PS组)119例,双支架策略组(DS组)92例,均使用了雷帕霉素洗脱支架.PS组于下述情况以“T”支架术式置入分支支架:(1)分支血管残余狭窄≥50％;(2)TIMI血流小于3级;(3)合并B型以上夹层.DS组采用DK-Crush技术56例(60.9％),“T”型支架置入技术26例(28.3％),Culotte技术置入10例(10.9％).无论DS组抑或PS组在支架置入后均强调完成分支高压后扩张和主、分支最终球囊对吻( FKI).主要研究终点为术后9个月内的主要不良心脏事件(MACE,包括心源性死亡、非致死性心肌梗死、再发心绞痛,再次靶血管重建),次要研究终点为9个月时血管造影主支和分支血管再狭窄.结果 9个月随访期内DS组与PS组的发生MACE分别为12例(13.0％)和14例(11.8％),两组间差异无统计学意义(x2=0.079,P＞0.05).随访血管造影主支再狭窄DS组与PS组分别为10例(10.9％)和12例(10.1％),组间比较无差异统计学意义(x2=0.034,P＞0.05),但分支再狭窄DS组18例(19.6％)显著低于PS组46例(38.7％)x2=8.948,P=0.003.结论 在糖尿病合并冠状动脉分叉病变患者中,单支架策略与双支架策略的9个月随访期的主要不良心脏事件无差异,但双支架策略显著减少了分支再狭窄.