分叉专用支架的进展

分叉病变的介入治疗具有很大的挑战性,分叉专用支架是为克服常规的分叉病变介入治疗的局限性而设计。大多数分叉专用支架的目的就是易于在必要时置入边支支架。这是一种令人激动的全新技术,可能使复杂的分叉病变治疗简单化。目前有11种分叉专用支架完成或正在进行人体试验。随着更多的药物释放支架平台和更大规模的对照试验出现,在不久的将来成为正式的治疗方法前其真正的临床价值、有效性和安全性会得到充分证明。     

Polymer-Free Biolimus-Eluting Stents or Polymer-Based Zotarolimus-Eluting Stents for Coronary Bifurcation Lesions

BackgroundA polymer-free biolimus-eluting stent (PF-BES) and a zotarolimus-eluting stent (ZES) recently showed similar clinical profiles and appear to be competing options in specific clinical settings of patients undergoing percutaneous coronary intervention (PCI). Whether they perform similarly also in complex procedural settings as coronary bifurcation lesions remains unaddressed.MethodsAll consecutive patients undergoing coronary bifurcation PCI with PF-BES or the new iteration of the ZES from three large multicenter real-world registries were included. The primary outcome was major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), target lesion revascularization (TLR) and stent thrombosis (ST). Multiple analyses to adjust for baseline differences were carried out including propensity-score matching, propensity-score stratification and inverse-probability-weighting. Outcomes are reported according to Cox proportional hazard models censored at 400-day follow-up.Results1169 patients treated with PF-BES (n = 440) or ZES (n = 729) on the main branch of a coronary bifurcation lesion were included (mean age 69 ± 11 years, 75.4% male, 53.8% acute coronary syndrome at presentation, 26.6% left main bifurcation, median dual antiplatelet therapy duration 12 [range 12–12] months). MACE, all-cause death, TLR and ST tended towards non-statistically higher rates with the PF-BES as compared to the ZES. Higher MI and target vessel revascularization occurrence was observed with PF-BES.ConclusionsIn this large contemporary cohort of patients undergoing coronary bifurcation PCI, the occurrence of MACE was non-statistically different with the use of PF-BES and ZES devices. However, differences favoring the ZES device that may entail clinical relevance were observed. Further studies are needed to confirm these findings and explore whether they remain valid when a short dual antiplatelet therapy is adopted.     

An Update to Hepatobiliary Stents

Endoscopic stent placement is a common primary management therapy for benign and malignant biliary strictures. However, continuous use of stents is limited by occlusion and migration. Stent technology has evolved significantly over the past two decades to reduce these problems. The purpose of this article is to review current guidelines in managing malignant and benign biliary obstructions, current endoscopic techniques for stent placement, and emerging stent technology. What began as a simple plastic stent technology has evolved significantly to include uncovered, partially covered, and fully covered self-expanding metal stents (SEMS) as well as magnetic, bioabsorbable, drug-eluting, and antireflux stents.¹     

国产雷帕霉素洗脱支架应用于冠状动脉分叉病变的效果评价

目的 评价冠状动脉分叉病变与非分叉病变支架植入术后预后是否存在差别.方法 回顾性分析1877例冠心病患者,其中568例冠状动脉分叉病变患者,1309例冠状动脉非分又病变患者.植入Excel支架.术后6、12及18个月临床随访两组主要不良心脏事件发生率的情况.结果 术后6、12及18个月两组死亡(心性和非心性)、非致死性心肌梗死及主要不良心脏事件的发生率均无差剐(P＞0.05),6及12个月两组靶病变血运重建的发生率无差别(P＞0.05),18个月两组靶病变血运重建的发生率存在差别(P＜0.05).结论 Excel支架治疗冠状动脉分叉病变具有安全性和可靠性.     

Update on Provisional Technique for Bifurcation Interventions

A series of scientific evidence supports the concept that provisional side-branch stenting should be the preferred strategy for percutaneous coronary intervention of bifurcation coronary lesions. However, to date, many interventional cardiologists still consider this technique unsuitable for complex bifurcation lesions. This is mainly due to the fact that provisional stenting may be performed in different ways and several technical refinements may influence the procedural outcome. We here systematically overviewed the arguments which should be considered during the following steps of the provisional strategy: branch wiring, side-branch predilation, “crossover” stenting, proximal optimization, kissing balloon and the side-branch rescue techniques. We suggest that provisional stenting should be regarded as a highly flexible technique which, with specific technical tricks, may allow us to safely treat patients with wide spectrum of bifurcated lesion complexity.     

Update on the Indications and Use of Colonic Stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.     

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).     

Biodegradable Polymer Drug-Eluting Stents Versus Second-Generation Drug-Eluting Stents for Patients With Coronary Artery Disease: An Update Meta-Analysis

Objective

Permanent polymer drug-eluting stents (DES) are associated with a higher risk of late and very late stent thrombosis (ST); biodegradable polymer drug-eluting stents (BP-DES) were designed to reduce these risks. However, their benefits are not completely clear.

Method

We undertook a meta-analysis of randomized studies identified in systematic searches of MEDLINE, EMBASE, and the Cochrane Database. Eligible studies were those that compared BP-DES with second-generation permanent polymer DES in patients undergoing percutaneous coronary intervention.

Results

Five studies (8,740 patients) with a mean follow-up of 19.2 months were included. Overall, BP-DES were associated with a broadly equivalent risk of definite and probable ST (odds ratio [OR], 1.07; 95 % confidence interval [CI], 0.67 to 1.71; P?=?0.76; I ²?=?5.0 %), target vessel revascularization (OR, 1.04; 95 % CI, 0.87 to 1.24; P?=?0.68; I ²?=?38.0 %), all-cause mortality (OR, 1.10; 95 % CI, 0.87 to 1.41; P?=?0.42; I ²?=?0.0 %), and major adverse cardiac events (OR, 1.03; 95 % CI, 0.88 to 1.20; P?=?0.74; I ²?=?0.0 %) when compared with second-generation DES. However, BP-DES significantly decreased in-stent late luminal loss (standard mean difference [SMD], ?0.01; 95 % CI, ?0.12 to 0.11; P?=?0.93; I ²?=?0.0 %) and in-segment late luminal loss (SMD, ?0.06; 95 % CI, ?0.17 to 0.05; P?=?0.27; I ²?=?0.0 %) compared with second-generation DES.

Conclusions

Compared with second-generation permanent polymer DES, biodegradable stents appear to have equivalent short- to medium-term clinical benefits, and it remains unclear whether they reduce the incidence of very late ST.     

Dedicated Tryton Side Branch Stents used in the treatment of coronary bifurcation lesions

IntroductionCoronary bifurcation lesions account for 15–20% of all percutaneous coronary interventions.Dedicated bifurcation stents have recently been introduced with the aim to simplify treatment and improve early and late outcomes following stenting of bifurcation lesions.The purpose of our study was to assess the safety and effectiveness of the Tryton dedicated side branch stent at a 6-month clinical and angiography follow-up.MethodsForty-two patients with bifurcation lesions were included in our study. The primary endpoint was a 6-month MACE and angiographic stent patency was also evaluated by MS-CT coronarography.ResultsTwenty-two patients (52.38%) were treated for acute coronary syndromes, 39 (92.85%) lesions were “true bifurcations”. The 6-month clinical follow-up was performed in all patients. The 6-month MACE rate (cardiac death, myocardial infarction and target lesion revascularization) was 9.52% (95% CI: 2.66–22.62%); of these one patient (2.38%; 95% CI: 0.06–12.57%) died due to cardiogenic shock caused by early stent thrombosis and three patients (7.14%; 95% CI: 1.50–19.48%) required repeated revascularization (TVR) due to in-stent restenosis, all of them in bare metal stents. Tryton stent implantation was successful in 100% lesions.6-Month MS-CT coronarography was performed in 39 (92.85%) patients. The implanted bifurcation Tryton stents were satisfactorily visualized in 97.43% of them and a satisfactory 6-month angiographic patency was demonstrated in 37 patients (88.1%).ConclusionThe usage of a dedicated bifurcation Tryton Side Branch Stent for PCI of the bifurcation lesions is technically feasible with satisfactory long-term results.     

Differential Prognostic Effect Between First- and Second-Generation Drug-Eluting Stents in Coronary Bifurcation Lesions: Patient-Level Analysis of the Korean Bifurcation Pooled Cohorts

ObjectivesThe purpose of this study was to investigate the differential clinical outcomes after percutaneous coronary intervention (PCI) for coronary bifurcation lesions with 1- or 2-stenting techniques using first- or second-generation drug-eluting stents (DES).BackgroundThe 2-stenting technique has been regarded to have worse clinical outcomes than the 1-stenting technique after bifurcation PCI with first-generation DES. However, there has been a paucity of data comparing the 1- and 2-stenting techniques with the use of second-generation DES.MethodsPatient-level pooled analysis was performed with 3,162 patients undergoing PCI using first- or second-generation DES for bifurcation lesions from the “Korean Bifurcation Pooled Cohorts” (COBIS [Coronary Bifurcation Stenting] II, EXCELLENT [Registry to Evaluate Efficacy of Xience/Promus Versus Cypher in Reducing Late Loss After Stenting], and RESOLUTE-Korea [Registry to Evaluate the Efficacy of Zotarolimus-Eluting Stent]). The 3-year clinical outcomes were compared between 1- and 2-stenting techniques, stratified by the type of DES.ResultsWith first-generation DES, rates of target lesion failure (TLF) or patient-oriented composite outcome (POCO) (a composite of all death, any myocardial infarction, any repeat revascularization, and cerebrovascular accidents) at 3 years were significantly higher after the 2-stenting than the 1-stenting technique (TLF 8.6% vs. 17.5%; p < 0.001; POCO 18.1% vs. 28.5%, p < 0.001). With second-generation DES, however, there was no difference between 1- and 2-stenting techniques (TLF 5.4% vs. 5.8%; p = 0.768; POCO 11.2% vs. 12.9%; p = 0.995). The differential effects of 2-stenting technique on the prognosis according to the type of DES were also corroborated with similar results by the inverse probability weighted model. The 2-stenting technique was a significant independent predictor of TLF in first-generation DES (hazard ratio: 2.046; 95% confidence interval: 1.114 to 3.759; p < 0.001), but not in second-generation DES (hazard ratio: 0.667; 95% confidence interval: 0.247 to 1.802; p = 0.425).ConclusionsPatient-level pooled analysis of 3,162 patients in Korean Bifurcation Pooled Cohorts demonstrated that the 2-stenting technique showed comparable outcomes to 1-stenting technique with second-generation DES, which is different from the results of first-generation DES favoring the 1-stenting technique.     

替罗非班加药物洗脱支架治疗冠脉狭窄分叉病变的近期疗效观察

目的:探讨应用阿司匹林 氯吡格雷 替罗非班及药物洗脱支架(DES)治疗冠状动脉狭窄分叉病变的临床疗效。方法:回顾分析应用阿司匹林 氯吡格雷 替罗非班及DES治疗冠脉分叉病变56例的临床疗效。结果:56例冠脉分叉病变患者采用支架植入术,手术成功率达到100%,术中无急性血栓形成。临床随访1～2年无死亡和AMI发生。结论:本研究结果显示阿司匹林 氯吡格雷 替罗非班及DES治疗冠脉狭窄病变包括分叉病变的近期临床疗效十分满意。     

A New Stent Design for the Treatment of True Bifurcation Lesions: H-Side Branch Stents

Background: There has been much debate for the adequate treatment strategies for true bifurcation lesions. The purpose of this study is to introduce and test a novel stent design for the treatment of true bifurcation lesions.
Methods: This side branch stent is composed of three parts: proximal, connecting, and distal parts. The distal part for the side branch vessel has a slope-side stent margin for circumferential coverage of the ostium and one radio-opaque marker for targeting the carina. The proximal part with two radio-opaque markers operates for safe stent delivery and useful guidance for a more precise placement of the distal part on the side branch ostium. Results of the in vitro test in the acrylic resin-made bifurcation phantom model were evaluated with microcomputer tomography. Animal experiments with this new stent platform were also performed in five pigs.
Results: In vitro test and microcomputer tomography showed complete coverage of the side branch ostium circumferentially with stent struts, and the absence of stent struts in the main vessel above the side branch ostium level. This side branch stents were successfully deployed in all 5 pigs. The results of animal experiments were also similar to those of in vitro tests.
Conclusions: In vivo and vitro tests demonstrated the effective modality of this side branch stent for the treatment of true bifurcation lesions. (J Interven Cardiol 2010;23:54–59)     

Percutaneous Management of a Coronary Bifurcation Aneurysm with Mesh-Covered Stents and the Simultaneous Kissing Stent Technique

A 63-year-old man was admitted with a clinical diagnosis of acute coronary syndrome (non-ST-segment elevation), characterized by regional hypokinesia of the left ventricular posterior and lateral walls and by positive cardiac biomarkers. The coronary angiogram showed a 12.5-mm-diameter aneurysm with a mural thrombus and possible distal embolism to the bifurcation of the left circumflex coronary artery and the 2nd marginal branch.The aneurysm was managed percutaneously by implanting 2 mesh-covered stents in accordance with the “simultaneous kissing stent” technique. Follow-up angiography and optical coherence tomography at 5 postprocedural months documented complete sealing of the aneurysm and diffuse in-stent restenosis. No sign of ischemia occurred during the subsequent follow-up.