Article

Perspective on bifurcation PCI.

Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.
Journal of Interventional Cardiology (impact factor: 1.18). 05/2009; 22(2):99-109. DOI:10.1111/j.1540-8183.2009.00441.x pp.99-109
Source: PubMed

ABSTRACT Coronary bifurcation lesion is a complex lesion with suboptimal angiographic and clinical results. There has been no satisfactory classification of the lesion that can guide selection of strategies and predict short- and long-term outcomes. The difference between left main (LM) bifurcation lesions and non-LM bifurcation is striking. So many stenting strategies have been proposed and tried in trials. They include the V, T, Y, one-stent, two-stent, crush, mini-crush, DK, and SKS techniques. However, because these techniques are time and labor intensive, dedicated bifurcated stents have been invented and trialed in humans. This review presents a historical perspective of interventions in bifurcated lesions, with the strengths and weaknesses of the major strategies and of the new dedicated stents.

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    Article: Expansion of the Multi-Link Frontier™ coronary bifurcation stent: micro-computed tomographic assessment in human autopsy and porcine heart samples.
    Stefan Kralev, Benjamin Haag, Jens Spannenberger, Siegfried Lang, Marc A Brockmann, Soenke Bartling, Alexander Marx, Karl-Konstantin Haase, Martin Borggrefe, Tim Süselbeck
    [show abstract] [hide abstract]
    ABSTRACT: Treatment of coronary bifurcation lesions remains challenging, beyond the introduction of drug eluting stents. Dedicated stent systems are available to improve the technical approach to the treatment of these lesions. However dedicated stent systems have so far not reduced the incidence of stent restenosis. The aim of this study was to assess the expansion of the Multi-Link (ML) Frontier™ stent in human and porcine coronary arteries to provide the cardiologist with useful in-vitro information for stent implantation and selection. Nine ML Frontier™ stents were implanted in seven human autopsy heart samples with known coronary artery disease and five ML Frontier™ stents were implanted in five porcine hearts. Proximal, distal and side branch diameters (PD, DD, SBD, respectively), corresponding opening areas (PA, DA, SBA) and the mean stent length (L) were assessed by micro-computed tomography (micro-CT). PD and PA were significantly smaller in human autopsy heart samples than in porcine heart samples (3.54±0.47 mm vs. 4.04±0.22 mm, p = 0.048; 10.00±2.42 mm(2) vs. 12.84±1.38 mm(2), p = 0.034, respectively) and than those given by the manufacturer (3.54±0.47 mm vs. 4.03 mm, p = 0.014). L was smaller in human autopsy heart samples than in porcine heart samples, although data did not reach significance (16.66±1.30 mm vs. 17.30±0.51 mm, p = 0.32), and significantly smaller than that given by the manufacturer (16.66±1.30 mm vs. 18 mm, p = 0.015). Micro-CT is a feasible tool for exact surveying of dedicated stent systems and could make a contribution to the development of these devices. The proximal diameter and proximal area of the stent system were considerably smaller in human autopsy heart samples than in porcine heart samples and than those given by the manufacturer. Special consideration should be given to the stent deployment procedure (and to the follow-up) of dedicated stent systems, considering final intravascular ultrasound or optical coherence tomography to visualize (and if necessary optimize) stent expansion.
    PLoS ONE 01/2011; 6(7):e21778. · 4.09 Impact Factor
  • Article: Classification and treatment of coronary artery bifurcation lesions: putting the Medina classification to the test.
    David M Zlotnick, Vijay S Ramanath, Jeremiah R Brown, Aaron V Kaplan
    [show abstract] [hide abstract]
    ABSTRACT: Coronary bifurcation lesions are common, difficult to treat, and associated with poorer outcomes compared to non-bifurcation lesions. The Medina classification has been widely adopted as the preferred system to classify bifurcation lesions, however there have been little efforts to characterize this metric. The objective of this study was to characterize the inter-observer variability of the Medina classification and examine its contribution to treatment selection strategy. We invited 150 interventional cardiologists from the United States and Europe to complete an online survey evaluating 12 freeze frame coronary angiograms of bifurcation lesions. Each respondent was asked to characterize the bifurcation lesions using the Medina classification and other metrics including side branch vessel size and angle. Respondents were asked to designate either a provisional (1 stent) or dedicated (2 stent) treatment strategy. 'Complex' lesions were defined as Medina scores 1.1.1, 0.1.1, or 1.0.1. A total of 49 interventional cardiologists responded. In 7 of the 12 angiograms evaluated, there was >75% agreement regarding lesion classification using the Medina system. There was moderate inter-observer agreement when using Medina to classify lesions as 'Complex' vs. 'non-Complex'. 'Complex' bifurcation designation and side branch size were predictive of selection of a dedicated treatment strategy, whereas side branch angle was not. The Medina classification is a useful tool in characterizing coronary bifurcation lesions. For the majority of the angiograms evaluated there was good inter-observer agreement in lesion classification using the Medina system. 'Complex' bifurcation designation and side branch size were predictive of selection of a dedicated treatment strategy.
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Keywords

bifurcated lesions
 
bifurcated stents
 
complex lesion
 
Coronary bifurcation lesion
 
historical perspective
 
labor intensive
 
lesion
 
long-term outcomes
 
main
 
major strategies
 
mini-crush
 
non-LM bifurcation
 
one-stent
 
satisfactory classification
 
short-
 
SKS techniques
 
stenting strategies
 
suboptimal angiographic
 
trialed
 
trials
 

Shao-Liang Chen