Real-life Bifurcation - Challenges and Potential Complications

Login or register to view PDF.
DOI
http://dx.doi.org/10.15420/icr.2012.7.2.95

Abstract

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?

To view the full article in PDF or eBook formats, please click on the icons above.

References
  1. Louvard Y, Lefevre T, Morice MC, Percutaneous coronary intervention for bifurcation coronary disease, Heart, 2004;90:713–22.
    Crossref | PubMed
  2. Meier B, Gruentzig AR, King SB 3rd, et al., Risk of side branch occlusion during coronary angioplasty, Am J Cardiol, 1984;53:10–4.
    Crossref | PubMed
  3. Al Suwaidi J, Yeh W, Cohen HA, et al., Immediate and one-year outcome in patients with coronary bifurcation lesions in the modern era (NHLBI dynamic registry), Am J Cardiol, 2001;87:1139–44.
    Crossref | PubMed
  4. Garot P, Lefevre T, Savage M, et al., Nine-month outcome of patients treated by percutaneous coronary interventions for bifurcation lesions in the recent era: a report from the Prevention of Restenosis with Tranilast and its Outcomes (PRESTO) trial, J Am Coll Cardiol, 2005;46:606–12.
    Crossref | PubMed
  5. Wilensky RL, Selzer F, Johnston J, et al., Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry), Am J Cardiol, 2002;90:216–21.
    Crossref | PubMed
  6. Brilakis ES, Lasala JM, Cox DA, et al., Two-year outcomes after utilization of the TAXUS paclitaxel-eluting stent in bifurcations and multivessel stenting in the ARRIVE registries, J Interv Cardiol, 2011;14:1540–8183.
    Crossref | PubMed
  7. Yeo KK, Mahmud E, Armstrong EJ, et al., Contemporary clinical characteristics, treatment, and outcomes of angiographically confirmed coronary stent thrombosis: results from a multicenter California registry, Catheter Cardiovasc Interv, 2011;11:23011.
    Crossref | PubMed
  8. Sheiban I, Albiero R, Marsico F, et al., Immediate and longterm results of “T” stenting for bifurcation coronary lesions, Am J Cardiol, 2000;85:1141–4.
    Crossref | PubMed
  9. Yamashita T, Nishida T, Adamian MG, et al., Bifurcation lesions: two stents versus one stent –immediate and follow-up results, J Am Coll Cardiol, 2000;35:1145–51.
    Crossref | PubMed
  10. Colombo A, Moses JW, Morice MC, et al., Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions, Circulation, 2004;109:1244–9.
    Crossref | PubMed
  11. Pan M, de Lezo JS, Medina A, et al., Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy, Am Heart J, 2004;148:857–64.
    Crossref | PubMed
  12. Tanabe K, Hoye A, Lemos PA, et al., Restenosis rates following bifurcation stenting with sirolimus-eluting stents for de novo narrowings, Am J Cardiol, 2004;94:115–8.
    Crossref | PubMed
  13. Niemela M, Kervinen K, Erglis A, et al., Randomized comparison of final kissing balloon dilatation versus no final kissing balloon dilatation in patients with coronary bifurcation lesions treated with main vessel stenting: the Nordic-Baltic Bifurcation Study III, Circulation, 2011;123:79–86.
    Crossref | PubMed
  14. Capodanno D, Tamburino C, Sangiorgi GM, et al., Impact of drug-eluting stents and diabetes mellitus in patients with coronary bifurcation lesions: a survey from the Italian Society of Invasive Cardiology, Circ Cardiovasc Interv, 2011;4:72–9.
    Crossref | PubMed
  15. Vigna C, Biondi-Zoccai G, Amico CM, et al., Provisional Tdrug- eluting stenting technique for the treatment of bifurcation lesions: clinical, myocardial scintigraphy and (late) coronary angiographic results, J Invasive Cardiol, 2007;19:92–7.
    PubMed
  16. Jim MH, Ho HH, Chan AO, Chow WH, Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): immediate procedure result and short-term clinical outcomes, Catheter Cardiovasc Interv, 2007;69:969–75.
    Crossref | PubMed
  17. Iakovou I, Schmidt T, Bonizzoni E, et al., Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents, JAMA, 2005;293:2126–30.
    Crossref | PubMed
  18. Ormiston JA, Currie E, Webster MW, et al., Drug-eluting stents for coronary bifurcations: insights into the crush technique, Catheter Cardiovasc Interv, 2004;63:332–6.
    Crossref | PubMed
  19. Baber U, Kini AS, Sharma SK, Stenting of complex lesions: an overview, Nat Rev Cardiol, 2010;7:485–96.
    Crossref | PubMed
  20. Bernardi G, Padovani R, Morocutti G, et al., Clinical and technical determinants of the complexity of percutaneous transluminal coronary angioplasty procedures: analysis in relation to radiation exposure parameters, Catheter Cardiovasc Interv, 2000;51:1–9; discussion 10.
    Crossref | PubMed
  21. Louvard Y, Thomas M, Dzavik V, et al., Classification of coronary artery bifurcation lesions and treatments: time for a consensus!, Catheter Cardiovasc Interv, 2008;71:175–83.
    Crossref | PubMed
  22. Spokojny A, Sanborn TM, The Bifurcation Lesion, Maryland, US: Williams and Wilkins, 1996.
  23. Lefevre T, Louvard Y, Morice MC, et al., Stenting of bifurcation lesions: classification, treatments, and results, Catheter Cardiovasc Interv, 2000;49:274–83.
    Crossref | PubMed
  24. Safian RD, Bifurcation Lesions, Missouri, US: Physician’s Press, 2001.
  25. Popma JJ, Leon MB, Ej T, Strategic approaches in coronary intervention, Pennsylvania, US: WB Saunders Company, 1994.
  26. Medina A, Suarez de Lezo J, Pan M, A new classification of coronary bifurcation lesions, Rev Esp Cardiol, 2006;59:183.
    Crossref | PubMed
  27. Movahed MR, Stinis CT, A new proposed simplified classification of coronary artery bifurcation lesions and bifurcation interventional techniques, J Invasive Cardiol, 2006;18:199–204.
    Crossref | PubMed
  28. Shams YH, Lindroos MC, Sylven C, A novel descriptive, intelligible and ordered (DINO) classification of coronary bifurcation lesions. Review of current classifications, Circ J, 2010;75:299–305.
    Crossref | PubMed
  29. Legrand V, Thomas M, Zelisko M, et al., Percutaneous coronary intervention of bifurcation lesions: state-of-the-art. Insights from the second meeting of the European Bifurcation Club, EuroIntervention, 2007;3:44–9.
    PubMed
  30. Hoye A, Iakovou I, Ge L, et al., Long-term outcomes after stenting of bifurcation lesions with the “crush” technique: predictors of an adverse outcome, J Am Coll Cardiol, 2006;47:1949–58.
    Crossref | PubMed
  31. Ge L, Iakovou I, Cosgrave J, et al., Treatment of bifurcation lesions with two stents: one year angiographic and clinical follow up of crush versus T stenting, Heart, 2006;92:371–6.
    Crossref | PubMed
  32. Ge L, Airoldi F, Iakovou I, et al., Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique: importance of final kissing balloon post-dilation, J Am Coll Cardiol, 2005;46:613–20.
    Crossref | PubMed
  33. Tsuchida K, Colombo A, Lefevre T, et al., The clinical outcome of percutaneous treatment of bifurcation lesions in multivessel coronary artery disease with the sirolimuseluting stent: insights from the Arterial Revascularization Therapies Study part II (ARTS II), Eur Heart J, 2007;28:433–42.
    Crossref | PubMed
  34. Zhang F, Dong L, Ge J, Simple versus complex stenting strategy for coronary artery bifurcation lesions in the drugeluting stent era: a meta-analysis of randomised trials, Heart, 2009;95:1676–81.
    Crossref | PubMed
  35. Brar SS, Gray WA, Dangas G, et al., Bifurcation stenting with drug-eluting stents: a systematic review and meta-analysis of randomised trials, EuroIntervention, 2009;5:475–84.
    Crossref | PubMed
  36. Steigen TK, Maeng M, Wiseth R, et al., Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study, Circulation, 2006;114:1955–61.
    Crossref | PubMed
  37. Hildick-Smith D, de Belder AJ, Cooter N, et al., Randomized trial of simple versus complex drug-eluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies, Circulation, 2010;121:1235–43.
    Crossref | PubMed
  38. Colombo A, Bramucci E, Sacca S, et al., Randomized study of the crush technique versus provisional side-branch stenting in true coronary bifurcations: the CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) study, Circulation, 2009;119:71–8.
    Crossref | PubMed
  39. Lefevre T, Louvard Y, Morice MC, et al., Stenting of bifurcation lesions: a rational approach, J Interv Cardiol, 2001;14:573–85.
    Crossref | PubMed
  40. Teirstein PS, Kissing Palmaz-Schatz stents for coronary bifurcation stenoses, Cathet Cardiovasc Diagn, 1996;37:307–10.
    Crossref | PubMed
  41. Sharma SK, Sweeny J, Kini AS, Coronary bifurcation lesions: a current update, Cardiol Clin, 2010;28:55–70.
    Crossref | PubMed
  42. Jensen JS, Galloe A, Lassen JF, et al., Safety in simple versus complex stenting of coronary artery bifurcation lesions. The Nordic Bifurcation Study 14-month follow-up results, EuroIntervention, 2008;4:229–33.
    Crossref | PubMed
  43. Gao Z, Yang YJ, Gao RL, Comparative study of simple versus complex stenting of coronary artery bifurcation lesions in daily practice in Chinese patients, Clin Cardiol, 2008;31:317–22.
    Crossref | PubMed
  44. Ferenc M, Gick M, Kienzle RP, et al., Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions, Eur Heart J, 2008;29:2859–67.
    Crossref | PubMed
  45. Erglis A, Kumsars I, Niemela M, et al., Randomized comparison of coronary bifurcation stenting with the crush versus the culotte technique using sirolimus eluting stents: the Nordic stent technique study, Circ Cardiovasc Interv, 2009;2:27–34.
    Crossref | PubMed
  46. Chen SL, Zhang JJ, Ye F, et al., Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH-1 Bifurcation Study with drug-eluting stents, Eur J Clin Invest, 2008;38:361–71.
    Crossref | PubMed
  47. McClure SJ, Wahr DW, Webb JG, Venture wire control catheter, Catheter Cardiovasc Interv, 2005;66:346–50.
    Crossref | PubMed
  48. Routledge H, Lefevre T, Ohanessian A, et al., Use of a deflectable tip catheter to facilitate complex interventions beyond insertion of coronary bypass grafts: three case reports, Catheter Cardiovasc Interv, 2007;70:862–6.
    Crossref | PubMed
  49. Burzotta F, Sgueglia GA, Trani C, et al., Provisional TAPstenting strategy to treat bifurcated lesions with drugeluting stents: one-year clinical results of a prospective registry, J Invasive Cardiol, 2009;21:532–7.
    PubMed
  50. Hermiller JB, Bifurcation intervention: keep it simple, J Invasive Cardiol, 2006;18:43–4.
    PubMed
  51. Ormiston JA, Webster MW, Ruygrok PN, et al., Stent deformation following simulated side-branch dilatation: a comparison of five stent designs, Catheter Cardiovasc Interv, 1999;47:258–64.
    Crossref | PubMed
  52. Fischman DL, Savage MP, Leon MB, et al., Fate of lesion-related side branches after coronary artery stenting, J Am Coll Cardiol, 1993;22:1641–6.
    Crossref | PubMed
  53. Aliabadi D, Tilli FV, Bowers TR, et al., Incidence and angiographic predictors of side branch occlusion following high-pressure intracoronary stenting, Am J Cardiol, 1997;80:994–7.
    Crossref | PubMed
  54. Poerner TC, Kralev S, Voelker W, et al., Natural history of small and medium-sized side branches after coronary stent implantation, Am Heart J, 2002;143:627–35.
    Crossref | PubMed
  55. Baim DS, Cutlip DE, O’Shaughnessy CD, et al., Final results of a randomized trial comparing the NIR stent to the Palmaz-Schatz stent for narrowings in native coronary arteries, Am J Cardiol, 2001;87:152–6.
    Crossref | PubMed
  56. Movahed MR, Coronary artery bifurcation lesion classifications, interventional techniques and clinical outcome, Expert Rev Cardiovasc Ther, 2008;6:261–74.
    Crossref | PubMed
  57. Kasaoka S, Tobis JM, Akiyama T, et al., Angiographic and intravascular ultrasound predictors of in-stent restenosis, J Am Coll Cardiol, 1998;32:1630–5.
    Crossref | PubMed
  58. Morino Y, Honda Y, Okura H, et al., An optimal diagnostic threshold for minimal stent area to predict target lesion revascularization following stent implantation in native coronary lesions, Am J Cardiol, 2001;88:301–3.
    Crossref | PubMed
  59. de Feyter PJ, Kay P, Disco C, Serruys PW, Reference chart derived from post-stent-implantation intravascular ultrasound predictors of 6-month expected restenosis on quantitative coronary angiography, Circulation, 1999;100:1777–83.
    Crossref | PubMed
  60. Iakovou I, Ge L, Colombo A, Contemporary stent treatment of coronary bifurcations, J Am Coll Cardiol, 2005;46:1446–55.
    Crossref | PubMed
  61. Colombo A, Latib A, The artisan approach for stenting bifurcation lesions, JACC Cardiovasc Interv, 2010;3:66–7.
    Crossref | PubMed
  62. Baran KW, Lasala JM, Cox DA, et al., A clinical risk score for the prediction of very late stent thrombosis in drug eluting stent patients, EuroIntervention, 2011;6:949–54.
    Crossref | PubMed
  63. Yang FS, Ohta I, Chiang HJ, et al., Non-surgical retrieval of intravascular foreign body: experience of 12 cases, Eur J Radiol, 1994;18:1–5.
    Crossref | PubMed
  64. Balbi M, Bezante GP, Brunelli C, Rollando D, Guide wire fracture during percutaneous transluminal coronary angioplasty: possible causes and management, Interact Cardiovasc Thorac Surg, 2010;10:992–4.
    Crossref | PubMed
  65. Stankovic G, Darremont O, Ferenc M, et al., Percutaneous coronary intervention for bifurcation lesions: 2008 consensus document from the fourth meeting of the European Bifurcation Club, EuroIntervention, 2009;5:39–49.
    Crossref | PubMed
  66. Hahn JY, Song YB, Lee SY, et al., Serial intravascular ultrasound analysis of the main and side branches in bifurcation lesions treated with the T-stenting technique, J Am Coll Cardiol, 2009;54:110–7.
    Crossref | PubMed
  67. Kim SH, Kim YH, Kang SJ, et al., Long-term outcomes of intravascular ultrasound-guided stenting in coronary bifurcation lesions, Am J Cardiol, 2010;106:612–8.
    Crossref | PubMed