Vascular Response after Directional Coronary Atherectomy for Left Main Bifurcation Lesion

Aims. To evaluate the vascular response after directional coronary atherectomy (DCA) for left main (LM) bifurcation lesion. Methods. This study was a retrospective, single-center study enrolling 31 patients who underwent stentless therapy using DCA followed by drug-coated balloon (DCB) angioplasty for LM bifurcation lesion. We compared intravascular ultrasound (IVUS) findings before and after DCA. Results. After DCA, the lumen and vessel areas significantly increased, whereas the plaque area (PA) and %PA were significantly reduced. When the lesions were divided into small vessel and large vessel groups using the median value of the vessel area, the maximum balloon pressure of the DCA catheter was greater in the large vessel group. Changes in the lumen and vessel areas were also significantly greater in the large vessel group. On the other hand, the changes in PA and %PA were similar between groups. Conclusions. The main vascular responses associated with lumen enlargement after DCA were plaque reduction and vessel expansion. Contribution of vessel expansion to lumen enlargement was larger than the effect of plaque reduction in large vessel lesions.

Management of bifurcation culprit lesion in the setting of anterior ST elevation myocardial infarction

Introduction Coronary bifurcation lesions are considered one of the challenging entities in the field of coronary intervention due to the risk of side branch loss and higher risk of stent thrombosis. However, there is limited data about the proper management of such lesions in the setting of myocardial infarction as most bifurcation lesion studies excluded patients with acute coronary syndrome (ACS). Aim To compare in-hospital and mid-term outcomes of single-stent and two-stents strategy in the management of bifurcation culprit lesions in patients presenting with anterior STEMI Methods This retrospective multi-center study included all consecutive patients presented with anterior STEMI who underwent primary PCI between January 2017 and December 2019, coronary angiography showed true bifurcation lesion with sizable side branch that can be managed by stenting. Patients with left main bifurcation lesion, patients indicated for urgent CABG, or patients in cardiogenic shock were excluded. Included patients were divided into two main groups according to the stenting strategy either single or two stents strategy. Six months of follow up data were collected by telephone calls and the examination of medical records Results Out of 1355 anterior STEMI patients presented between January 2017 and December 2019, 158 patients (11.6%) were identified to have bifurcation culprit lesions with a sizable diagonal branch. The baseline characteristics and angiographic findings were similar in both groups except for higher side branch involvement in the two stents group (83.31%± 11.20 and 71.88%±15.05, t=−5.39, p<0.001). Mean fluoroscopy time (23.96±8.90 vs 17.81±5.72 min) and contrast volume (259.23±59.45 vs 232.58±96.18 ml) were significantly higher in two stents group than single stent group (p=0.049). However the angiographic success rates (residual stenosis ≤30% and restoration of TIMI flow grade II or III) were comparable (96.8% vs 99%, MC p=0.151). There is no significant difference regarding the overall incidence rate of MACCE in both groups 6 months following the index procedure (13.9% vs 16.9%, FEp=0.698), with no difference between different bifurcation stenting techniques in patients managed with two stents Conclusion Although two stents strategy in the setting of STEMI is much complex with more fluoroscopy time and contrast volume, the procedural success rate and the incidence of complications between two groups were comparable on the medium-term follow up FUNDunding Acknowledgement Type of funding sources: None.

The impact of bifurcation lesion in infarct-related artery of NSTE-ACS patients

Introduction Angioplasty of bifurcation lesions remains challenging. In most studies, long-term outcomes were less favourable compared to non-bifurcation lesions. Patients with bifurcation lesions were excluded from most of the randomised studies of AMI. Purpose The aim of this study was to determine the prognostic impact of bifurcation lesion on three-year outcome in a prospective cohort of NSTE-ACS patients. Bifurcation lesions (BFLs) remain a challenging lesion subset, often associated with lower success rates than less complex lesions. There are few data regarding the impact of BFLs in the setting of NSTE-ACS. Methods Patients admitted for NSTE-ACS and indication for coronary angiography were prospectively evaluated. Patients were divided into 2 groups according to whether infarct-related-artery lesions were vs. were not a bifurcation lesion. Major outcomes were assessed at 3 years. Results A total of 296 patients were evaluated: mean age was 62±12 years and 58% were male. The three-year mortality was 12.2% (36 patients) and the three-year MACCE was 26.4% (78 patients). The bifurcation lesion group included 62 patients (20.9%).The three-year mortality and MACCE in the patients of the bifurcation lesion group was significantly higher (19.4% vs. 10.3%; p=0.046) and (45.2% vs. 21.4%; p≤10–3) respectively. Conclusion In NSTE-ACS, bifurcation lesions portend worse prognosis. This may guide prognostication and decision making in treatment. FUNDunding Acknowledgement Type of funding sources: None. MACCE occurrence: Bifurcation impact

Effect of Balloon Embedded Bifurcating Stenting with Single Stent Strategy for Side Branch Protection

Background: Intervention for bifurcation lesions is associated with increased risk of adverse events and includes acute side branch (SB) occlusion during main branch (MB) stenting. This acute occlusion of side branch can often be catastrophic for the patient. We here in describe our experience in National Institute of Cardiovascular Diseases and Hospital (NICVD), Dhaka, Bangladesh with a technique which can be incorporated into bifurcation stenting to reduce or almost eliminate the incidence of side branch occlusion or catastrophe. Methods: A prospective, observational, non-blinded study in patients from a single tertiary referral cardiac center National Institute of Cardiovascular Diseases & Hospital (NICVD), Dhaka, Bangladesh. Patients with an indication for percutaneous coronary intervention (PCI) of a denovo bifurcation lesion were screened. The study included 51 patients who underwent coronary angiogram in our institution and had bifurcation lesions suitable for single stent strategy between March 2017 to September 2018. Results: 51 patients with bifurcation lesion were included in the study and underwent a balloon embedded bifurcation stenting with a semi inflated balloon placed across the SB ostium. Angiographic success was achieved in all the patients but procedural success was achieved in 88.2% of the patients. TIMI 3 flow of main branch (MB) was achieved 96.08% and side branch (SB) was achieved 88.2%. Incidence of dissection was 5.9%, acute occlusion of SB was 2.0% and MACE was 3.9%. Mean fluoroscopy time and contrast volume was similar to that of conventional bifurcation stenting. The jailed SB balloon and wire could be successfully removed in all patients. Conclusion: The present study suggests that balloon embedded bifurcation stenting with a semi inflated balloon to protect the SB is feasible, with minimal procedural adverse events and successful in minimizing or almost eliminating the incidence of acute side branch occlusion or dissection as well as MACE. Bangladesh Heart Journal 2021; 36(1): 17-23

Vascular Response after Directional Coronary Atherectomy for Left Main Bifurcation Lesion

Purpose: To evaluate the vascular response after directional coronary atherectomy (DCA) for left main (LM) bifurcation lesion.Methods: This study was a retrospective, single-center study enrolling 31 patients who underwent stent-less therapy using DCA followed by drug-coated balloon angioplasty for LM bifurcation lesion. We compared the intravascular ultrasound (IVUS) findings pre- and post DCA. Results: After DCA, the lumen and vessel areas significantly increased whereas the plaque area (PA) and %PA significantly decreased. When the lesions were divided into small and large vessel groups using the median vessel area value, the maximum balloon pressure of the DCA catheter was greater in the large than in the small vessel group. Changes in the lumen and vessel areas were also significantly greater in the large than in the small vessel group. Conversely, the PA and %PA changes were similar between the groups. Conclusion: The main vascular responses associated with lumen enlargement after DCA were plaque reduction and vessel expansion. Contribution of vessel expansion to lumen enlargement was larger than the effect of plaque reduction in large than in small-vessel lesions.