Immediate results of bifurcational stenting assessed with optical coherence tomography

Background : A tubular stent may adapt with difficulty to coronary bifurcation lesions (CBLs). Methods : Time domain or frequency domain (FD) optical coherence tomography (OCT) was performed to assess strut apposition immediately after stent implantation across four segments inside the bifurcation, in a consecutive series of patients. OCT pullbacks were performed in the main vessel (MV). Results : A total of 13,142 struts in 45 CBL in 41 patients were assessed. Strut malapposition was significantly more frequent in the half bifurcation facing the side‐branch (SB) ostium (42.9%) than in the proximal segment of the bifurcation 11.8%, half bifurcation opposite the SB 6.7%, or the distal segment 5.7% (all P < 0.0001). Lesions (n = 15) treated with stenting of both MV and SB had a total higher rate of malapposition than those (n = 30) treated with stenting of the MV only (17.6% vs. 9.5%; P = 0.0014). In latter group, lesions treated with FD‐OCT‐guided stent implantation (n = 13) presented a lower rate of malapposition than those treated with conventional angiographic‐guided stent implantation (n = 17) (7.1% vs. 17.5%; P = 0.005). Conclusions : In CBL, strut malapposition is particularly high at the SB ostium. However, a strategy of stenting MV only with adjunctive FD‐OCT guidance is associated with lower rates of malapposition. © 2012 Wiley Periodicals, Inc.     

Active SB-P Versus Conventional Approach to the Protection of High-Risk Side Branches: The CIT-RESOLVE Trial

ObjectivesThe aim of this study was to determine whether an active side branch protection (SB-P) strategy is superior to the conventional strategy in reducing side branch (SB) occlusion in high-risk bifurcation treatment.BackgroundAccurate prediction of SB occlusion after main vessel stenting followed by the use of specific strategies to prevent occlusion would be beneficial during bifurcation intervention.MethodsEligible patients who had a bifurcation lesions with high risk for occlusion as determined using the validated V-RESOLVE (Visual Estimation for Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention) score were randomized to an active SB-P strategy group (elective 2-stent strategy for large SBs and jailed balloon technique for small SBs) or a conventional strategy group (provisional stenting for large SBs and jailed wire technique for small SBs) in a 1:1 ratio stratified by SB vessel size. The primary endpoint of SB occlusion was defined as an angiography core laboratory–assessed decrease in TIMI (Thrombolysis In Myocardial Infarction) flow grade or absence of flow in the SB immediately after full apposition of the main vessel stent to the vessel wall.ResultsA total of 335 subjects at 16 sites were randomized to the SB-P group (n = 168) and conventional group (n = 167). Patients in the SB-P versus conventional strategy group had a significantly lower rate of SB occlusion (7.7% [13 of 168] vs. 18.0% [30 of 167]; risk difference: –9.1%; 95% confidence interval: −13.1% to −1.8%; p = 0.006), driven mainly by the difference in the small SB subgroup (jailed balloon technique vs. jailed wire technique: 8.1% vs. 18.5%; p = 0.01).ConclusionsAn active SB-P strategy is superior to a conventional strategy in reducing SB occlusion when treating high-risk bifurcation lesions. (Conventional Versus Intentional Strategy in Patients With High Risk Prediction of Side Branch Occlusion in Coronary Bifurcation Intervention [CIT-RESOLVE]; NCT02644434)     

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)     

Novel Insights of Jailed Balloon and Jailed Corsair Technique for Percutaneous Coronary Intervention of Bifurcation Lesions

BackgroundThe optimal technique for percutaneous coronary intervention (PCI) of a bifurcation lesion remains uncertain. JBT/JCT techniques are now emerging for protection of the side branch (SB). We aimed to compare jailed balloon (JBT) and jailed Corsair (JCT) techniques to the conventional jailed wire technique.MethodsWe analyzed 850 consecutive patients (995 bifurcation lesions), who underwent PCI. The bifurcation lesions were classified as jailed wire (?), jailed wire (+), JBT, and JCT. We assessed temporary thrombolysis in myocardial infarction (TIMI) flow grade ≤2, permanent TIMI flow grade ≤2 in the SB, and SB occlusion related myocardial infarction and compared these endpoints with inverse probability treatment weighted analysis.ResultsThe percentage of each group is as follows: jailed wire (?); 44.7%; jailed wire (+) 50.9%; JBT 1.7%; JCT 2.7%. The Corsair could not be delivered with a stent because of severe calcifications (3.7%) and a jailed balloon was entrapped with the stent after dilatation (5.9%). Compared to the jailed wire (+), JBT/JCT had a higher percentage of true bifurcations, arterial sheath size ≥7 Fr, and a lower proportion of wire recrossing (all, P < 0.05). After adjustment, temporary and permanent TIMI flow grade ≤2 in the SB, and SB occlusion related myocardial infarction were not significantly different (OR: 1.08, CI: 0.32–3.71, P = 0.90; OR: 0.88, CI: 0.11–6.91, P = 0.91; OR: 1.94, CI: 0.23–16.5, P = 0.55 respectively).ConclusionsOur data could not prove the efficacy of JBT/JCT, but revealed novel insights about these techniques. A larger study is necessary to prove the efficacy of JBT/JCT.     

Predictors and Periprocedural Myocardial Injury Rate of Small Side Branches Occlusion in Coronary Bifurcation Intervention

Occlusion of small side branch (SB) may result in significant adverse clinical events. We aim to characterize the predictors of small SB occlusion and incidence of periprocedural myocardial injury (PMI) in coronary bifurcation intervention.Nine hundred twenty-five consecutive patients with 949 bifurcation lesions (SB ≤ 2.0 mm) treated with percutaneous coronary intervention (PCI) were studied. All clinical characteristics, coronary angiography findings, PCI procedural factors, and quantitative coronary angiographic analysis data were collected. SB occlusion after main vessel (MV) stenting was defined as no blood flow or any thrombolysis in myocardial infarction (TIMI) flow grade decrease in SB after MV stenting. Multivariate logistic regression analysis was performed to identify independent predictors of small SB occlusion. Creatine kinase-myocardial band activity was determined by using an immunoinhibition assay and confirmed by mass spectrometry. Incidence of PMI between no SB occlusion group and SB occlusion group was compared.SB occlusion occurred in 86 (9.1%) of 949 bifurcation lesions. Of SB occlusion, total occlusion occurred in 64 (74.4%) lesions and a decrease in TIMI flow occurred in 22 (25.6%) lesions. True bifurcation lesion, irregular plaque, predilation in SB, preprocedural SB TIMI flow grade, preprocedural diameter stenosis of distal MV, preprocedural diameter stenosis of bifurcation core, bifurcation angle, diameter ratio between MV and SB, diameter stenosis of SB before MV stenting, and MV lesion length were independent risk factors of SB occlusion. We observed a significantly higher incidence of PMI in each cutoff level in patients with SB occlusion compared with those without SB occlusion.True bifurcation lesion, irregular plaque, and 8 other predictors were independent predictors of SB occlusion. Patients with small SB occlusion had significant higher incidence of PMI.     

A Novel‐Modified Provisional Bifurcation Stenting Technique: Jailed Semi‐Inflated Balloon Technique

Objective

We proposed a new technique for the treatment of coronary bifurcation lesions, called jailed semi‐inflated balloon technique (JSBT).

Background

Currently, provisional approach is recommended to treat most of coronary bifurcation lesions. However, it is associated with the risk of side branch (SB) occlusion after main vessel (MV) stenting due to plaque or carina shift into the SB. The SB occlusion may cause peri‐procedural myonecrosis or hemodynamic compromise. Therefore, strategies are needed to reduce the SB occlusion during provisional approach.

Methods

Between September 2014 and April 2015, we selected 137 patients (104 male, 33 female; mean age 63.6 ± 11.7 years) with 148 distinct coronary bifurcation lesions underwent percutaneous coronary intervention using JSBT. All patients were followed with hospital visits or telephone contact up to 1 month.

Results

The majority of the patients had acute coronary syndrome (64.2%) and Medina 1.1.1. bifurcation lesions (62.8%). The lesion localization was distal left main (LM) coronary artery in 28 patients. After the MV stenting, thrombolysis in myocardial infarction (TIMI) 3 flow was established in 100% of both MV and SB. There was no SB occlusion in any patient. There was no major adverse cardiac event during in‐hospital stay and 1 month follow‐up.

Conclusions

The JSBT technique can be successfully performed in both LM and non‐LM bifurcation lesion. This technique provides high rate of procedural success, excellent SB protection during MV stenting and excellent immediate clinical outcome. (J Interven Cardiol 2015;28:420–429)

     

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 outcomes following bioresorbable scaffold implantation for bifurcation lesions: Overall outcomes and comparison between provisional and planned double stenting strategy

The aim of this study was to investigate clinical outcomes of patients treated with a provisional stenting (PS) versus a double stenting (DS) strategy for coronary bifurcation lesions with bioresorbable scaffolds (BRS). There are limited data available with regards to outcomes following BRS implantation for bifurcation lesions. A total of 132 bifurcation lesions treated with BRS between 2012 and 2014 were analyzed. Of the total of 132 bifurcation lesions, 10 lesions were treated without crossover stenting. 99 lesions (81%) were treated with a PS strategy and 23 lesions (19%) with a DS strategy. The DS group consisted of patients with a greater number of true bifurcation lesions (PS 52.0% vs. DS 91.3%: P < 0.001). In the PS group, seven lesions (7.1%) were crossed‐over to T‐stenting. In the DS group, 13 lesions (57%) were treated with BRS to the side branch (SB). A hybrid stenting technique [BRS to the main branch, and metallic drug‐eluting stent (DES) to the SB] was utilized in 10 (43%) lesions. Target lesion revascularization (TLR) rates were 5.5% for PS and 11.2% for DS (P = 0.49) at 1‐year follow‐up. Definite scaffold thrombosis did not occur at the site of any bifurcation lesion. These findings suggest that BRS implantation for bifurcation lesions is technically feasible. The rates of TLR tended to be higher in the DS group compared to when a PS strategy was employed. Larger studies are eagerly awaited to determine longer‐term follow‐up of this treatment strategy. © 2015 Wiley Periodicals, Inc.     

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.     

A modified provisional stenting approach to coronary bifurcation lesions: clinical application of the "jailed-balloon technique"

Objectives: To demonstrate the application of a novel provisional side branch (SB) stenting strategy for coronary bifurcation lesions using a “jailed‐balloon” technique (JBT). Background: Adverse cardiac events are higher for percutaneous coronary intervention (PCI) of bifurcation lesions. Recent studies support the use of provisional SB stenting, but a risk of SB closure and a higher rate of target lesion revascularization (TLR) remain important limitations. Methods: From December 2007 to August 2010, 100 patients with 102 bifurcation lesions underwent PCI using the JBT. Baseline and postprocedural quantitative coronary angiography (QCA) analysis were performed. Procedural and immediate clinical outcomes were reviewed. Results: The majority of patients presented with acute coronary syndrome (68%) and had Medina class 1,1,1 bifurcation lesions (91%). TIMI 3 flow was established in 100% of main branch and 99% of SB lesions. QCA revealed preservation of the bifurcation angle after PCI (pre‐PCI: 59.6 ± 30.0; post‐PCI: 63.3 ± 26.8, P = 0.41). Nine patients (9%) had lesions that required rewiring and two patients (2%) required provisional stenting of the SB. SB loss occurred in one patient (1%). The jailed‐balloon or wire was not entrapped during any PCI. One patient (1%) suffered a periprocedural myocardial infarction (MI). Conclusions: Provisional stenting of complex coronary bifurcation lesions using a JBT is associated with a high procedural success rate, improved SB patency, and a low rate of immediate cardiac events. Further study is warranted to evaluate the role of JBT in improving long‐term clinical outcomes in PCI of complex bifurcation lesions. (J Interven Cardiol 2012;25:289–296)     

Optical coherence tomography-derived predictors of stent expansion in calcified lesions

Background

Severe coronary artery calcification is associated with stent underexpansion and subsequent stent failure.

Aims

We aimed to identify optical coherence tomography (OCT)-derived predictors of absolute (minimal stent area [MSA]) and relative stent expansion in calcified lesions.

Methods

This retrospective cohort study included patients who underwent percutaneous coronary intervention (PCI) with OCT assessment before and after stent implantation between May 2008 and April 2022. Pre-PCI OCT was used to assess calcium burden and post-PCI OCT was used to assess absolute and relative stent expansion.

Results

A total of 361 lesions in 336 patients were analyzed. Target lesion calcification (defined as OCT-detected maximum calcium angle ≥ 30°) was present in 242 (67.0%) lesions. Following PCI, median MSA was 5.37 mm² in calcified lesions and 6.24 mm² in noncalcified lesions (p < 0.001). Median stent expansion was 78% in calcified lesions and 83% in noncalcified lesions (p = 0.325). In the subset of calcified lesions, average stent diameter, preprocedural minimal lumen area, and total calcium length were independent predictors of MSA in multivariable analysis (mean difference 2.69 mm²/mm², 0.52 mm²/mm, and −0.28 mm²/5 mm, respectively, all p < 0.001). Total stent length was the only independent predictor of relative stent expansion (mean difference −0.465% per mm, p < 0.001). Calcium angle, thickness, and the presence of nodular calcification were not significantly associated with MSA or stent expansion in multivariable analyses.

Conclusion

Calcium length appeared to be the most important OCT-derived predictor of MSA, whereas stent expansion was mainly determined by total stent length.     

Comparative Analysis of Sequential Proximal Optimizing Technique Versus Kissing Balloon Inflation Technique in Provisional Bifurcation Stenting: Fractal Coronary Bifurcation Bench Test

ObjectivesThis study used a fractal bifurcation bench model to compare 6 optimization sequences for coronary bifurcation provisional stenting, including 1 novel sequence without kissing balloon inflation (KBI), comprising initial proximal optimizing technique (POT) + side-branch inflation (SBI) + final POT, called “re-POT.”BackgroundIn provisional bifurcation stenting, KBI fails to improve the rate of major adverse cardiac events. Proximal geometric deformation increases the rate of in-stent restenosis and target lesion revascularization.MethodsA bifurcation bench model was used to compare KBI alone, KBI after POT, KBI with asymmetric inflation pressure after POT, and 2 sequences without KBI: initial POT plus SBI, and initial POT plus SBI with final POT (called “re-POT”). For each protocol, 5 stents were tested using 2 different drug-eluting stent designs: that is, a total of 60 tests.ResultsCompared with the classic KBI-only sequence and those associating POT with modified KBI, the re-POT sequence gave significantly (p < 0.05) better geometric results: it reduced SB ostium stent-strut obstruction from 23.2 ± 6.0% to 5.6 ± 8.3%, provided perfect proximal stent apposition with almost perfect circularity (ellipticity index reduced from 1.23 ± 0.02 to 1.04 ± 0.01), reduced proximal area overstretch from 24.2 ± 7.6% to 8.0 ± 0.4%, and reduced global strut malapposition from 40 ± 6.2% to 2.6 ± 1.4%.ConclusionsIn comparison with 5 other techniques, the re-POT sequence significantly optimized the final result of provisional coronary bifurcation stenting, maintaining circular geometry while significantly reducing SB ostium strut obstruction and global strut malapposition. These experimental findings confirm that provisional stenting may be optimized more effectively without KBI using re-POT.     

True caring is protecting who is at your side

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

     

Atrial coronary artery occlusion during elective percutaneous coronary angioplasty

BackgroundAtrial arteries arise from the right and left circumflex coronary arteries and they may be accidentally occluded during percutaneous coronary angioplasty; however, this complication is not well known. The aim of our study was to analyze the incidence and risk factors of accidental atrial branch occlusion (ABO) during elective angioplasty.Methods and MaterialsClinical records and coronary angiography of 200 patients undergoing elective angioplasty were retrospectively analyzed. Atrial branches were identified and in each vessel we measured the luminal diameter, flow grade, and the location of atherosclerotic plaques. Patients were allocated either into the ABO group if atrial branch flow fell from TIMI grades 2–3 to 0–1 after procedure or in the non-ABO group if TIMI flow was preserved.ResultsAtrial branch occlusion occurred in 43 (21.5%) patients. The atrial branch diameter was larger in non-ABO than in ABO group (1.29 mm, SD 0.33 versus 0.97 mm, SD 0.22, p = < 0.0001). Plaques at atrial branch origin were present in 93% of ABO group, only in 31.8% of non-ABO (p ≤ 0.0001). Predictors of ABO were a cut-off vessel diameter of 1.00 mm (ROC 77% sensitivity and 67.5% specificity, p ≤ 0.0001), the presence of atherosclerotic plaque at the ostium of atrial branch and maximal inflation pressure during stenting.ConclusionsThe occurrence of ABO is frequent after elective angioplasty of right or circumflex coronary arteries in an experienced interventional center. Risk factors were the diameter and the presence of ostial plaques in the atrial branches, and the maximal inflation pressure during stenting.     

Differences in Culprit Lesions Between Premenopausal and Postmenopausal Women With Acute Coronary Syndrome: An Optical Coherence Tomography Study

BackgroundDifferences in culprit lesion characteristics remain unclear between premenopausal and postmenopausal women with acute coronary syndrome (ACS). Optical coherence tomography (OCT) enables high-resolution in vivo identification of plaques. We investigated potential differences in culprit lesions between premenopausal and postmenopausal women with ACS by means of OCT.MethodsWe included 191 ACS patients who had undergone preinterventional OCT and stratified them into 2 groups according to their menopausal status: premenopausal (n = 97) and postmenopausal (n = 94). The characteristics of culprit lesions were compared between the 2 groups.ResultsMultivessel lesions were more commonly noted on angiography in the postmenopausal group than in the premenopausal group (40.21% vs 72.34%; P < 0.0001). On OCT, the most common type of culprit plaque was the fibrous plaque in the premenopausal group and the lipid plaque in the postmenopausal group. Compared with the premenopausal group, plaque rupture was more common in the postmenopausal group (39.18% vs 55.32%; P = 0.0254); culprit lesions had more vulnerable features, including macrophage accumulation (58.76% vs 87.23%; P < 0.0001), microchannel (38.14% vs 84.04%; P < 0.0001), cholesterol crystals (30.93% vs 62.77%; P < 0.0001), lipid-rich plaque (32.99% vs 58.51%; P < 0.0001), thin-cap fibroatheroma (3.09% vs 21.28%; P = 0.0001), and calcium (20.62% vs 44.68%; P = 0.0004); maximum lipid arc was larger (121.06 ± 110.99° vs 220.12 ± 115.47°, P < 0.0001); and lipid length was longer (5.78 ± 5.29 mm vs 12.90 ± 8.97 mm; P < 0.0001).ConclusionsCompared with premenopausal women with ACS, postmenopausal women with ACS had more vulnerable culprit lesions. These finding suggest potential optimised lipid-lowering therapy for postmenopausal women with ACS.     

Difference of neointimal growth patterns in bifurcation lesions among four kinds of drug‐eluting stents

Aim: Neointimal proliferation of bifurcation lesions after implantation of drug‐eluting stents (DES) has not been well evaluated. Thus, we compared neointimal proliferation of bifurcation lesions among four DES using optical coherence tomography (OCT). Methods: 8‐month follow‐up OCT was performed in 68 bifurcation lesions treated by 15 sirolimus‐eluting stents (SES) and 17 paclitaxel‐eluting stents (PES) as first‐generation DES, and by 17 zotarolimus‐eluting stents (ZES) and 19 everolimus‐eluting stents (EES) as second‐generation DES. Cross‐sectional images of the bifurcation lesion using OCT were analyzed every 450 µm. All images were divided into three areas: inner wall of the bifurcation (IB), outer wall of the bifurcation (OB), and ostium of the side branch (SB). We compared the incidence of uncovered struts (IUS) among three areas and the averaged neointimal thickness (NIH) between IB and OB in each stent and also compared these OCT parameters among all DES. Results: There were no significant differences of IUS between IB and OB in second‐generation DES, while in first‐generation DES, IUS of IB and OB showed significant differences. The IUS of SES in both areas was significantly higher than in the other DES (all P < 0.001). PES had a significantly higher IUS in SB than the others (all P < 0.001). NIH of OB was significantly higher than that of IB in PES, ZES, and EES, but in SES the NIH was similar in the two areas. Conclusions: OCT revealed different neointimal growth patterns among SES, PES, ZES, and EES in bifurcation lesions. © 2014 Wiley Periodicals, Inc.     

Prospective evaluation of myocardial ischemia related to post‐procedural side‐branch stenosis in bifurcated lesions treated by provisional approach with drug‐eluting stents

Objectives : To prospectively assess the impact of post‐procedural side‐branch (SB) stenosis on inducible myocardial ischemia in patients with bifurcated lesions undergoing percutaneous interventions. Background : Provisional‐stenting with drug‐eluting stents (DES) is the recommended strategy to treat percutaneously bifurcated lesions but is associated to variable degrees of residual SB stenosis. The role of SB residual stenosis on post‐procedural myocardial ischemia is uncertain. Methods : Patients with bifurcations treated by DES according to provisional‐stenting technique were enrolled in the study if they had no other untreated lesion. Patients were divided into two groups according to post‐procedural 3D‐quantitative coronary analysis (3DQCA): group OR (optimal result: stenosis < 50% of SB lumen area at 3DQCA) and group SR, suboptimal result: (stenosis ≥ 50% of SB lumen area at 3DQCA). Treadmill exercise stress test (EST) was performed within 1 week from PCI. The primary study endpoint was myocardial ischemia (≥1 mm ST‐segment depression at EST). Results : Sixty patients were enrolled: 49 (81.7%) comprised group OR and 11 (18.3%) group SR. Post‐PCI myocardial ischemia at EST was inducible in 17 (34.7%) patients of group OR versus 10 (90.9%) patients of group SR (P = 0.0007). During the follow‐up, patients of Group SR (vs. Group OR) had a significantly higher occurrence of inducible myocardial ischemia during late (>8 weeks) stress tests (P < 0.001). Conclusions : In patients with bifurcated lesions treated by a provisional‐stenting technique, residual SB stenosis ≥ 50% at 3DQCA is associated with post‐procedural inducible myocardial ischemia at EST. © 2011 Wiley Periodicals, Inc.     

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.     

Predictors of Rapid Plaque Progression: An Optical Coherence Tomography Study

ObjectivesThis study sought to identify morphological predictors of rapid plaque progression.BackgroundTwo patterns of plaque progression have been described: slow linear progression and rapid step-wise progression. The former pattern will cause stable angina when the narrowing reaches a critical threshold, whereas the latter pattern may lead to acute coronary syndromes or sudden cardiac death.MethodsPatients who underwent optical coherence tomography (OCT) imaging during the index procedure and follow-up angiography with a minimum interval of 6 months were selected. Nonculprit lesions with a diameter stenosis of ≥30% on index angiography were assessed. Lesion progression was defined as a decrease of angiographic minimum lumen diameter ≥0.4 mm at follow-up (mean, 7.1 months). Baseline morphological characteristics of plaques with rapid progression were evaluated by OCT. In a subgroup with follow-up OCT imaging for plaques with rapid progression, morphological changes from baseline to follow-up were assessed.ResultsAmong 517 lesions in 248 patients, 50 lesions showed rapid progression. These lesions had a significantly higher prevalence of lipid-rich plaque (76.0% vs. 50.5%, respectively), thin-cap fibroatheroma (TCFA) (20.0% vs. 5.8%, respectively), layered plaque (60.0% vs. 34.0%, respectively), macrophage accumulation (62.0% vs. 42.4%, respectively), microvessel (46.0% vs. 29.1%, respectively), plaque rupture (12.0% vs. 4.7%, respectively), and thrombus (6.0% vs. 1.1%, respectively) at baseline compared with those without rapid progression. Multivariate analysis identified lipid-rich plaque (odds ratio [OR]: 2.17; 95% confidence interval [CI]: 1.02 to 4.62; p = 0.045]), TCFA (OR: 5.85; 95% CI: 2.01 to 17.03; p = 0.001), and layered plaque (OR: 2.19; 95% CI: 1.03 to 4.17; p = 0.040) as predictors of subsequent rapid lesion progression. In a subgroup analysis for plaques with rapid progression, a new layer was detected in 25 of 41 plaques (61.0%) at follow-up.ConclusionsLipid-rich plaques, TCFA, and layered plaques were predictors of subsequent rapid plaque progression. A new layer, a signature of previous plaque disruption and healing, was detected in more than half of the lesions with rapid progression at follow-up. (Massachusetts General Hospital Optical Coherence Tomography Registry; NCT01110538)     

Predictors of provisional stenting in patients undergoing lower extremity arterial interventions

Predictors of provisional stenting in patients undergoing lower extremity arterial interventions remain unclear. We performed an ad hoc analysis on the predictors of provisional stenting during infrainguinal arterial percutaneous interventions using data from the Percutaneous Lower Extremity Arterial Interventions Using Primary Balloon Angioplasty versus Silverhawk Atherectomy (SA) and Adjunctive Balloon Angioplasty trial. In the above trial, SA of infrainguinal de novo arterial lesions was shown to reduce significantly provisional stenting compared with primary percutaneous transluminal angioplasty (PTA). In this ad hoc analysis, patients were divided into two groups based on whether provisional stenting has occurred. Univariate analysis was conducted between the stent versus the no-stent group. Logistic regression (LR) analysis was performed to model for the predictors of provisional stenting. Variables included were diabetes, presence of moderate calcification (versus none to little), age, gender, hypercholesterolemia, Transatlantic Intersociety Consensus (TASC) D lesion (vs. TASC A to C), and treatment method (primary PTA vs. SA with adjunctive PTA). By LR analysis, predictors of stenting were as follows: moderate calcification (odds ratio [OR] 6.56, 95% confidence interval [CI] 1.21 to 35.56, p = 0.029), primary PTA (vs. SA) (OR 0.19, 95% CI 0.04 to 0.93, p = 0.04), and TASC D lesions (vs. A to C) (OR 0.10, 95% CI 0.01 to 0.87, p = 0.037). Provisional stenting in infrainguinal interventions is predicted by the use of primary PTA, presence of moderate calcification, and TASC D lesions after controlling for gender, age, hypercholesterolemia, and diabetes.