Single versus two-stent strategies for coronary bifurcation lesions: a systematic review and meta-analysis of randomized trials with long-term follow-up

Background: The majority of coronary bifurcation lesions are treated with a provisional single‐stent strategy rather than an up‐front 2‐stent strategy. This approach is supported by multiple randomized controlled clinical trials with short‐ to medium‐term follow‐up; however, long‐term follow‐up data is evolving from many data sets. Methods and Results: Meta‐analysis of randomized controlled trials evaluating long‐term outcomes (≥1 year) according to treatment strategy for coronary bifurcation lesions. Nine randomized controlled trials with 3265 patients reported long‐term clinical outcomes at mean weighted follow‐up of 3.1±1.8 years. Provisional single stenting was associated with lower all‐cause mortality (2.94% versus 4.23%; risk ratio: 0.69; 95% confidence interval, 0.48–1.00; P=0.049; I2=0). There was no difference in major adverse cardiac events (15.8% versus 15.4%; P=0.79), myocardial infarction (4.8% versus 5.5%; P=0.51), target lesion revascularization (9.3% versus 7.6%; P=0.19), or stent thrombosis (1.8% versus 1.6%; P=0.28) between the groups. Prespecified sensitivity analysis of long‐term mortality at a mean of 4.7 years of follow‐up showed that the provisional single‐stent strategy was associated with reduced all‐cause mortality (3.9% versus 6.2%; risk ratio: 0.63; 95% confidence interval, 0.42–0.97; P=0.036; I2=0). Conclusions: Coronary bifurcation percutaneous coronary intervention using a provisional single‐stent strategy is associated with a reduction in all‐cause mortality at long‐term follow‐up

How should I treat a patient with significant angina and a severe left anterior descending artery stenosis beyond the insertion of a left internal mammary artery jump graft (diagonal to LAD)?

BACKGROUND: A 60-year-old man with a history of previous coronary artery bypass grafting (saphenous vein grafting [SVG] to native right coronary artery [RCA] and sequential left internal mammary artery [LIMA] jump grafting to his native first diagonal [D1] and left anterior descending [LAD] arteries), who had developed a previous ischaemic cerebrovascular accident following femoral angiography, re-presented with further ischaemic cardiac symptoms.\ud \ud INVESTIGATIONS: Physical examination, electrocardiography, biochemistry including high-sensitive troponin, echocardiography, and trans-radial angiography.\ud \ud DIAGNOSIS: Severe native 3 vessel disease including ostial occlusion of the LAD, distal left circumflex and obtuse marginal (LCX/OM) disease and proximal RCA occlusion; occluded SVG to RCA, and evidence of a critical stenosis in the mid LAD distal to the insertion of the tortuous LIMA jump graft (diagonal to LAD).\ud \ud TREATMENT: PCI to mid LAD lesion via LIMA jump graft from left trans-radial approach

A case of an obstructive intramural haematoma during percutaneous coronary intervention successfully treated with intima microfenestrations utilising a cutting balloon inflation technique

During percutaneous coronary interventions (PCI), good lesion preparation with adequate balloon predilatation is a fundamental step before stent deployment in order to achieve optimal stent expansion and favourable long-term outcomes post PCI. During PCI, inadvertent vessel tearing can occur, resulting in coronary dissections and formation of intramural haematomas. The latter might be associated with compression of the vessel lumen and significant compromise of the coronary blood flow leading to myocardial ischaemia and infarction. Herein, we present a case of intramural haematoma that occurred after PCI of the left anterior descending artery resulting in occlusion of the vessel and the subsequent use of a cutting balloon inflation technique to resolve the haematoma and restore the normal coronary blood flow

Association between inflammatory biomarkers and neointimal response following elective implantation of the ABSORB bioresorbable vascular scaffold

Introduction The ABSORB bioresorbable vascular scaffold (BVS) is associated with greater neointimal proliferation and thrombotic rate than the metal stent. The role of inflammatory biomarkers on neointimal proliferation has not been studied in the setting of BVS implantation. Patients and methods Thirty patients had arterial blood sampling before elective percutaneous coronary intervention with the ABSORB BVS and at 9-months follow-up. Plasma levels of interleukin-6, soluble CD40 ligand, monocyte chemotactic protein-1 and C-reactive protein were measured using enzyme-linked immunosorbent assay. Baseline and follow-up levels were compared for each biomarker. Optical frequency domain imaging was performed at follow-up and the neointimal burden was calculated as the ratio of neointimal area to scaffold area. The levels of inflammatory mediators were correlated with the neointimal burden. Results There was no significant increase in the levels of biomarkers from baseline to follow-up. Median C-reactive protein levels changed from 1.1 [interquartile range (IQR): 0.5–2.5] to 2.2 (IQR: 0.5–3.5) μg/ml, interleukin-6 from 1.0 (IQR: 0.6–1.4) to 1.0 (95% confidence interval: 0.6–1.4) pg/ml, monocyte chemotactic protein-1 from 120.4 (IQR: 86.0–153.4) to 102.0 (IQR: 70.3–148.1) pg/ml and soluble CD40 ligand from 108.3 (IQR: 74.1–173.7) to 112.0 (IQR: 71.0–225.9) pg/ml. The average neointimal burden in the cohort was 18±6%. Baseline, follow-up and change in plasma levels of inflammatory markers between these two time points did not correlate with the neointimal burden. Conclusion Elective percutaneous coronary intervention with the ABSORB BVS does not provoke a chronic inflammatory response. The degree of neointimal proliferation after elective implantation of the ABSORB BVS is independent of the pre-existing inflammatory environment

Cost-effectiveness of stepwise provisional versus systematic dual stenting strategies in patients with distal bifurcation left main stem lesions: Economic analysis of the EBC MAIN trial

\ua9 2024 BMJ Publishing Group. All rights reserved.Background In patients with distal bifurcation left main stem lesions requiring intervention, the European Bifurcation Club Left Main Coronary Stent Study trial found a non-significant difference in major adverse cardiac events (MACEs, composite of all-cause death, non-fatal myocardial infarction and target lesion revascularisation) favouring the stepwise provisional strategy, compared with the systematic dual stenting. Aims To estimate the 1-year cost-effectiveness of stepwise provisional versus systematic dual stenting strategies. Methods Costs in France and the UK, and MACE were calculated in both groups to estimate the incremental cost-effectiveness ratio (ICER). Uncertainty was explored by probabilistic bootstrapping. The analysis was conducted from the perspective of the healthcare provider with a time horizon of 1 year. Results The cost difference between the two groups was €-755 (€5700 in the stepwise provisional group and €6455 in the systematic dual stenting group, p value<0.01) in France and €-647 (€6728 and €7375, respectively, p value=0.08) in the UK. The point estimates for the ICERs found that stepwise provisional strategy was cost saving and improved outcomes with a probabilistic sensitivity analysis confirming dominance with an 80% probability. Conclusion The stepwise provisional strategy at 1 year is dominant compared with the systematic dual stenting strategy on both economic and clinical outcomes