Distribution and Magnitude of Shear Stress after Coronary Bifurcation Lesions Stenting with the Classical Crush Technique: A New Predictor for In‐Stent Restenosis

Background: Wall shear stress (SS) plays an important role in the initiation and proliferation of coronary atherosclerosis, especially for bifurcations. Stenting in the coronary artery will cause many different changes in velocity, flow, cross‐sectional area, and especially the wall SS. However, it is still unknown how much wall SS distribution varies with stenting in coronary bifurcation. Objective: The purpose of this study was to investigate the magnitude and distribution of wall SS after the classical crush stenting for bifurcation lesions. Methods: Eleven patients with true coronary bifurcation stenting by the classical crush technique were included. We studied the difference of wall SS between restenosis and nonrestenosis groups in these patients. The differences in SS between preprocedure and postprocedure, as well as between immediately postprocedure and after an 8‐month follow‐up, were also analyzed. Diameter stenosis or minimal lumen diameter were measured by quantitative coronary analysis. The commercial CD STAR‐CCM+ was used to calculate the SS. Results: At baseline, the SS in all the segments of all patients was high. The baseline SS of the restenosis group was 50% lower than the nonrestenosis group. Immediately after percutaneous coronary intervention (PCI), the SS in both areas decreased; however, the SS of the nonrestenosis group decreased to its lowest level possible while the SS of the restenosis group decreased moderately. Eight months later, the SS of all the segments of the nonrestenosis group remained persistently low at the same level of right after PCI. In contrary, the SS in the restenosis group returned to near its baseline level. Conclusion: From our study, after a 2‐stent crush technique using drug‐eluting stents (DES), the degree of SS reduction appears to predict in‐stent restenosis (ISR). A SS decrease to its lowest level and remaining homogenously low is a prime condition to prevent ISR. A baseline low SS, which decreases minimally after PCI and recovers to around its baseline level, appears to be the setting for restenosis. These conditions can be evaluated as predictors of lesions that may need surveillance angiography and proper IVUS evaluation to prevent future in‐stent restenosis. (J Interven Cardiol 2010;23:330–340)     

3-Year Outcomes After 2-Stent With Provisional Stenting for Complex Bifurcation Lesions Defined by DEFINITION Criteria

BackgroundThe multicenter and randomized DEFINITION II (Two-Stent vs Provisional Stenting Techniques for Patients With Complex Coronary Bifurcation Lesions) trial showed less 1-year target lesion failure (TLF) after a 2-stent approach for complex coronary bifurcation lesions compared with provisional stenting (PS). The authors report the 3-year clinical outcome of the DEFINITION II trial.ObjectivesThe aim of the present study was to investigate the difference in TLF at 3 years after a planned 2-stent approach vs PS for complex coronary bifurcation lesions stratified by DEFINITION (Definitions and Impact of Complex Bifurcation Lesions on Clinical Outcomes After Percutaneous Coronary Intervention Using Drug-Eluting Stents) criteria.MethodsA total of 653 patients with complex coronary bifurcation lesions were randomly assigned to either the 2-stent group or the PS group in the DEFINITION II trial and were followed for 3 years. The primary endpoint was the occurrence of TLF at 3 years. Stent thrombosis was the safety endpoint.ResultsAt 3 years, TLF had occurred in 52 patients (16.0%) in the PS group and in 34 (10.4%) patients in the 2-stent group (HR: 0.63; 95% CI: 0.41-0.97; P = 0.035), driven mainly by increased target vessel myocardial infarction (8.0% vs 3.7%; HR: 0.45; 95% CI: 0.23-0.89; P = 0.022) and target lesion revascularization (8.3% vs 4.3%; HR: 0.50; 95% CI: 0.26-0.96; P = 0.038). There was no difference in TLF between the 2 groups between year 1 and year 3.ConclusionsFor patients with complex coronary bifurcations who reach 1-year postprocedure without experiencing endpoint events, there is still a risk for future events. The type of procedure performed initially is no longer a future event risk determinant. (Two-Stent vs Provisional Stenting Techniques for Patients With Complex Coronary Bifurcation Lesions; NCT02284750)     

The Relation Between Optical Coherence Tomography-Detected Layered Pattern and Acute Side Branch Occlusion after Provisional Stenting of Coronary Bifurcation Lesions

Background/purposeLayered pattern (presumed to be healed plaque after a thrombotic event) can be observed by optical coherence tomography (OCT). We sought to assess the ability of OCT-detected plaque composition to predict acute side branch (SB) occlusion after provisional bifurcation stenting.MethodsThis is a retrospective observational study using pre-intervention OCT in the main vessel to predict Thrombolysis in Myocardial Infarction (TIMI) flow grade ≤1 in a SB (diameter ≥ 1.5 mm) after provisional bifurcation stenting. OCT-detected layered pattern was defined as plaque with a superficial layer that had a different optical intensity and a clear demarcation from underlying tissue.ResultsOverall, 207 patients with stable coronary disease were included. SB occlusion occurred in 26/207 (12.6%) bifurcation lesions. Operators decided not to perform additional treatment, and TIMI flow did not improve to ≥2 in cases with SB occlusion. The prevalence of OCT-detected layered pattern was more common in lesions with versus without SB occlusion (88.5% versus 33.7%, p < 0.0001); OCT-detected layered pattern was more often located on the same side of the SB (73.9% versus 21.3%, p < 0.0001) circumferentially compared to lesions without SB occlusion. Multivariable analysis showed that OCT-detected layered pattern was an independent predictor of SB occlusion (odds ratio 18.8, 95% confidence interval 5.1–68.8, p < 0.0001) along with true bifurcation lesion and wider angiographic bifurcation angle.ConclusionsThe presence of an OCT-detected layered pattern near its ostium was a strong predictor of SB occlusion after provisional bifurcation stenting.     

3-Year Outcomes of the DKCRUSH-V Trial Comparing DK Crush With Provisional Stenting for Left Main Bifurcation Lesions

ObjectivesThe present study aimed to investigate the difference in target lesion failure (TLF) at 3 years after double kissing (DK) crush stenting versus provisional stenting (PS) for unprotected left main distal bifurcation (UPLMb) lesions.BackgroundThe multicenter and randomized DKCRUSH-V (Double Kissing Crush versus Provisional Stenting for Left Main Distal Bifurcation Lesions: The DKCRUSH-V Randomized Trial) study showed fewer 1-year TLF after DK crush for UPLMb lesions compared with PS. The study reports the 3-year clinical outcome of the DKCRUSH-V study.MethodsA total of 482 patients with UPLMb lesions who were randomly assigned to either the DK crush group (DK group) or PS group in the DKCRUSH-V study were followed for 3 years. The primary endpoint was the occurrence of a TLF at 3 years. Stent thrombosis (ST) was the safety endpoint. Patients were classified by lesion’s complexity and NERS (New Risk Stratification) II or SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) score.ResultsAt 3 years, TLF occurred in 41 (16.9%) patients in the PS group and in 20 (8.3%) patients in the DK group (p = 0.005), mainly driven by increased target vessel myocardial infarction (5.8% vs. 1.7%; p = 0.017) and target lesion revascularization (10.3% vs. 5.0%; p = 0.029). Definite or probable ST rate at 3 years was 4.1% in the PS group and 0.4% in the DK group (p = 0.006). Notably, DK crush was associated with a significant reduction in both primary and secondary endpoints for patients with complex lesions or at high risk.ConclusionsProvisional stenting for UPLMb lesions was associated with significantly increased rates of TLF and ST over 3 years of follow-up. Further randomized study is warranted to confirm the benefits of DK crush stenting for complex UPLMb lesions. (Double Kissing and Double Crush versus Provisional T Stenting Technique for the Treatment of Unprotected Distal Left Main True Bifurcation Lesions: A Randomized, International, Multi-center Clinical Trial; ChiCTR-TRC-11001213).     

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)     

双对吻挤压技术治疗分叉病变

即使在今天药物洗脱支架时代,介入治疗冠状动脉分叉病变依然是极具挑战性的,主要表现为再狭窄率高,随访期内主要心脏不良事件发生率较高.从金属裸支架开始的多项临床就已经证实双支架术式并不比单支架术优异,主要原因在于分支血管开口的再狭窄率没有得到有效的降低.但是,位于特殊部位的分叉病变必须使用双支架术,这就促使开展双支架术的深入研究.在回顾不同双支架术的基础上,详细介绍了改良后的双对吻挤压技术及特殊类型分叉病变专用支架.     

Meta-Analysis of Provisional Versus Systematic Double-Stenting Strategy for Left Main Bifurcation Lesions

ObjectiveWe sought to compare the clinical outcomes with provisional versus double-stenting strategy for left main (LM) bifurcation percutaneous coronary intervention (PCI).BackgroundDespite two recent randomized controlled trials (RCTs) and several observational reports, the optimal LM bifurcation PCI technique remains controversial.MethodsPubMed, Cochrane Central Register of Controlled-Trials (CENTRAL), Clinicaltrials.gov, International Clinical Trial Registry Platform were leveraged for studies comparing PCI bifurcation techniques for LM coronary lesions using second-generation drug eluting stents (DES). The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), target vessel or lesion revascularization, and stent thrombosis.ResultsTwo RCTs and 10 observational studies with 7105 patients were included. Median follow-up duration was 42 months (IQR: 25.7). Double stenting was associated with a trend towards higher incidence of MACE (odds ratio [OR] 1.20; 95 % confidence interval [CI] 0.94 to 1.53) compared with provisional stenting. This was mainly driven by higher rates of target lesion revascularization (TLR) (OR 1.50; 95 % CI 1.07 to 2.11). There were no statistically significant differences in the incidence of all-cause mortality, cardiovascular mortality, MI, or stent thrombosis. On subgroup analysis according to the study type, provisional stenting was associated with lower MACE and TLR in observational studies, but not in RCTs.ConclusionFor LM bifurcation PCI using second-generation DES, a provisional stenting strategy was associated with a trend towards lower incidence of MACE driven by statistically significant lower rates of TLR, compared with systematic double stenting. These differences were primarily driven by observational studies. Further RCTs are warranted to confirm these findings.     

Twenty-Four-Month Update on Double-Kissing Crush Stenting of Bifurcation Lesions

A group of 312 patients who underwent percutaneous coronary intervention for bifurcation lesions at 12 centers in China, Singapore, Thailand, Israel, India, and Japan were enrolled in a prospective, randomized DKCRUSH-1 trial. The goal of the study was to compare the double kissing (DK) crush technique with the classical crush stenting technique. This study was carried out to determine the differences in the rates of final kissing balloon inflations (FKBI) and the long-term clinical outcomes. The 8-month results of the DKCRUSH-1 study have been previously reported. Here, we present several subgroups analysis and a 24-month clinical update. The results confirmed a sustained, lower MACE rate at 24 months with the double kissing (DK) crush stenting technique compared with that for the classical crush stenting technique (18.1% vs. 29.9%, p = 0.044).     

E-选择素介导的炎症反应与冠状动脉内支架术后再狭窄

再狭窄是限制冠状动脉内支架术远期成功的重要因素。它是一个由内皮损伤触发的多种因子参与的损伤修复过程,主要包括：机械损伤内皮处非阻塞性血栓形成、新生内膜增生及血管重构等反应。E-选择素仅表达于活化的内皮细胞表面,主要作用是在炎症发生时介导白细胞与血管内皮细胞的起始黏附,以及介导白细胞之间、白细胞与血小板之间的黏附形成血栓,从而对支架置入后损伤的内膜增生过程产生影响。E-选择素的研究对揭示再狭窄发生机制及寻找新的治疗途径均具有重要意义。     

Ventricular Septal Defect Pulmonary Atresia: Provisional Bifurcation Strategy for Confluence Stenosis During Patent Ductus Arteriosis Stenting

Neonates with pulmonary atresia survive only if duct patency is maintained before staged surgical repair. Ductal stenting is an effective alternative to conventional shunt surgery, as it avoids thoracotomy. With today's generation of coronary stents having better profile, flexibility, and trackability, it may be achieved safely, with less difficulty than previously described. The strategy during patent ductus arteriosus (PDA) stenting with trifurcation narrowing is a real challenge. We present an underweight newborn with ventricular septal defect pulmonary atresia, restrictive PDA, and bilateral branch stenosis at the ostia. We performed a successful PDA stenting as well as addressed the ostia of branch pulmonary arteries.     

Impact of Diabetes Mellitus on Intravascular Ultrasound‐Guided Provisional Stenting in Coronary Bifurcation Lesions J‐REVERSE Sub‐Study

Objective

To investigate the impact of diabetes mellitus (DM) on provisional coronary bifurcation stenting under the complete guidance of intravascular‐ultrasound (IVUS).

Background

The efficacy of such intervention has not yet been fully elucidated in the DM patients.

Methods

A total of 100 DM and 139 non‐DM patients in a prospective multi‐center registry of IVUS‐guided bifurcation stenting were compared in angiographic results at 9 months. Vessel and luminal changes during the intervention were analyzed using the IVUS. Vascular healing at the follow‐up was also investigated in 23 lesions in each group using optical coherence tomography (OCT).

Results

No difference was detected regarding baseline reference vessel diameter and minimum lumen diameter in proximal main vessel (MV), distal MV, and side branch (SB). The rate of everolimus‐eluting stent use (78.4% vs. 78.3%), final kissing inflation (60.1% vs. 49.0%), and conversion to 2‐stent strategy (2.9% vs. 2.8%) were also similar. In the DM group, late loss was greater in proximal MV (DM 0.23 ± 0.29 vs. non‐DM 0.16 ± 0.24 mm, P < 0.05) and SB (0.04 ± 0.49 vs. ?0.08 ± 0.35 mm, P < 0.05). Smaller vessel area restricted stent expansion in the proximal MV (6.18 ± 1.67 vs. 6.72 ± 2.07 mm², P < 0.05). More inhomogeneous neointimal coverage (unevenness score, 1.90 ± 0.33 vs. 1.72 ± 0.29, P < 0.05) and more frequent thrombus attachment (26% vs. 4%, P < 0.05) were documented in the proximal MV at 9‐month follow‐up OCT.

Conclusions

Despite IVUS optimization for coronary bifurcation, DM is potentially associated with smaller luminal gain, higher late‐loss, and inhomogeneous vascular healing with frequent thrombus attachment in the proximal MV.

     

Multivariate Analysis of Clinical Factors in Restenosis after Coronary Stenting

Ojbective To find the independent predictors for restenosis after coronary stenting. Methods Quantitative angiography was performed on 60 cases (67 successfully dilated lesions) after angio-plasty over 6-months follow-up, and both univariate and multivariate logistic regression analysis were done to i-dentify the correlations of restenosis with clinical factors. Results The total restenosis rate was 31. 3% (21 of 67 lesions), and according to univariate analysis the patients who underwent coronary stenting≥ 3. 5mm had a lower rate of restenosis ( P < 0. 01). Collateral circulation to the obstruction site, high maximal inflation pressure, smoking and the less minimal lumen diameter after PTCA made the rate of restenosis higherower ( P < 0. 05) . Multivariate logistic regression analysis showed that coronary stenting ≥3. 5mm had a low rate of restenosis, but high maximal inflation pressure and smoking made the restenosis rate higher. Conclusion Coronary stent size, maximal inflation pressure and. smokin