Clinical follow up of bifurcation lesions in EXPAND and ... · and treated with at least one BVS...

ClinicalfollowupofbifurcationlesionsinEXPANDandSTEMI-FIRST

RobertoDilettiErasmusMC,Thoraxcenter

Rotterdam

Methods

• Patientswithatleastonecoronarybifurcationlesioninvolvingaside-branch≥2mmindiameterandtreatedwithatleastoneBVSwereexamined.

• Proceduralandangiographicdatawerecollectedandadedicatedmethodologyforoff-linequantitativecoronaryangiography(QCA)inbifurcationwasapplied(eleven-segmentmodel),toassessside-branchimpairmentoccurringanytimeduringtheprocedure.

Methods

• Two- andthree-dimensionalQCAwasused.

• Opticalcoherencetomography(OCT)analysiswasperformedinasubgroupofpatientsandlong-termclinicaloutcomesreported.

PercentageMaximalfootprintfordifferentBVSsizes

ImpactofStrutwidth

ImpactofStrutwidth

DePaolis Int JCardiol.2016Oct 15;221:656-64

• “Side-branchimpairment”,aspreviouslydescribedanddefinedasacompositeof:

1)SBTIMIflowgrade<3afterMVstenting,2)needofguidewire(s)differentfromthedefaultwiretorewireSBafterMVstenting,3)failuretorewiretheSBafterMVstenting,or4)failuretodilatetheSBafterMVstentingandSBrewiring

• “SBacuteangiographicresult”,definedasthecomparisonbetween:

thepre- andthepost-procedure2-dimensionalQCA–estimatedminimallumendiameterof3-mmostialSBsub-segment,accordingtothemodifiedeleven-segmentmodelanalysis

SBanalysis

BaselineClinicalCharacteristics

Valuesareexpressedasmean± standarddeviation(SD)orcount(n)andpercentages(%).

ClinicalCharacteristics N=102

Male 83(81.4)FamilyHistoryofCAD 30(29.4)Diabetesmellitus 16(15.7)Hypercholesterolemia 53(52.0)Hypertension 57(55.9)Activesmoking 42(41.2)Kidneydisease 6(5.9)PreviousMI 23(22.5)PreviousPCI 15(14.7)PreviousCABG 2(2.0)PreviousTIA/stroke 4(3.9)Peripheralarterialdisease 7(6.9)Chronicobstructivepulmonarydisease 5(4.9)

BaselineClinicalCharacteristics

Valuesareexpressedasmean± standarddeviation(SD)orcount(n)andpercentages(%).

ClinicalCharacteristics N=102

Singlevesseldisease 60(56.1)

2-vesseldisease 40(37.4)

3-vesseldisease 6(5.6)

Leftmain 1(0.9)

Clinicalpresentation

Acutecoronarysyndrome 59(57.8)

STEMI 19(18.6)

Acuteheartfailure 2(2.0)

Out-hospitalcardiacarrest 2(2.0)

AngiographicCharacteristics

Valuesareexpressedascount(n)andpercentages(%).

NumberofBifurcations N=107

Targetbifurcation

Distalleftmain 2(1.9)

Leftanteriordescending/Diagonal 73(68.2)

Circumflex/Marginal 26(24.3)

Rightposteriordescending/posteriorlateral 6(5.6)

ACC/AHAmodifiedlesionclassification

TypeB2 73(68.2)

TypeC 34(31.8)

Truebifurcations 45(42.0)

Moderateorseverecalcification 31(28.9)

Lengthlesion>20mm 59(55.1)

Chronictotalocclusion 10(9.3)



NumberofBifurcations N=107Medinabifurcationclassification

1.1.1 20(18.7)1.1.0 24(22.4)1.0.1 11(10.3)0.1.1 14(13.1)1.0.0 14(13.1)0.1.0 18(16.8)0.0.1 6(5.6)

MVTIMIflowpre-procedure0 13(12.1)1 4(3.7)2 3(2.8)3 87(81.3)

SBTIMIflowpre-procedure0 9(8.4)1 4(3.7)2 2(1.9)3 92(85.9)




TechniqueProvisional 100(93.4)T-stenting 5(4.7)Culotte 1(0.9)Mini-crush 1(0.9)

MVdirectstenting 14(13.1)MVpre-dilation 90(84.1)

Semi-compliantballoon 82(76.6)Non-compliantballoon 17(15.9)

SBwiringbeforeMVprovisionalstenting 38(38.0)*Defaultsupportivewire 41(38.3)

MVsupportivewire 35(32.7)SBsupportivewire 10(9.3)

BVSinbifurcationsCulottetechnique




Cuttingballoon 1(0.9)Rotablator 2(1.9)SBostiumdilationbeforeMVtreatment 25(23.4)Totalnumberofscaffolds 178

Meanscaffoldsper-bifurcation 1.66± 0.84MVScaffold 104(97.2)

Scaffolddiameter(mm) 3.03± 0.4Scaffoldlength(mm) 19.95± 5.6

SBScaffold 14(13.1)Scaffolddiameter(mm) 2.8± 0.3Scaffoldlength(mm) 16.21± 4.8

MVpost-dilation 64(59.8)Semi-compliantballoon 17(15.9)Non-compliantballoon 52(48.5)

POT 38(35.5)Finalkissingballooninflation 5(4.6)SBostiumdilationafterMVstent

Balloondiameter(mm)39(36.4)2.03± 0.48

Contrastmedia (ml) 208.15± 90.82

Proceduralresults

Valuesareexpressedascount(n)andpercentages(%).SBtroublerateSES16%,EES11% Burzotta etal.JAmColl Cardiol Intv 2011;4:327–35


Devicesuccess 106(99.1)

Proceduralsuccess 101(94.3)

FinalMVTIMIflowgrade3 106(99.1)

FinalSBTIMIflowgrade3 103(96.3)

SBimpairment 13(12.1)

SBTIMIflowgrade<3afterMVstenting 10(9.3)

SBTIMIflowgrade=0afterMVstenting 4(3.7)



Guide-wire(s)differentfromthedefaulttorewireSBafterMVstenting

5(4.7)

FailuretorewiretheSBafterMVstenting 1(0.9)

FailuretodilatetheSBafterMVstenting 1(0.9)

Pre- andpost-proceduralvesseldiameters2D-QCA-evaluation

Valuesareexpressedasmeanandstandarddeviation.

Pre-PCI(N=103)

Post-PCI(N=103)

pvalue

Mainvessel

Referencediameter(mm) 2.63± 0.61 2.77± 0.55 0.286

Minimallumendiameter(mm)%diameterstenosis

1.30± 0.5550.13± 18.86

2.35± 0.5215.14± 8.40

<0.001<0.001

Sidebranch



1.45± 0.4126.93± 16.89

1.48± 0.4227.80± 15.57

0.5870.904

3-mmostialsidebranchsub-segment



1.51± 0.3823.97± 15.99

1.53± 0.4425.82± 16.15

0.5670.697

Angle

ProximalMainVessel/SideBranch(°) 143.58± 17.44 143.53± 18.04 0.282

DistalMainVessel/SideBranch(°) 53.47± 15.65 52.68± 17.95 0.764

Pre- andpost-proceduralvesselsdiametersandareas3DQCA-evaluation


Pre-PCI(N=40)

Post-PCI(N=40)

pvalue

MainvesselReferencediameter(mm) 2.60± 0.72 2.77± 0.48 0.128Minimallumendiameter(mm) 1.48± 0.59 2.43± 0.46 <0.001

Minimallumenarea(mm2) 1.99± 1.52 4.81± 1.70 <0.001Percentageareastenosis 63.47± 21.49 22.15± 12.27 <0.001

Sidebranch

Referencediameter(mm) 2.00± 0.28 2.08± 0.34 0.280Minimallumendiameter(mm) 1.54± 0.37 1.61± 0.41 0.363Minimallumenarea(mm2) 1.97± 0.89 2.17± 1.09 0.334

Percentageareastenosis 42.25± 21.50 38.62± 21.33 0.3053-mmostialsidebranchsub-segment

Referencediameter(mm) 2.03± 0.28 2.10± 0.32 0.123Minimallumendiameter(mm) 1.59± 0.35 1.62± 0.41 0.760Minimallumenarea(mm2) 2.10± 0.86 2.19± 1.10 0.660Percentageareastenosis 34.98± 19.98 37.48± 20.28 0.798

AngleProximalMainVessel/SideBranch(°) 139.19± 15.94 140.86± 14.70 0.597DistalMainVessel/SideBranch(°) 59.02± 12.31 55.23± 13.34 0.189ProximalMainVessel/DistalMainVessel(°) 152.40± 13.08 155.74± 10.27 0.128

Sub-segmentslocationinthetreatedbifurcationlesion

OCTanalysispost-scaffoldimplantationinbifurcatedcoronarylesions


Numberofbifurcations(N=19)

5-mm proximal MV sub-segment (N = 19)

Malapposed struts 2.11± 4.53

% malapposed struts 6.41± 16.99

Polygon of confluence (POC) (N = 19)



SB-related struts 2.0± 2.13

5-mm distal MV sub-segment (N = 19)




Clinicaloutcomesat1-yearfollow-up

Clinicalevents N=102

Majoradversecardiacevents 5.5%

Allcausedeath 2.2%

Cardiacdeath 1.1%

Myocardialinfarction 4.4%

Targetlesionrevascularization 3.3%

Targetvesselrevascularization 6.6%

Non- Targetvesselrevascularization 3.4%

DefiniteST 2.2%

ProbableST 0.0%

PossibleST 1.1%

Clinicalfollow-upratewas91.1%AllDefiniteSTwerelateST

Conclusions

Theresultsofthepresentinvestigationsuggestfeasibilityandrelativesafetyof BVSimplantationincoronarybifurcations.BVSwidestrutshavealowimpactonside-branchimpairmentwhenconsideringbifurcationswithside-branchdiameter≥2mm.

Clinical follow up of bifurcation lesions in EXPAND and ... · and treated with at least one BVS...

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