Bifurcation Lesions
2010; Lippincott Williams & Wilkins; Volume: 3; Issue: 2 Linguagem: Inglês
10.1161/circinterventions.110.952416
ISSN1941-7632
AutoresAntonio Colombo, Rasha Al‐Lamee,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculation: Cardiovascular InterventionsVol. 3, No. 2Bifurcation Lesions Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBBifurcation LesionsAn Inside View Antonio Colombo, MD and Rasha Al-Lamee, MD Antonio ColomboAntonio Colombo From the Interventional Cardiology Unit (A.C., R.A.L.), San Raffaele Scientific Institute, Milan, Italy; Interventional Cardiology Unit (A.C., R.A.L.), EMO GVM Centro Cuore Columbus, Milan, Italy; Imperial College Healthcare NHS Trust (R.A.L.), London, England. and Rasha Al-LameeRasha Al-Lamee From the Interventional Cardiology Unit (A.C., R.A.L.), San Raffaele Scientific Institute, Milan, Italy; Interventional Cardiology Unit (A.C., R.A.L.), EMO GVM Centro Cuore Columbus, Milan, Italy; Imperial College Healthcare NHS Trust (R.A.L.), London, England. Originally published1 Apr 2010https://doi.org/10.1161/CIRCINTERVENTIONS.110.952416Circulation: Cardiovascular Interventions. 2010;3:94–96Listening to dodecaphonic music requires patience and a willingness to be prepared to study the same piece over and over again. We experienced a similar feeling after reading 2 important studies about bifurcation lesions featured in this issue of Circulation: Cardiovascular Interventions. The first read gives a general impression; however, understanding and appreciation only comes after reading them a few times and devoting an effort to understand them. Bifurcation lesions historically have been associated with high restenosis rates1,2 and early atherogenesis,3,4 with the ostium of the side branch (SB) being the most common site of restenosis after stenting.1,5 Improvements in bifurcation stent techniques, the results from numerous randomized controlled trials,6–8 and registry data have led to the commonly held belief that provisional stenting should be our first-line strategy in the majority of lesions.9,10 However, the mechanism of SB neointimal hyperplasia and the implications of our choice of bifurcation stent technique still require further evaluation to ensure that we understand the long-term outcomes after percutaneous coronary intervention (PCI) in this complex lesion subgroup. The featured articles address a few of our ongoing queries with regard to bifurcation disease and provide some further information on the anatomy of these lesions and the relative significance of the SB.Articles see pp 105 and 113Koo et al11 evaluated the mechanisms of changes in the geometry of the ostium of the SB after main branch (MB) stenting and investigated the predictors of a functionally significant SB stenosis using intravascular ultrasound (IVUS) and fractional flow reserve (FFR). The authors enrolled patients with a predetermined provisional SB strategy for de novo, proximal, or mid left anterior descending (LAD) artery lesions and went on to perform IVUS of the MB before and after MB stenting to measure the vessel volume index, lumen volume index, and plaque volume index in the proximal and mid-MB, thereby testing the hypothesis that MB stenting was likely to cause worsening of an SB ostial lesion as a result of MB plaque and carina shift. In addition, FFR of the SB was measured after intervention and compared with preintervention angiographic and IVUS parameters to assess the predictors of a functionally significant SB stenosis (defined as FFR <0.75) after PCI to the MB.The main findings of this study in terms of IVUS evaluation after MB stent implantation were (1) a significant increase in the vessel and lumen volume index in both the proximal and distal segments of the MB, (2) a significant decrease in the plaque volume index in the proximal segment of the MB, and (3) no change in the plaque volume index in the distal segment of the MB after PCI. Furthermore, the preintervention angiographic and IVUS predictors of a functionally significant SB stenosis were (1) SB minimal lumen diameter, (2) plaque volume index of the proximal MB, (3) SB percentage stenosis, and (4) lumen volume index of the distal MB. The investigators concluded that the decrease in plaque volume in the proximal MB, with no associated increase in plaque volume in the distal MB, was indirect evidence of plaque shift from the MB to the SB ostium after stent implantation. Additionally, the increased luminal volume in the distal MB, with no significant decrease in the plaque volume, was believed to be due to vessel enlargement and provided support to the theory that carina shift is likely to contribute to the degree of luminal narrowing of the SB. Furthermore, preintervention factors such as the size of the SB, the degree of SB stenosis, the degree of plaque within the proximal MB, and the size of the lumen in the distal MB may be useful in predicting the likelihood of significant SB stenosis by FFR after PCI.Interestingly, FFR assessment of the SB after intervention revealed that a hemodynamically significant SB stenosis was present only in 54.5% of lesions classified as severe by angiography and that 29.4% of angiographically nonsignificant SB lesions were associated with an abnormal FFR. These results are not entirely consistent with a previous study by Koo et al12 in which only 27% of SB with a severe stenosis by angiography had an FFR <0.75, and no SB lesions with an angiographic stenosis of 10 mm in length) of the SB, whereas Oviedo et al15 mainly assessed LMCA lesions with moderate stenosis by angiography. Therefore, neither study evaluated the anatomy of severe bifurcation lesions with large plaque burden in the SB.The recently published British Bifurcation Coronary Study: Old, New, and Evolving Strategies study evaluated the clinical implications of the choice of bifurcation stent technique in a cohort of patients in which the majority (>80%) had true bifurcations by the Medina classification system.10 The results suggest a significantly higher incidence of periprocedural myocardial infarction and major adverse cardiac events at 9-month follow-up after the use of a complex bifurcation technique compared with a simple provisional strategy. However, it is possible that an appropriate use of IVUS after complex bifurcation PCI, and a critical FFR-guided appraisal of the results obtained following a simple strategy, would have given different outcomes.Perhaps the most pragmatic advice is that each operator should continue to apply his or her most preferred and successful approach to make individual procedures simpler and more streamline. In addition, the optimum strategy should be tailored to each interventional case, and although provisional T-stenting has its technical advantages, it is not ideal for all lesions. With that in mind, we leave with the final thought that the simplest approach is not always the best approach.The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.DisclosuresAntonio Colombo is a minor share holder in Cappella, Inc, a company manufacturing a self-expanding bare-metal stent for ostial lesions.FootnotesCorrespondence to Antonio Colombo, MD, Columbus Hospital, EMO-GVM, Via Buonarroti 48, 20145 Milan, Italy. E-mail [email protected] References 1 Colombo A, Moses JW, Morice MC, Ludwig J, Holmes DR Jr, Spanos V, Louvard Y, Desmedt B, Di Mario C, Leon MB. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation. 2004; 109: 1244–1249.LinkGoogle Scholar2 Ge L, Iakovou I, Cosgrave J, Agostoni P, Airoldi F, Sangiorgi GM, Michev I, Chieffo A, Montorfano M, Carlino M, Corvaja N, Colombo A. Treatment of bifurcation lesions with two stents: one year angiographic and clinical follow up of crush versus T stenting. Heart. 2006; 92: 371–376.CrossrefMedlineGoogle Scholar3 Kimura BJ, Russo RJ, Bhargava V, McDaniel MB, Peterson KL, DeMaria AN. Atheroma morphology and distribution in proximal left anterior descending coronary artery: in vivo observations. J Am Coll Cardiol. 1996; 27: 825–831.CrossrefMedlineGoogle Scholar4 Hahn JY, Song YB, Lee SY, Choi JH, Choi SH, Kim DK, Lee SH, Gwon HC. 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: 110–117.CrossrefMedlineGoogle Scholar5 Tanabe K, Hoye A, Lemos PA, Aoki J, Arampatzis CA, Saia F, Lee CH, Degertekin M, Hofma SH, Sianos G, McFadden E, Smits PC, van der Giessen WJ, de Feyter P, van Domburg RT, Serruys PW. Restenosis rates following bifurcation stenting with sirolimus-eluting stents for de novo narrowings. Am J Cardiol. 2004; 94: 115–118.CrossrefMedlineGoogle Scholar6 Ferenc M, Gick M, Kienzle RP, Bestehorn HP, Werner KD, Comberg T, Kuebler P, Buttner HJ, Neumann FJ. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J. 2008; 29: 2859–2867.CrossrefMedlineGoogle Scholar7 Erglis A, Kumsars I, Niemela M, Kervinen K, Maeng M, Lassen JF, Gunnes P, Stavnes S, Jensen JS, Galloe A, Narbute I, Sondore D, Makikallio T, Ylitalo K, Christiansen EH, Ravkilde J, Steigen TK, Mannsverk J, Thayssen P, Hansen KN, Syvanne M, Helqvist S, Kjell N, Wiseth R, Aaroe J, Puhakka M, Thuesen L. 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.LinkGoogle Scholar8 Steigen TK, Maeng M, Wiseth R, Erglis A, Kumsars I, Narbute I, Gunnes P, Mannsverk J, Meyerdierks O, Rotevatn S, Niemela M, Kervinen K, Jensen JS, Galloe A, Nikus K, Vikman S, Ravkilde J, James S, Aaroe J, Ylitalo A, Helqvist S, Sjogren I, Thayssen P, Virtanen K, Puhakka M, Airaksinen J, Lassen JF, Thuesen L. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation. 2006; 114: 1955–1961.LinkGoogle Scholar9 Tsuchida K, Colombo A, Lefevre T, Oldroyd KG, Guetta V, Guagliumi G, von Scheidt W, Ruzyllo W, Hamm CW, Bressers M, Stoll HP, Wittebols K, Donohoe DJ, Serruys PW. The clinical outcome of percutaneous treatment of bifurcation lesions in multivessel coronary artery disease with the sirolimus-eluting stent: insights from the Arterial Revascularization Therapies Study part II (ARTS II). Eur Heart J. 2007; 28: 433–442.CrossrefMedlineGoogle Scholar10 Hildick-Smith D, de Belder AJ, Cooter N, Curzen NP, Clayton TC, Oldroyd KG, Bennett L, Holmberg S, Cotton JM, Glennon PE, Thomas MR, Maccarthy PA, Baumbach A, Mulvihill NT, Henderson RA, Redwood SR, Starkey IR, Stables RH. 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: 1235–1243.LinkGoogle Scholar11 Koo B-K, Waseda K, Kang H-J, Kim H-S, Nam C-W, Hur S-H, Kim J-S, Choi D, Jang Y, Hahn J-Y, Gwon H-C, Yoon M-H, Tahk S-J, Chung W-Y, Cho Y-S, Choi D-J, Hasegawa T, Kataoka T, Oh S-J, Honda Y, Fitzgerald PJ, Fearon WF. Anatomic and functional evaluation of bifurcation lesions undergoing percutaneous coronary intervention. Circ Cardiovasc Interv. 2010; 3: 113–119.LinkGoogle Scholar12 Koo BK, Kang HJ, Youn TJ, Chae IH, Choi DJ, Kim HS, Sohn DW, Oh BH, Lee MM, Park YB, Choi YS, Tahk SJ. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol. 2005; 46: 633–637.CrossrefMedlineGoogle Scholar13 Park SJ, Kim YH, Park DW, Lee SW, Kim WJ, Suh J, Yun SC, Lee CW, Hong MK, Lee JH, Park SW. Impact of intravascular ultrasound guidance on long-term mortality in stenting for unprotected left main coronary artery stenosis. Circ Cardiovasc Interv. 2009; 2: 167–177.LinkGoogle Scholar14 Valgimigli M, Malagutti P, Rodriguez Granillo GA, Tsuchida K, Garcia-Garcia HM, van Mieghem CA, van der Giessen WJ, De Feyter P, de Jaegere P, Van Domburg RT, Serruys PW. Single-vessel versus bifurcation stenting for the treatment of distal left main coronary artery disease in the drug-eluting stenting era. Clinical and angiographic insights into the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated at Rotterdam Cardiology Hospital (T-SEARCH) registries. Am Heart J. 2006; 152: 896–902.CrossrefMedlineGoogle Scholar15 Oviedo C, Maehara A, Mintz GS, Araki H, Choi S-Y, Tsujita K, Kubo T, Doi H, Templin B, Lansky AJ, Dangas G, Leon MB, Mehran R, Tahk SJ, Stone GW, Ochiai M, Moses JW. Intravascular ultrasound classification of plaque distribution in left main coronary artery bifurcations: where is the plaque really located? Circ Cardiovasc Interv. 2010; 3: 105–112.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sheiban I, Figini F, Gasparetto V, D'Ascenzo F, Moretti C and Leonardo F (2021) Side Branch is the Main Determinant Factor of Bifurcation Lesion Complexity: Critical Review with a Proposal Based on Single-centre Experience, Heart International, 10.17925/HI.2021.15.2.67, 15:2, (67), . 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Iakovou I, Kadota K, Papamentzelopoulos S, Pavlides G and Mitsudo K (2010) Is there a higher risk of stent thrombosis in bifurcation lesion or is it related to the technique?, EuroIntervention, 10.4244/EIJV6SUPJA17, 6:J, (J107-J111), Online publication date: 1-Dec-2010. Giannoglou G, Antoniadis A, Koskinas K and Chatzizisis Y (2010) Flow and atherosclerosis in coronary bifurcations, EuroIntervention, 10.4244/EIJV6SUPJA4, 6:J, (J16-J23), Online publication date: 1-Dec-2010. April 2010Vol 3, Issue 2 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCINTERVENTIONS.110.952416PMID: 20407110 Originally publishedApril 1, 2010 Keywordsbifurcation lesionscoronary diseaseintravascular ultrasoundfractional flow reserveEditorialsPDF download Advertisement SubjectsImagingStent
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