SCAI 22 BIF and LM lesions Flashcards
What is bifurcation percutaneous coronary intervention (PCI)?
Bifurcation PCI is one of the most technically challenging, controversial, and interesting aspects of interventional cardiology.
What is the significance of arterial bifurcations in PCI?
Arterial bifurcations produce areas of variable endothelial shear stress, leading to atherosclerotic plaque formation in low shear stress areas.
Areas of low stress like the lateral wall of the main vessel and side branch. These areas are prone to more atherosclerosis.
Areas of high stress like the carina are usually spared.
What percentage of PCI procedures involve bifurcation lesions?
Bifurcation lesions comprise approximately 20% of all PCI procedures.
What was the main concern prior to the stent era regarding bifurcation PCI?
There were concerns about dissection or abrupt closure of the main vessel or side branch.
What are the risks associated with bifurcation PCI?
Bifurcation PCI is associated with a higher risk of procedural complications and short- and long-term clinical sequelae.
What is the relationship between bifurcation lesions and left main (LM) PCI?
Any discussion of bifurcation lesion PCI is incomplete without discussing LM PCI, as the LM bifurcation is involved in 61% of all LM lesions.
What was the traditional treatment for LM disease before the advancement of PCI?
Coronary artery bypass grafting (CABG) was the mainstay of treatment for both simple and complex LM disease.
What unique considerations must be made for LM lesions during PCI?
LM lesions comprise the highest risk lesion subset, necessitating unique considerations when planning and performing PCI.
What is the significance of recent trials regarding bifurcation and LM PCI?
Recent trials provide further evidence to inform clinical decision making, highlighting the heterogeneity within bifurcation and LM lesions.
How can a coronary bifurcation be conceptualized?
A coronary bifurcation can be conceptualized as three different diameter vessels: the proximal main vessel (PMV), the distal main vessel (DMV), and the side branch.
What does Murray’s law define?
Murray’s law defines the relationship of the diameters of the PMV, DMV, and side branch, summarized by
Finet’s formula: PMV diameter = 0.678 (DMV diameter + side-branch diameter).
What is the definition of a bifurcation lesion according to Louvard et al?
A bifurcation lesion is defined as ‘a coronary artery narrowing occurring adjacent to, and/or involving, the origin of a significant side branch.’
What constitutes a ‘significant’ side branch?
A significant side branch is one that ‘you do not want to lose in the global context of a particular patient.’ Examples, maybe symptoms, location of ischemia, branch, responsible of ischemia symptoms, viability, collateralizing vessel, left ventricular function, etc..
How is a clinically significant vessel defined?
A clinically significant vessel is defined as one that subtends >10% of myocardial mass.
What percentage of non-LM side branches are considered clinically significant?
Only a minority (~20%) of non-LM side branches are considered clinically significant.
What length of side branches meets the definition of clinical significance?
Side branches >73 mm in length meet the definition of clinical significance.
What scoring system can help predict the significance of a side branch?
The SNuH score, which considers the diameter of a side branch, the number of other side branches, and height of a side branch, can help predict significance.
What additional data may be useful in assessing side branch significance?
Data from functional testing and cardiac computed tomography (CT) may also be of use.
What is the most prevalent classification system for bifurcation lesions?
The Medina classification is the most prevalent in both literature and clinical practice.
What is considered a significant stenosis in the Medina classification?
A stenosis greater than 50% is considered significant.
How is the presence of significant stenosis denoted in the Medina classification?
The number one (1) denotes the presence of a significant stenosis, while zero (0) denotes its absence.
What segments are recorded in the Medina classification?
The classification records the presence or absence of significant stenosis in the PMV, DMV, and side branch.
In what order are the segments recorded in the Medina classification?
The order is PMV, DMV, and side branch.
How would a lesion involving both the PMV and DMV but not the side branch be recorded?
It would be recorded as 1,1,0.
What is Medina classification for this by BIF in the picture?
Medina 1, 0, 0
What is the Medina identification for this picture?
1,1,1
What is the Medina classification?
The Medina classification is a straightforward and user-friendly anatomical classification system for bifurcation lesions.
What are the limitations of the Medina classification?
It does not provide information on several lesion characteristics that predict complications, such as bifurcation angle, size of the side branch, length of the side-branch lesion, and presence of calcification.
What is a ‘true bifurcation’?
A ‘true bifurcation’ is a concept used in trials and clinical practice with variable definitions (e.g., Medina 1,1,1, 1,0,1, or 0,1,1).
Why is planning important for bifurcation lesions?
Adequate planning and understanding of available evidence are crucial for procedural success and optimizing long-term outcomes.
What approaches are favored in current consensus documents for bifurcation lesions?
Consensus documents promote simple and safe approaches that respect original bifurcation anatomy, minimize stents, and optimize flow and function after PCI.
What are the two major methods of bifurcation stenting?
The two major methods are provisional stenting and two-stent strategy.
What is provisional stenting?
Provisional stenting involves stenting the main vessel across the side-branch ostium, with further intervention only if the side branch is significantly compromised.
What does the two-stent strategy entail?
The two-stent strategy involves upfront stenting of both the main vessel and side branch, encompassing a range of techniques.
What is required to understand the three-dimensional structure of bifurcations?
Multiple angiographic angulations are required to obtain a clear understanding of all three segments of the bifurcation ( see picture )
What is recommended if a side branch is deemed significant?
Wiring of both the main vessel and side branch is recommended.
Which branch should be wired first?
The most difficult branch to wire should be wired first.
What should be avoided when wiring the second wire?
The second wire should be minimally manipulated to avoid ‘wire wrap.’
When is wiring the side branch particularly necessary?
Wiring the side branch is necessary when a two-stent approach is adopted. however, wiring the side branch is also thought to have several benefits when using a provisional approach.
What is a critical consideration when using rotational atherectomy?
A second wire is likely to be damaged by the rotational atherectomy burr if it is left in situ.
What challenge does rotational atherectomy present in bifurcation lesions ?
The presence of a second wire is problematic because the burr may damage the wire. Rotational atherectomy may lead to dissection, complicating the rewiring of the side branch when the wire is removed before use of atherectomy.
When is it desirable to leave a second wire in situ when performing atherectomy ?
It is desirable for very difficult to wire side branches or clinically important branches like the left circumflex in LM PCI. In this situation, use a large French guide catheter for example 8 French or above, then follow the microcatheter and advanced it over the second wire to protect the wire from the rotational atherectomy burr.
How can a second wire be protected during rotational atherectomy?
A microcatheter can be advanced over the second wire using a large French guide catheter (≥8 Fr) to protect it.
What should be done if multiple rotational atherectomy runs are performed?
The microcatheter should be advanced or retracted a small amount to reduce the risk of damaging it.
What is the general recommendation for preparing the main vessel?
Preparation of the main vessel with balloon angioplasty should be performed in most cases.
What should be avoided if a provisional approach is adopted?
Preparation of the side branch should be avoided as it may lead to dissection.
What should be done if an up-front two-stent approach is decided?
Both the main vessel and side branch should be prepared.
What are the two strategies for treating bifurcation lesions?
The two strategies are provisional stenting and two-stent strategy.
What does current evidence suggest about provisional stenting in simple bifurcation lesions?
Current evidence suggests equal or better outcomes with provisional stenting in simple bifurcation lesions, when compare with upfront to stent technique.
What advantages does provisional stenting have over two-stent strategies?
Provisional stenting has significantly shorter procedure times, fluoroscopy times, and lower contrast volumes.
How are complex lesions defined?
Complex lesions are defined by the DEFINITION criteria, which utilize angiographic characteristics predicting major adverse events post-PCI.
What did the DEFINITION II study establish about two-stent strategies in complex lesions?
The DEFINITION II study established that upfront two-stent strategies have reduced rates of target lesion revascularization, target vessel myocardial infarction (MI), and target vessel failure in complex lesions that meet DEFINITION criteria.
What do current consensus documents recommend regarding stenting strategies?
Current consensus documents recommend provisional stenting as the standard approach, reserving up-front two-stent strategies for lesions with complex anatomy.
You should know DEFINITION criteria very well:
What is the purpose of placing wires in both the side branch and main vessel during provisional stenting?
To provide a marker for rewiring in case of side-branch occlusion, assist in anchoring the guiding catheter, facilitate access to the side branch, and allow passage of a small balloon behind the main vessel stent struts if needed.
What factors influence the decision to wire a side branch?
The area of myocardium supplied by the side branch, lesion complexity, and the degree of disease in the ostial/proximal side branch.
What is the Proximal Optimization Technique (POT)?
The main vessel stent should be sized to the distal vessel. The proximal edge of the stent should be placed so that enough stent length is present to allow for POT – usually 6 to 8 mm minimum length proximal to the bifurcation.
POT is the technique of post-dilation of the stent proximal to the bifurcation.
What should be considered when placing the proximal edge of the stent?
Enough stent length must be present to allow for POT, with a minimum length determined by the shortest available balloon length (usually 6-8 mm).
How can the proximal vessel size and POT balloon size be determined?
By quantitative coronary angiography, intravascular imaging, or Finet’s formula.
What type of balloon should be used for POT?
A noncompliant balloon, ensuring the distal edge is inflated just proximal to the carina.
A recent study has shown that POT may also reduce the need for additional side branch intervention.
What is ‘jailing’ in the context of stenting?
Leaving the side-branch wire in place while performing main vessel stenting and POT.
What are the concerns associated with wire jailing?
The possibility of wire damage and fracture when removing jailed wires.
What did a study suggest about polymer-coated wires ( Fielder , Pilot , whisper )?
They are more resistant to retrieval damage and more efficient in crossing the side-branch ostium than nonpolymer-coated wires.
What potential benefit was suggested by the COBIS III registry regarding wire jailing?
Significantly lower rates of side-branch occlusion in patients with a side branch or main vessel stenosis ≥60%.
What is assessed after POT?
Angiography is performed and the side branch is assessed.
What factors are considered in assessing side-branch compromise?
Diameter and length of the side branch, degree of angiographic stenosis, presence or absence of symptoms, ECG changes, and TIMI flow.
What is the decision-making complexity regarding side-branch rescue?
The decision to rescue a compromised side branch by further intervention is complex.
What is an example of a side branch that may not be intervened on?
A 2 mm diameter side branch with 90% stenosis and TIMI 2 flow with no symptoms or ECG changes may not be intervened on.
What is an example of a side branch that is likely to be rescued?
A 3.5 mm diameter side branch with 95% ostial stenosis and TIMI 3 flow with associated chest pain and ECG changes is likely to be rescued.
What assessment may be used when side-branch compromise is unclear?
Functional assessment using fractional flow reserve (FFR) may be used. Studies have shown physiological studies good alternative to assess the side branch and outcomes are clinically comparable compared to angiogram assessment.
What is the goal when rescuing a side branch?
To use a balloon to restore flow to the side branch while maintaining the architectural integrity of the main vessel stent.
Rescue is performed by rewiring the side branch through a distal STENT strut .
This process allows better STRUT clearance from the side branch ostium and also allows STENTS scaffold to be positioned opposite to the CARINA. ( needs more clarification here )
What is Kissing Balloon Inflation (KBI)?
What should follow after side branch rewiring is debatable: the goal is to use a balloon to restore the flow to the side branch while maintaining the architecture of the main vessel stent. This is sometimes achieved using kissing balloon inflation.
KBI is inflating two balloons – one across the side-branch ostium and the other in the main vessel – which ‘kiss’ in the PMV.
❗️In provisional stenting, routine KBI , regardless of the side branch compromise, has not demonstrated clear, clinical benefits, and may cause harm. Therefore, KBI is selective not a must.
What type of balloons should be used if KBI is performed?
Noncompliant balloons should be used. NC balloons have been associated with a reduction in side branch STENTING and PERI – procedural MI. so in general, we use NC balloons and we do not use compliant balloons.
What alternative process has been proposed for side-branch dilatations?
A process of sequential POT-side-branch-POT dilatations has been proposed. this approach has been scrutinized because of main vessel STENT distortion and reduced ostial side branch area.
What may occur if an acceptable result is achieved with balloon dilatation?
No further intervention may be required.
What may be done if side-branch results are suboptimal after balloon dilatation?
A decision may be made to insert a second stent. Here if the BIF angle is 90° then it may be suitable for T STENTING. However, of the angle is more acute than you can do either CULOTTE or TAP OR REVERSE CRUSH.
What are two-stent techniques?
Two-stent techniques refer to methods used in upfront two-stent interventions for bifurcation lesions.
Why is knowledge of various techniques important?
Knowledge of a variety of techniques is required due to the anatomical diversity of bifurcation lesions.
What have studies attempted to determine regarding two-stent techniques?
Several studies have attempted to determine which two-stent strategy has superior clinical outcomes.
What is the MADS classification?
The MADS classification helps describe and define two-stent techniques based on the position of the first stent: Main proximal first, main Across the side branch, Double proximal lumen, and Side-branch first.
Examples include Skirt stent, TAP, simultaneous kissing stents, and DK crush.
What does the MADS classification include regarding subsequent balloon techniques?
The MADS classification includes coded descriptions: P for postdilation of the PMV, S for balloon dilatation of the side-branch ostium, and K for KBI.
What is the Crush technique?
The Crush technique involves stenting the side-branch first, with some degree of proximal STENT hanging from the side branch into the main branch. Then deploying the main-branch stent to crush the proximal side-branch stent to the artery wall.
The ‘mini’ crush is similar but with less stent hanging into the main branch.
Why is the Crush technique no longer recommended?
The Crush technique is no longer recommended due to a greater risk of failed KBI, which may lead to worse clinical outcomes.
What is the Reverse Crush technique?
This is obviously used as a part of an initial provisional technique.
This is when we realize that the side branch requires STENTING.
The Reverse Crush technique involves placing a balloon in the main branch, positioning a stent in the side branch, pulling it back 2 to 3 mm across the ostium, and deploying it.
Then, after removing of the stent balloon from the side branch, the main branch balloon is deployed at high pressure.
So I think it’s like TAP but without NEO – CARINA.
What is the Double Kissing Crush technique?
In the Double Kissing Crush technique:
- the side branch is stented,
- followed by balloon inflation in the main branch (balloon crush ) ,
- kissing balloons in both branches,
- stenting the main vessel, and performing POT and KBI.
Before rewiring always do POT!
What is the Culotte technique?
The Culotte technique uses two stents to create ‘pant legs’ by deploying a stent across the side branch and performing several steps including POT and KBI.
This technique is best for bifurcations where the side branch and DMV have similar diameters (up to 0.5 mm difference) and narrow bifurcation angles (<70°).
What is the Culotte technique?
The Culotte technique uses two stents to create ‘pant legs’ in bifurcation lesions.
What is the first step in the Culotte technique?
Both branches are individually predilated.
What happens after deploying the first stent in the Culotte technique?
A stent is deployed across the side branch with the proximal portion positioned into the main branch.
What is performed after deploying the first stent?
A POT (Proximal Optimization Technique) is then performed (Always POT before next rewiring).
What is done after rewiring the main branch through the distal strut of the first stent?
The main branch is predilated.
What is the next step after predilating the main branch?
A stent is positioned through the first stent into the main branch.
What is done after positioning the stent into the main branch?
A POT is performed again (really?) and the jailed side-branch wire is removed before stent deployment.
What is the final step in the Culotte technique?
The side branch is rewired, POT before rewiring, KBI (Kissing Balloon Inflation) is performed, followed by a final POT.
When is the Culotte technique best utilized?
It is best utilized in bifurcations where the side branch and DMV have similar diameters (up to 0.5 mm difference) and narrow (<70°) bifurcation angles.
What is the first step in the T and Protrusion technique?
The first step involves stenting the main branch while jailing the guide wire in the side branch. I.e. provisional technique.
What follows after stenting the main branch in the T and Protrusion technique?
The side branch is rewired, and then KBI is performed.
What is done after rewiring the side branch in the T and Protrusion technique?
A stent is placed in the side branch and a balloon is kept in the main branch.
How is the side-branch stent positioned in the T and Protrusion technique?
The side-branch stent is pulled back just enough to cover the ostium.
What is the final step in the T and Protrusion technique?
Kissing balloon is performed with the side-branch and main-branch balloons.
What is the positioning of the stent in the T Stent technique?
A stent is placed in the side branch and positioned right at the ostium with no protrusion into the main branch.
How does the balloon in the main branch assist in the T Stent technique?
A balloon in the main branch is helpful in positioning the side-branch balloon.
What is done after the side-branch stent deployment in the T Stent technique?
A stent is placed in the main branch.
What does the ‘modified’ T stent involve?
It involves positioning of the side-branch and main-branch stents simultaneously.
What is the order of deployment in the modified T stent technique?
The side-branch stent is deployed first, and equipment is removed before deploying the main-branch stent. it is very important to remove the equipment before deploying the main branch STENT because you don’t want to sandwich the wire between both stents.
What is V Stenting?
A method where two stents are deployed simultaneously in both a main branch and a side branch such that the stents touch at their proximal portions forming a ‘carina.’
What is required for V Stenting?
This method requires a ≥7 Fr guiding catheter.
What is Simultaneous Kissing Stents (SKS)?
SKS is a process similar to V stenting, where proximal stents hang back into the main vessel by more than 5 mm.
What is another name for the SKS technique?
Some operators refer to SKS as the ‘double barrel’ technique, especially in left-main bifurcation stenting.
What is an advantage of the SKS technique?
Neither branch access is lost nor ‘recrossing’ is required.
What is the guiding catheter requirement for SKS?
SKS requires a guiding catheter of ≥7 Fr.
What is the majority location of LM disease?
The majority of LM disease involves the distal bifurcation.
What percentage of LM disease involves the ostium?
23% of LM disease involves the ostium.
What percentage of LM disease involves the midshaft?
15% of LM disease involves the midshaft.
How do clinical outcomes compare for PCI of the LM ostium and midshaft versus the bifurcation?
Patients who undergo PCI of the LM ostium and midshaft appear to have better clinical outcomes than those who undergo PCI to the LM bifurcation.
What did the EXCEL trial subanalysis find regarding distal LM PCI?
Distal LM PCI was associated with higher rates of target-vessel revascularization at 3 years compared with CABG.
How do outcomes for PCI at the ostium or midshaft compare to CABG?
Patients who underwent PCI with disease at the ostium or midshaft have similar outcomes to CABG.
What should be a decisive factor when selecting a revascularization strategy?
Lesion location should be a decisive factor when selecting a LM revascularization strategy.
What does Panel A of the figure show?
Panel A shows RAO caudal projection of the left coronary system of a patient postcardiac transplant with severe stenosis of the ostial and proximal LAD, chronic total occlusion of the ramus intermedius, and moderate left main disease.
What is depicted in Panel B?
Panel B shows RAO cranial projection of the LAD with Medina 1,1,0 disease at the bifurcation and a large first diagonal.
What was the primary strategy for treatment?
The primary strategy was provisional stenting to the LAD and left main bifurcations with IVUS guidance.
What does Panel C demonstrate?
Panel C demonstrates TIMI 1 flow in the diagonal after both vessels were wired and the LAD predilated.
What decision was made after Panel C?
A decision was made to convert to a two-stent approach with a DK crush technique.
What is shown in Panel D?
Panel D shows positioning of the diagonal stent prior to deployment, with a balloon in place in the LAD to facilitate crush.
What does Panel E illustrate?
Panel E demonstrates the first kissing balloon inflation, completing the remainder of the LAD/diagonal DK crush.
What is depicted in Panel F?
Panel F shows a stent being positioned at the ostium of the left main, overlapping with the previously deployed LAD stent, and a second wire placed in the aortic root to guide stent placement.
What was done after stent placement as shown in Panel F?
Postdilatation of the left main and LAD stents was guided by IVUS.
What does Panel G show?
Panel G shows the final result in the RAO caudal projection with TIMI 3 flow in the left circumflex.
What is shown in Panel H?
Panel H shows the final results of the LAD/diagonal DK crush in the RAO cranial projection.
What is the indication for intervention in LM stenoses?
Intervention is indicated for stenoses >50%.
What was demonstrated by a study utilizing intravascular ultrasound (IVUS) regarding LM diameter?
The average LM diameter is 5 mm with ranges between 3.5 and 6.5 mm.
What size guiding catheters should be considered if rotational atherectomy is required?
Larger-size guiding catheters (≥7 Fr) should be considered.
What is the benefit of using a more passive guide such as judkins left, for ostial LM lesions?
It is easier to retract and advance, allowing for accurate positioning of an ostial stent.
What is debated regarding wiring the left anterior descending artery (LAD) and LCx in LM stenting ?
Some argue that wiring only the LAD is necessary, while others believe wiring both vessels is important for side-branch rescue.
What role does intracoronary imaging play in LM PCI?
It provides useful information prestenting and poststenting.
What imaging techniques can provide important information during and after stenting?
IVUS and optical coherence tomography (OCT) are used to provide important information during and after stenting.
How does IVUS help in assessing LM stenosis?
IVUS is particularly useful in determining the severity of LM stenosis.
What minimum luminal area (MLA) on IVUS predicts physiological significance of LM disease?
An MLA of <6 mm² on IVUS strongly predicts the physiological significance of LM disease.
What is the outcome of deferring revascularization in patients with LM MLA ≥6 mm²?
Deferring revascularization in patients with an MLA ≥6 mm² results in similar rates of cardiac death-free survival and event-free survival compared with revascularized patients.
What is the acceptable LM MLA in Asian populations?
In Asian populations, an MLA of 4.5 mm² may be acceptable.
What additional information can intracoronary imaging provide?
Intracoronary imaging can delineate plaque configuration, including side-branch involvement, and assist in deciding on the most appropriate stenting strategy.
What are the benefits of using OCT in stenting?
OCT can confirm side-branch wire crossing location (proximal or distal STRUTS) and guide positioning of the side-branch stent.
What clinical benefits does intracoronary imaging provide as an adjunct to PCI?
Intracoronary imaging has significant clinical benefits, including lower rates of target vessel failure compared to angiography alone.
What did the ULTIMATE trial demonstrate regarding bifurcation lesions?
The ULTIMATE trial demonstrated significantly lower rates of target vessel failure in patients with bifurcation lesions when using intracoronary imaging.
What long-term outcomes were observed with IVUS guidance in complex bifurcation lesions?
A prospective study showed reduced major adverse cardiovascular events (MACE) with IVUS guidance up to 7 years post-PCI.
What did the MAIN-COMPARE registry study find regarding IVUS-guided LM PCI?
The MAIN-COMPARE registry study found lower mortality in patients undergoing IVUS-guided LM PCI versus angiography alone.
What did a substudy of the NOBLE trial reveal about IVUS post-PCI?
The substudy demonstrated significantly less target lesion revascularization in patients who underwent IVUS post-PCI.
What is the importance of pressure wire-based functional assessment in PCI?
Pressure wire-based functional assessment is vital in bifurcation and LM PCI.
How does FFR relate to angiographic assessment in side branch stenting?
FFR is a viable alternative to angiographic assessment of the side branch after main vessel stenting.
What is the limitation of angiography in assessing LM disease severity?
Angiography tends to underestimate or overestimate the severity of LM disease. hence the potential use of pressure wire assessment.
What percentage of patients with LM stenoses of <50% have hemodynamically significant disease?
Up to 40% of patients with LM stenoses of <50% are found to have hemodynamically significant disease by pressure-wire assessment.
What are the outcomes of deferring revascularization in patients with FFR-negative intermediate stenoses?
Deferring revascularization in patients with FFR-negative (<0.80) intermediate angiographic stenoses (30%-49%) has favorable outcomes.
What is the recommended duration of dual antiplatelet therapy (DAPT) after PCI in stable coronary artery disease?
6 months
Recommended for 12 months in ACSs with allowances to prolong or truncate based on bleeding and ischemia risks.
What does the 2016 AHA/ACC update say about DAPT duration for patients undergoing LM or bifurcation PCI?
It does not provide specific recommendations.
What is the recommendation level for prolonged DAPT in complex PCI according to the 2017 ESC update?
Class IIb level of recommendation.
What is a current topic of debate regarding DAPT and PCI ?
The optimum duration of DAPT after bifurcation PCI.
What is the risk associated with two-stent techniques in bifurcation PCI?
The optimum duration of DAPT after bifurcation PCI.
In general, if there is a two stent strategy, there is higher risk for thrombosis. meticulous attention to optimize STENT apposition, and expansion is very important.
What did a pooled patient-level analysis find regarding truncated DAPT of 3 or 6 months?
Complex PCI, including bifurcation lesions, treated with two stent technique, was associated with a higher incidence of 1-year major adverse cardiac events.
What does DAPT for ≥12 months in provisional technique and two stents bifurcation technique support according to a multicenter registry study?
It is associated with a lower risk of death or MI at 4 years post-PCI. it is important to mention that about 60% were treated for acute coronary syndrome.
What was the outcome of the substudy of the GLOBAL LEADERS trial regarding prolonged ticagrelor monotherapy?
No benefit in reducing all-cause death or new Q-wave MI in bifurcation PCI patients.
What is the general characteristic of the LM vessel regarding restenosis and thrombosis?
Rates are relatively low, especially if the distal bifurcation is not involved.
What did the PRODIGY trial retrospective analysis find regarding prolonged DAPT?
A 50% reduction in stent thrombosis with 24 months of DAPT compared to 6 months, in patients with left main or proximal LAD disease, regardless of whether PCI was performed to these vessels.
What was the result of the study comparing biodegradable polymer stents followed by truncated DAPT with standard durable polymer stents followed by 12 month DAPT?
Noninferior at 2 years with respect to major adverse cardiac events.
Truncated means 4 to 6 months and usually less than 12 months.
What are the two methods of revascularization considered for patients with LM disease?
The two methods are PCI (Percutaneous Coronary Intervention) and CABG (Coronary Artery Bypass Grafting).
What is the role of the SYNTAX score in revascularization strategy?
The SYNTAX score measures the complexity of coronary artery disease and guides the revascularization strategy.
How are patients categorized based on the SYNTAX score?
Patients are categorized into low (≤22), intermediate (23-32), and high-complexity (≥33) terciles.
What did the SYNTAX trial demonstrate regarding high syntax scores and PCI?
The SYNTAX trial demonstrated significantly higher cardiovascular events in patients with high syntax scores undergoing PCI. While, Equipoise was demonstrated in patients with SYNTAX scores less than 33.
This score is very important in guiding the strategy (PCI versus bypass) in patient with left main disease.
What do current European and American revascularization guidelines recommend for patients with significant LM and highly complex disease i.e. high syntax score.
The guidelines recommend CABG over PCI for these patients. That is because most of the studies comparing PCI to bypass in left main disease, in the literature, excluded highly complex disease.
What did the ten-year mortality data for left main disease, from the SYNTAX trial demonstrate?
Similar 10 year mortality rates of all-cause death in those undergoing PCI or CABG for LM disease.
What did the five-year outcome data from the EXCEL trial for left main disease, show?
No significant difference in the combined primary endpoint of death, stroke, or MI. ( PCI versus bypass).
What did the updated five-year follow-up data of the NOBLE trial demonstrate, for left main disease?
Persistent superiority of CABG over PCI.
What do the 2018 ESC/EACTS and 2021 ACC/AHA/SCAI revascularization guidelines state about bifurcation PCI?
They do not provide explicit classes of recommendation regarding bifurcation PCI.
What is noted as the preferred approach for most bifurcation lesions in the 2018 ESC/EACTS guidelines?
Provisional stenting should be the preferred approach.
What is reserved for more complex lesions and true distal LM bifurcations according to the 2018 ESC/EACTS guidelines?
Up-front two-stent strategies.
What does the 2018 ESC/EACTS document say about evidence favoring bifurcation techniques for non-LM lesions?
There is no compelling evidence to favor one technique over another.
Which bifurcation technique is noted to have the most favorable outcome data for true LM lesions?
DK crush.
Few notes from the guidelines for left main disease:
1 – assessment of left main disease: IVUS is reasonable for !intermediate stenosis.
2 – bypass is recommended to !improve survival in patients with significant left main stenosis.
3 – in patient with silent ischemia or stable angina with left main disease above 50% with documented ischemia or significant FFR, !bypass is recommended
4 – in !selected patients with significant left main stenosis, !PCI is reasonable to !improve survival, when PCI can provide equivalent revascularization to bypass.
5– in patients with !high complexity coronary artery disease with left main stenosis, choose bypass, not PCI.
6 – left main stenosis with low syntax score below 22, bypass or PCI !equally recommended.
7 – left main disease with intermediate syntax score (23–32), bypass recommendations remains
!higher than PCI
8 – in patients with left main stenosis and high syntax score above 33, choose bypass. PCI is !not recommended.
9 – IVUS can be useful in patience with left main disease or complex coronary stenting to !reduce ischemic events.
What are the common causes of subclavian and brachiocephalic disease?
Atherosclerotic disease, fibromuscular dysplasia, medium- and large-vessel vasculitides, thoracic outlet syndrome, or radiation-induced disease.
Where is subclavian and brachiocephalic disease predominantly located?
It is predominantly ostial or proximal in location.
What are the symptoms of subclavian obstruction?
Arm claudication, which manifests as fatigue, paresthesia, or pain during exertion.
What additional symptoms may arise from proximal left subclavian artery stenosis?
Symptoms of vertebrobasilar insufficiency or angina when the left internal mammary artery (LIMA) has been used for CABG.
When is revascularization of the brachiocephalic or subclavian arteries indicated?
In the presence of significant symptoms like arm claudication, vertebrobasilar insufficiency, or angina.
Is revascularization appropriate when the LIMA is required for CABG surgery?
Yes, empiric revascularization of left subclavian artery stenosis is appropriate even in the absence of symptoms.
Should isolated identification of flow reversal in the vertebral artery prompt revascularization in asymptomatic patients?
No, it should not prompt revascularization unless the internal mammary is needed for arterial bypass.
