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Stent in the Percutaneous Coronary Intervention of Coronary Bifurcation Lesions

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Stent in the Percutaneous Coronary Intervention of Coronary Bifurcation Lesions International Journal of Cardiovascular Interventions 2001 4, 173–180 © 2001 International Journal of Cardiovascular Interventions. All rights reserved. ISSN 1462-8848 173 Use of R™ stent in the percutaneous coronary intervention of coronary bifurcation lesions Mazhar M Khan, Vaikom S Mahadevan, Vincent P Moohan and Samuel W Webb Regional Medical Cardiology Centre, BACKGROUND: Percutaneous Coronary which had unstable angina. The mean age Royal Victoria Hospital, Intervention (PCI) of coronary bifurcation was 59 6 10 and 89% were male. Adjunc- Belfast, BT12 6BA lesion is technically quite demanding. It tive medical therapy included clopidro- Northern Ireland has been associated with a lower proce- gel, aspirin and intraprocedure heparin. dural success, higher rates of complica- Abciximab (ReoPro) was given to 9 Correspondence: tion and restenosis. Side-branch patients. Mazhar M Khan occlusion and plaque shifting or ‘snow RESULTS: Successful stent deployment Regional Medical Cardiology Centre Royal Victoria Hospital plow’ effect are not uncommon. Stenting was achieved in all patients. Thirty-four R Belfast of the main vessel may cause ‘stent jail’ of Stents and 16 other stents were used. BT12 6BA the side-branch. Modern stent design Two patients had post-procedure rise in Northern Ireland may allow passage of a balloon or stent cardiac enzymes. There were no major into the side-branch through the struts of adverse events at 30 days. LAD/D1 with Received 6 March 2001 the stent placed in the main vessel. A LAD/diagonal was the target lesion in the Revised 5 October 2001 newly developed 316 stainless steel majority of patients. Stenting of the side- Accepted 15 February 2002 tubular stent, the R™ stent is uniquely branch was done in 18 and balloon designed to provide exibility, radial dilatation in 9 patients. At 3–23 months strength on deployment and conformabil- (mean 11.8) follow-up, repeat angiogra- ity. Its large cell size facilitates PCI of phy was done in 18 patients with bifurcation lesion. restenosis in 4, two of them had repeat AIM: To assess the feasibility of R™ stent PCI and one had coronary artery bypass in the treatment of symptomatic patients graft (CABG). with bifurcation coronary lesions. The CONCLUSION: Coronary bifurcation main objective was to assess the ease of lesions are not uncommon. Current deployment, side-branch access and advances in stent technology offer a safe overall success of the R™ stent in this and effective revascularisation strategy group of patients without any major for such complex lesions. The R™ stent adverse events. appears to be a suitable device that pro- METHODS: Between December 1998 and vides good wall coverage, radial strength, September 2000 the R™ stent was used conformability and easy side-branch as a main stent in 28 consecutive patients access. (Int J Cardiovasc Intervent 2002; 4: with coronary bifurcation lesions, 46% of 173–180) Keywords: bifurcation stenting – R™ stent – percutaneous intervention of bifurcation lesion. Introduction nicant side-branch disease. Vessel bifurcation may be pre- disposed to atheromatous plaque formation because of Percutaneous intervention of coronary bifurcation lesion turbulent ow and increased shear stress.5 Although true represents a technical challenge to the interventional cardi- bifurcation lesions account for 4–11% of all PTCA proce- ologist. It has been associated with lower procedural dures, the vast majority involves LAD/diagonal bifurca- success, higher complication and restenosis rates.1–4 A tion.5–7 bifurcation lesion is dened as the presence of signicant Balloon angioplasty of such lesions is often associated (greater than 50%) stenosis involving a parent (main) with a signicant risk of side-branch occlusion.4–6 Several vessel at the ostium of the side-branch with or without sig- techniques including debulking or stenting have been 174 MM Khan, VS Mahadevan, VP Moohan and SW Webb developed to improve the outcome of intervention.7–10 Important considerations include the likelihood of imme- diate and future revascularisation of the side-branch, the size of the side-branch and the amount of myocardium Type 1 Type 2B supplied by the side-branch. Stenting of the parent vessel frequently leads to plaque shift or ‘stent jail’ of the side- branch.9 Modern stent designs allow placement of the stent in the parent vessel across the side-branch and passage of a second balloon or stent through the struts of the rst.8 The outcome of such a measure is often variable. It depends upon the type of stent and the size and angulation of the Type 2A Type 3 branch vessel. Stenting both vessels in a complex bifurca- tion lesion can be difcult. It is often associated with plaque shift, stent overlap and uncovered area at the carina of the bifurcation.10 With improvement in the implanta- tion technique, stent and balloon technology and potent adjunctive pharmacological therapy, stenting of bifurca- tion lesion has become an accepted PCI procedure with acceptable risk. However, stent deformity following balloon dilatation of the side-branch is a known risk.11 Type 4 The rst attempt at treating bifurcation lesions was with the rst generation Palmaz–Schatz 153 or Cook stent. Initial experience proved to be unpredictable and unsatis- factory as side-branches were sacriced in a substantial proportion of cases. The other major problem is plaque shifting at side-branch ostium after stent implantation, particularly in patients without signicant disease of the Figure 1 side-branch. This observation is not uncommon after stent Classication of coronary bifurcation lesion. implantation and can result in minor or major complica- tions including non-Q-wave myocardial infarction or sig- nicant cardiac enzyme elevation.12 The recent generation of stents has provided a new Subjects and methods dimension in the management of such lesions, with the availability of low prole balloons and large internal Since December 1998, angioplasty and stenting utilizing lumen of guide catheters. It is now possible to treat such the R™ stent (ORbus Medical Technologies, Fort Landale, lesions with greater success. Intra-coronary stenting thus FL, USA) as a primary stent for bifurcation lesion has been represents one of the most important advances in the prac- performed on 28 consecutive patients. Informed consent tice of coronary intervention.13 Greater operator experience was obtained from all patients. The R™ coronary stent is and improvement in stent design with greater tractability, designed to overcome major problems of rst– and exibility and conformability have extended the indica- second–generation stents of the slotted tube, coil and tions of stenting. modular designs. It is a balloon expandable stainless steel stent with a dual helical conguration, thus providing the radial strength of a slotted tube and the exibility of coil Classication of bifurcation lesions design. Each cell is expandable to at least 4.5mm in dia- meter and permits side-branch access. Initially unmounted Several classications have been proposed for bifurcation stents of 9 and 16 mm in length crimped on a low prole lesions.12,14 The likelihood of signicant side-branch occlu- balloon were used, later pre-mounted stents of 9, 13, 16 sion depends largely on the lesion location and the origin and 18 mm lengths were used. of the side-branch in relation to the primary lesion in the Table 1 gives the clinical characteristics of the patients: main vessel. We classied bifurcation lesions into four 46% had unstable angina: 89% of patients were male with Types and Type 2 is further divided depending upon the a mean age of 59 (6 10) years. All patients received side-branch involvement (Figure 1). 6000–12000 units of heparin for a target ACT of > 250 The classication adopted here is a modication of the seconds, 300mg aspirin and clopidrogel 75 mg once daily. classication proposed by Lefevre et al12 except that it does Those patients not on clopidrogel already were com- not include ostial lesions of the individual branches. menced on 300mg loading dose followed by 75 mg daily. All patients had cardiac enzymes and electrocardiogram checked 6–8 hours after the procedure and the next day. Twenty-six out of 28 patients were discharged the follow- Use of R™ stent in the percutaneous coronary intervention of coronary bifurcation lesions 175 Number (%) 28 (100%) Left main stem 2 Male 25 (89%) – Unprotected 1 Mean age 59 (42–76 years) – Protected 1 Unstable angina 13 (46%) LAD / D1 17 Previous MI 10 (38%) RCA / PDA 4 Diabetic 10 (36%) Circumex / OM 5 Hypertension 11 (39%) Smoking 14 (50%) Table 3 Previous CABG 03 (11%) Target vessel. Table 1 Bifurcation stenting: patient characteristics. Type 1 11 Type 2 12 Double kissing balloon 27 Type 3 2 Side-branch stents 18 Type 4 3 Side-branch PTCA only 9 Number of R™ stents 34 Table 4 Other stents 16 Lesion classication (bifurcation type). ReoPro 9 7 French Guide 25 6 French Guide 3 vessel was stented rst. The side-branch was then entered through the struts of the main vessel stent and after Table 2 balloon angioplasty, through the stent struts; a stent was Procedure details. placed if necessary. Side-branch stenting can be accom- plished with any low prole stent. Our choice here is S 670™ stent (Medtronic AVE, Galway, Ireland), Carbo ing day. The procedure was accomplished using 6 or 7 Medic™ stent (Sorin Biomedic, Italy), R™ stent mounted on French Guide Catheter. Procedure details are shown in a low prole balloon like Maxum™ (Boston Table 2. Scientic/Sciemed, Galway, Ireland) or recently introduced Talos™ and Evolution™ (Orbis Technologies, Netherlands) stent delivery system. Technique of stent deployment Final kissing balloon dilatation is an important step in the treatment of bifurcation lesions. Stent conformability LAD/Diagonal was the target lesion in the majority of is maintained with simultaneous dilatation of both patients (Table 3).
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