Risk of side branch occlusion during coronary angioplasty

Meier, Bernhard; Gruentzig, Andreas R.; King, Spencer B.; Douglas, John S.; Hollman, Jay; Ischinger, Thomas; Aueron, Fred M.; Galan, Kathy

doi:10.1016/0002-9149(84)90675-1

Cited by 258 publications

(98 citation statements)

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“…1 The advent of coronary stenting reduced the risks, but in-stent restenosis was noted to be frequent at the ostium of the side branch. 2 Two-stent techniques were developed to try to combat this phenomenon 2,3 but gave inferior results to the provisional T technique in nonrandomized studies.…”

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confidence: 99%

Randomized Trial of Simple Versus Complex Drug-Eluting Stenting for Bifurcation Lesions

et al. 2010

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Background-The optimal strategy for treating coronary bifurcation lesions remains a subject of debate. With bare-metal stents, single-stent approaches appear to be superior to systematic 2-stent strategies. Drug-eluting stents, however, have low rates of restenosis and might offer improved outcomes with complex stenting techniques. Methods and Results-Patients with significant coronary bifurcation lesions were randomized to either a simple or complex stenting strategy with drug-eluting stents. In the simple strategy, the main vessel was stented, followed by optional kissing balloon dilatation/T-stent. In the complex strategy, both vessels were systematically stented (culotte or crush techniques) with mandatory kissing balloon dilatation. Five hundred patients 64Ϯ10 years old were randomized; 77% were male. Eighty-two percent of lesions were true bifurcations (Ͼ50% narrowing in both vessels). In the simple group (nϭ250), 66 patients (26%) had kissing balloons in addition to main-vessel stenting, and 7 (3%) had T stenting. In the complex group (nϭ250), 89% of culotte (nϭ75) and 72% of crush (nϭ169) cases were completed successfully with final kissing balloon inflations. The primary end point (a composite at 9 months of death, myocardial infarction, and target-vessel failure) occurred in 8.0% of the simple group versus 15.2% of the complex group (hazard ratio 2.02, 95% confidence interval 1.17 to 3.47, Pϭ0.009). Myocardial infarction occurred in 3.6% versus 11.2%, respectively (Pϭ0.001), and in-hospital major adverse cardiovascular events occurred in 2.0% versus 8.0% (Pϭ0.002), respectively. Procedure duration and x-ray dose favored the simple approach. Conclusions-When coronary bifurcation lesions are treated, a systematic 2-stent technique results in higher rates of in-hospital and 9-month major adverse cardiovascular events. This difference is largely driven by periprocedural myocardial infarction. Procedure duration is longer, and x-ray dose is higher. The provisional technique should remain the preferred strategy in the majority of cases. Clinical Trial Registration Information-URL: http://www.clinicaltrials.gov. Unique identifier: NCT 00351260.

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confidence: 99%

Randomized Trial of Simple Versus Complex Drug-Eluting Stenting for Bifurcation Lesions

et al. 2010

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“…[1][2][3][4][5] Meier et al were among the first to identify the risk of side branch occlusion associated with parent vessel angioplasty. 1 They emphasized that side branches involved in vessel narrowing are at high risk for side branch occlusion during PCI. Boxt et al has reported that vessels with angiographic ostial stenosis >50% have a higher risk of occlusion than those without ostial stenosis.…”

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confidence: 99%

Intravascular Ultrasound Predictors of Side Branch Occlusion in Bifurcation Lesions After Percutaneous Coronary Intervention

Furukawa

Hibi

Kosuge

et al. 2005

Circ J

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lthough success rates of percutaneous coronary intervention (PCI) are high, PCI of bifurcation lesions is associated with a relatively low success rate and a relatively high incidence of procedural complications, including side branch occlusion and myocardial infarction. . [1][2][3][4][5] Meier et al were among the first to identify the risk of side branch occlusion associated with parent vessel angioplasty. 1 They emphasized that side branches involved in vessel narrowing are at high risk for side branch occlusion during PCI. Boxt et al has reported that vessels with angiographic ostial stenosis >50% have a higher risk of occlusion than those without ostial stenosis. 2 Prior studies have demonstrated that intravascular ultrasound (IVUS) provides information not generated by angiography alone, and the use of sonographic measurements of vascular dimensions has improved short-and long-term outcomes. 6-10 Despite several lines of evidence suggesting that IVUS guidance can reduce the need for target lesion revascularization after PCI, 9,10 it remains controversial whether preintervention IVUS findings can help to identify side branches likely to occlude after PCI of bifurcation lesions.We examined whether preintervention IVUS provides information not available by angiography alone and if it can be used to predict side branch occlusion after PCI. Circulation Journal Vol.69, March 2005 Methods Lesions and the Patient PopulationThe study group consisted of 105 bifurcation lesions in 96 patients with coronary artery disease, all of which had undergone preintervention IVUS examination in the native coronary artery. No directional coronary atherectomy, rotational atherectomy, nor thrombectomy were performed. The clinical diagnoses included: acute myocardial infarction (AMI) (57%), stable angina pectoris (17%), unstable angina pectoris (15%), and previous myocardial infarction (11%). We studied bifurcation lesions involving the main branch and the ostium of the side branch. 11 Only side branches with an estimated reference luminal diameter of 1 mm or greater were considered. Twenty-four lesions were excluded for the following reasons: kissing balloon technique or sequential dilatation was performed (n=6) and extensive target lesion calcification or artifacts which precluded accurate cross-sectional evaluation of the vessel involved (n=18). The remaining 81 bifurcation lesions in 72 patients were studied.Side branch occlusion was defined as a thrombolysis in myocardial infarction (TIMI) flow of ≤2 by the final angiogram after PCI procedures. 12 Quantitative Coronary AngiographyAngiograms were reviewed before introduction of coronary guidewire and after balloon dilation or stent deployment. The coronary flow pattern of side branches was graded according to the classification system of the TIMI trial. 12 Angiograms were digitized and analyzed using an automated edge-detection algorithm (QCA-CMS, version 4.0, Medical Imaging Systems, Rotterdam, The Netherlands).

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“…The risk is increased if there is an eccentric lesion at the bifurcation site and a stenosis in the ostium of the side branch. 181,182 To diminish this plaque shifting, the ''kissing'' balloon technique was developed. 183 …”

Section: Bifurcationsmentioning

confidence: 99%

“…181,[184][185][186] Treatment of bifurcations with directional atherectomy (without stenting) has been shown to improve the immediate procedural outcome compared with balloon dilatation alone, but the incidence of restenosis remains high. 187 The use of coronary stents has improved the treatment of bifurcation lesions, but it is technically challenging and there is still a high incidence of compromising the branch vessel.…”

Section: Yamashita Colombo and Tobismentioning

confidence: 99%

Limitations of coronary angiography compared with intravascular ultrasound: Implications for coronary interventions☆

Yamashita

Colombo

Tobis

1999

Progress in Cardiovascular Diseases

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The use of intravascular ultrasound catheters to produce images of lumen and plaque cross-sectional areas has had a profound effect on the practice of interventional cardiology. This imaging modality provides, for the first time, a low-power microscopic view of vascular anatomy within a living patient. This article will review some of the advantages of intravascular ultrasound imaging compared with angiography when used for diagnostic or interventional therapeutic procedures.Copyright 1999 by W.B. Saunders Company C oronary angiography is the primary mode of imaging coronary artery disease and guiding interventional procedures. Although coronary angiography was essential for the development of catheter-based coronary interventions, as the complexity of interventional cases increased, several limitations of angiography surfaced. Problems associated with coronary intervention, such as acute closure and restenosis, are related in part to properties of the lesion. Angiographic studies have reported inconsistent predictors of such adverse events. 1,2 One of the main reasons for this inconsistency is the limited power of angiography to delineate the complex anatomy of coronary atherosclerotic lesions. Intravascular ultrasound (IVUS) is a technique that provides two-dimensional, tomographic views of the coronary lumen and wall morphology in vivo, which has several advantages compared with angiography. 3 This article reviews the limitations of angiography and describes the information that IVUS imaging provides to complement angiography during diagnostic and interventional procedures. The ability of IVUS to evaluate lesion characteristics and dimensions alters therapeutic decisions and permits the operator to optimize each intervention. Lesion EvaluationEvaluation of coronary atherosclerotic lesions by angiography has been described by the joint American College of Cardiology/American Heart Association (ACC/AHA) committee. 4 This system delineates lesions by the degree of eccentricity and complexity. However, this analysis is limited by the ability of angiography to visualize only the lumen and not the atherosclerotic plaque itself. 91IVUS provides new insights for lesion evaluation because it produces a tomographic view of the artery and it is the only technique that permits visualization of the diseased artery wall in vivo. This capability is especially useful for diagnosing disease when vessels overlap or if there is a short stenosis. In addition, IVUS images are at a higher magnification than angiography, and its internal scale has been shown to be more accurate than angiographic assessment of plaque dimensions. Moreover, the ability of angiography to provide information on tissue characterization is limited. The following discussion will attempt to describe these differences between angiography and IVUS. Tomographic ImagingAn angiogram shows a longitudinal, two-dimensional view of the lumen of the vessel and does not directly show us the pathology, that is, the atherosclerotic plaque. If the plaque impinges on...

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Risk of side branch occlusion during coronary angioplasty

Cited by 258 publications

References 4 publications

Randomized Trial of Simple Versus Complex Drug-Eluting Stenting for Bifurcation Lesions

Randomized Trial of Simple Versus Complex Drug-Eluting Stenting for Bifurcation Lesions

Intravascular Ultrasound Predictors of Side Branch Occlusion in Bifurcation Lesions After Percutaneous Coronary Intervention

Limitations of coronary angiography compared with intravascular ultrasound: Implications for coronary interventions☆

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