Real-life Bifurcation – Challenges and Potential Complications

2012 ◽  
Vol 7 (2) ◽  
pp. 95 ◽  
Author(s):  
Inga Narbute ◽  
Sanda Jegere ◽  
Indulis Kumsars ◽  
Dace Juhnevica ◽  
Agnese Knipse ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Real Life ◽  
Coronary Intervention ◽  
Side Branch ◽  
The Body ◽  
Chronic Total Occlusions ◽  
Vein Grafts ◽  
Procedural Complications ◽  
Drug Eluting ◽  
Bifurcation Lesions

Together with calcified lesions, saphenous vein grafts, chronic total occlusions and unprotected left main lesions, bifurcation lesions are complex lesions that remain among the outstanding challenges of treatment with percutaneous coronary intervention. Bifurcation lesions are associated with increased rates of procedural complications, restenosis and adverse events than lesions in the body of the vessel. The introduction of drug-eluting stents for the treatment of bifurcation lesions has dramatically decreased restenosis rates, especially in patients suffering from diabetes. However, abrupt side branch closure, side branch ostial restenosis and stent thrombosis remain areas where further improvement is needed. Although a provisional T-stent strategy is most often used when side branch stenting is required, there are true bifurcation lesions where the selected use of more complex bifurcation approaches (such as the crush technique, T-stenting or the culotte technique) seem appropriate, particularly when the main branch and side branch are larger vessels with more diffuse side branch disease. The major challenge with any technique is to ensure that the side branch is protected and there is a satisfactory final result. Many technical questions rise in trying to ensure this outcome and lower the risk of intra- and post-procedural complications such as side branch closure and restenosis, stent thrombosis, dissection and fracture of a jailed wire: how can difficult side branch access be solved? How can unfavourable side branch anatomy be re-wired after main vessel stent placement? How can fracture of a jailed wire be avoided? Is side-strut dilation beneficial?

Real-life Bifurcation – Challenges and Potential Complications

2011 ◽  
Vol 7 (4) ◽  
pp. 283
Author(s):  
Inga Narbute ◽  
Sanda Jegere ◽  
Indulis Kumsars ◽  
Dace Juhnevica ◽  
Agnese Knipse ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Real Life ◽  
Coronary Intervention ◽  
Side Branch ◽  
The Body ◽  
Chronic Total Occlusions ◽  
Vein Grafts ◽  
Procedural Complications ◽  
Drug Eluting ◽  
Bifurcation Lesions

Together with calcified lesions, saphenous vein grafts, chronic total occlusions and unprotected left main lesions, bifurcation lesions are complex lesions that remain among the outstanding challenges of treatment with percutaneous coronary intervention. Bifurcation lesions are associated with increased rates of procedural complications, restenosis and adverse events than lesions in the body of the vessel. The introduction of drug-eluting stents for the treatment of bifurcation lesions has dramatically decreased restenosis rates, especially in patients suffering from diabetes. However, abrupt side branch closure, side branch ostial restenosis and stent thrombosis remain areas where further improvement is needed. Although a provisional T-stent strategy is most often used when side branch stenting is required, there are true bifurcation lesions where the selected use of more complex bifurcation approaches (such as the crush technique, T-stenting or the culotte technique) seem appropriate, particularly when the main branch and side branch are larger vessels with more diffuse side branch disease. The major challenge with any technique is to ensure that the side branch is protected and there is a satisfactory final result. Many technical questions rise in trying to ensure this outcome and lower the risk of intra- and post-procedural complications such as side branch closure and restenosis, stent thrombosis, dissection and fracture of a jailed wire: how can difficult side branch access be solved? How can unfavourable side branch anatomy be re-wired after main vessel stent placement? How can fracture of a jailed wire be avoided? Is side-strut dilation beneficial?

Real-life Bifurcation – Challenges and Potential Complications

2011 ◽  
Vol 6 (2) ◽  
pp. 145
Author(s):  
Inga Narbute ◽  
Sanda Jegere ◽  
Indulis Kumsars ◽  
Dace Juhnevica ◽  
Agnese Knipse ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Real Life ◽  
Coronary Intervention ◽  
Side Branch ◽  
The Body ◽  
Chronic Total Occlusions ◽  
Vein Grafts ◽  
Procedural Complications ◽  
Drug Eluting ◽  
Bifurcation Lesions

Together with calcified lesions, saphenous vein grafts, chronic total occlusions and unprotected left main lesions, bifurcation lesions are complex lesions that remain among the outstanding challenges of treatment with percutaneous coronary intervention. Bifurcation lesions are associated with increased rates of procedural complications, restenosis and adverse events than lesions in the body of the vessel. The introduction of drug-eluting stents for the treatment of bifurcation lesions has dramatically decreased restenosis rates, especially in patients suffering from diabetes. However, abrupt side branch closure, side branch ostial restenosis and stent thrombosis remain areas where further improvement is needed. Although a provisional T-stent strategy is most often used when side branch stenting is required, there are true bifurcation lesions where the selected use of more complex bifurcation approaches (such as the crush technique, T-stenting or the culotte technique) seem appropriate, particularly when the main branch and side branch are larger vessels with more diffuse side branch disease. The major challenge with any technique is to ensure that the side branch is protected and there is a satisfactory final result. Many technical questions rise in trying to ensure this outcome and lower the risk of intra- and post-procedural complications such as side branch closure and restenosis, stent thrombosis, dissection and fracture of a jailed wire: how can difficult side branch access be solved? How can unfavourable side branch anatomy be re-wired after main vessel stent placement? How can fracture of a jailed wire be avoided? Is side-strut dilation beneficial?

Percutaneous Coronary Intervention for Complex Bifurcation Lesions

2010 ◽  
Vol 5 (1) ◽  
pp. 58
Author(s):  
Yves Louvard ◽  
Morice Marie-Claude ◽  
Thomas Hovasse ◽  
Thierry Lefèvre ◽  
◽  
...  
Keyword(s):  
Percutaneous Coronary Intervention ◽  
Coronary Intervention ◽  
Side Branch ◽  
Drug Eluting Stents ◽  
Open Angle ◽  
Balloon Inflation ◽  
Percutaneous Coronary ◽  
Drug Eluting ◽  
Bifurcation Lesions ◽  
Stent Diameter

Coronary bifurcations are prone to the development of atherosclerosis. They pose technical difficulties for angioplasty treatment and are a predictor of stent thrombosis and restenosis. Treatment of coronary bifurcations is still subject to debate, especially when the side branch (SB) is large, not easily accessible and narrowed by a long lesion. There is currently no indexed treatment for this type of lesion (Medina classification), as the strategy of provisional SB stenting with drug-eluting stents (DES) has proved to be equally efficient as the dualstent technique. Complex techniques are associated with poor outcome in certain lesion types, such as T-stenting when the angle between the two distal branches is small or the crush and culotte technique in the presence of an open angle. Provisional SB stenting may be used when primary dual stenting is required, with a low risk of failure provided that the following guidelines are implemented: stenting of the main branch through the protected SB with a stent diameter adapted to the distal main branch, immediate optimisation of the proximal stent segment (Finet’s law), guidewire exchange, kissing balloon inflation with non-compliant balloons selected according to the diameter of the distal branches and T-stenting of the SB before final kissing inflation.

Abstract 3350: Long-Term Outcomes After Drug-Eluting Stenting of Bifurcation Lesions With the Simultaneous Kissing Stents (SKS) Technique

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Samin K Sharma ◽  
Madhu Prattipati ◽  
Angelica M Mares ◽  
Oana C Ivan ◽  
Vatsal Inamdar ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
De Novo ◽  
Side Branch ◽  
Left Main ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Drug Eluting ◽  
Bifurcation Lesions

Percutaneous coronary interventions (PCI) of bifurcation lesions using simultaneous kissing stents (SKS) technique have shown to have good short-term and mid-term results. Limited data are available regarding long-term outcome with this strategy. Methods: We analyzed the long-term outcome of 300 consecutive patients treated with drug-eluting stenting using SKS technique for 305 de novo bifurcation lesions. Cypher stents were used in 265 lesions and Taxus stents were used in 40 lesions, from May 2003 to September 2006 at Mount Sinai Hospital. Clinical follow-up was obtained in 98.6%. All pts were given Aspirin and Plavix 75 mg daily for one year and GP IIb/IIIa inhibitors were used in 72% of cases. Results: Overall procedural success was 99% for main vessel (MV) and 98% for side-branch (SB), with one case of intra-procedural stent thrombosis of left main bifurcation. 30-day MACE (MI, death, repeat target vascularization or stent thrombosis) occurred in 5% of cases. Long-term follow-up results at a mean of 14 ± 5 months are shown in the Table . Overall incidence of stent thrombosis was 1.7% (1.5% for Cypher vs. 2.5% for Taxus). Multivariate predictors of TVR were left main (LM) intervention (odds ratio [OR] 4.97; 95% confidence interval [CI] 2.00 to 12.37, p = 0.01) and diabetes mellitus (OR 4.21; 95% CI 1.15 to 18.56, p = 0.04) and of follow-up MACE were LM intervention (OR 3.79; 95% CI 1.76 to 8.14, p = 0.01) and acute MI (OR 3.24; 95% CI 0.95 to 15.32, p = 0.02). Conclusions: The SKS technique for bifurcation lesions using Cypher or Taxus DES is associated with long-term favorable outcomes in this complex, high-risk PCI group. Delayed stent thrombosis with dual antiplatelet therapy remains within acceptable limits. Further work is needed to lower the event rates in some specific subgroups such as LM lesions and AMI settings (perhaps by IVUS guidance and Plavix 75 mg twice a day).

Dedicated Bifurcation Stents Strategy

2009 ◽  
Vol 4 (1) ◽  
pp. 70
Author(s):  
Chen Shao-Liang ◽  
Imad Sheiban ◽  
◽  
Keyword(s):  
Interventional Cardiology ◽  
Daily Practice ◽  
Side Branch ◽  
Control Groups ◽  
Coronary Bifurcation ◽  
Percutaneous Approach ◽  
Coronary Bifurcation Lesions ◽  
Drug Eluting ◽  
Bifurcation Lesions ◽  
Provisional Stenting

Coronary bifurcation lesions represent an area of ongoing challenges in interventional cardiology, mainly due to the higher rate of residual stenosis and restenosis at the side branch ostium. Multiple two-stent bifurcation strategies, including T-stenting, V-stenting, simultaneuos kissing stenting, culotte stenting and classic crush techniques, have no advantages over one-stent techniques. This led to provisional stenting being considered as a mainstream approach, based on the results of numerous randomised trials. Dedicated bifurcation stents have been designed specifically to treat coronary bifurcations with the aim of addressing some of the shortcomings of the conventional percutaneous approach and facilitating the provisional approach. The development of more drug-eluting platforms and larger studies with control groups demonstrating their clinical applicability, efficacy and safety are required before these stents are widely incorporated into daily practice.

Provisional and Complex Techniques for Bifurcation Treatment – Trading Apposition for Scaffolding?

2012 ◽  
Vol 7 (1) ◽  
pp. 44
Author(s):  
Nicolas Foin ◽  
Eduardo Alegria-Barrero ◽  
Ryo Torii ◽  
Pak H Chan ◽  
Ajay K Jain ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
New Technology ◽  
Coronary Intervention ◽  
Target Lesion ◽  
Side Branch ◽  
Simultaneous Increase ◽  
Stent Restenosis ◽  
Percutaneous Coronary ◽  
Stent Coverage ◽  
Bifurcation Lesions

Provisional T-stenting with stenting of the main branch and optional side branch (SB) stenting in the case of significant SB occlusion with thrombolysis in myocardial infarction (TIMI) flow <3 is the strategy chosen nowadays by most interventionalists for treating simple bifurcation lesions. Percutaneous coronary intervention (PCI) of complex true bifurcation lesions remains, however, the subject of debate: treatment of complex bifurcation lesions requires more time than treatment of simple bifurcations and can lead to significantly higher rates of restenosis, target lesion revascularisation and myocardial infarction. Current bifurcation techniques often fail to ensure continuous stent coverage of the SB ostium and of the two bifurcation branches without a simultaneous increase in the rate of malapposed struts. Stent struts left unapposed in the lumen disturb blood flow and are increasingly recognised as increasing the risk of stent thrombosis and focal in-stent restenosis, limiting the success of stent procedures in these lesions. New technology and dedicated designs may, in the near future, overcome such limitations of conventional two-stent bifurcation strategies.

Abstract 4486: Stent Thrombosis After Drug-Eluting Stent Implantation: Incidence, Timing and Relation to Discontinuation of Clopidogrel Therapy Over a 4-Year Period

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Stefanie Schulz ◽  
Julia Ellert ◽  
Julia Goedel ◽  
Robert A Byrne ◽  
Raisuke Iijma ◽  
...  
Keyword(s):  
Stent Thrombosis ◽  
Cumulative Incidence ◽  
High Volume ◽  
Coronary Intervention ◽  
Drug Eluting Stent ◽  
Time Interval ◽  
Number Of Patients ◽  
Drug Eluting ◽  
Clopidogrel Therapy ◽  
Observational Cohort

To assess the incidence, timing and relation of drug-eluting stent thrombosis (ST) to discontinuation of clopidogrel therapy. This prospective observational cohort study includes 6816 consecutive patients that underwent a successful drug-eluting stent (DES) implantation between July 2002 through December 2006 in 2 tertiary, high-volume percutaneous coronary intervention (PCI) centers in Germany. The primary end point was definite ST (ARC definition). During 4-year follow-up, 4.2% of the patient population incurred a myocardial infarction (MI), 8.6% had died and 3.1% had experienced a bleeding complication. Definite ST was observed in 73 patients, corresponding to a cumulative incidence of 1.2% at 4 years. Cumulative incidence of ST was 0.5% at 30 days and 0.8% at 1 year. In comparison to patients without ST, patients with ST carried a higher risk of MI (93% versus 3%; OR 48.5 [41.3 to 57.1]) and death (42% versus 8%; OR 5.2 [3.6 to 7.6]). Figure 1 shows the number of patients with ST in each time interval from discontinuation of clopidogrel therapy. Figure 2 depicts the cumulative incidence of ST in patients who were on clopidogrel therapy and in those who discontinued clopidogrel. The 4-year incidence of ST after DES implantation is low in high-volume PCI centers. A relevant number of ST occur early after discontinuation of clopidogrel therapy. The dependence of ST on discontinuation of clopidogrel therapy is evident during the first 6 months but not thereafter.

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