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Drug eluting stents: focus on Cypher sirolimus-eluting coronary stents in the treatment of patients with bifurcation lesions.

Chieffo A, Aranzulla TC, Colombo A - Vasc Health Risk Manag (2007)

Bottom Line: The introduction of drug-eluting stent (DES) has remarkably improved the outcome in bifurcation lesions compared to BMS, resulting in lower adverse events and main branch (MB) restenosis rates.Furthermore, although the "provisional" stenting technique (second stent on the SB placed, after the MB stenting, only in case of suboptimal or inadequate result) remained the prevailing approach, several two-stent techniques emerged (crush) or were re-introduced (V, T, culottes) to allow stenting in both branches when needed.Moreover, no study has so far addressed which is the best strategy to use among the several techniques reported in the literature when both branches are intentionally stented from the outset.

View Article: PubMed Central - PubMed

Affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.

ABSTRACT
Coronary bifurcations represent a challenging lesions subset and account for up to 15% of all current PCI. Regardless of the stenting technique used, however, restenosis rate after bare metal stent (BMS) is high, especially at the ostium of the side branch (SB). The introduction of drug-eluting stent (DES) has remarkably improved the outcome in bifurcation lesions compared to BMS, resulting in lower adverse events and main branch (MB) restenosis rates. Furthermore, although the "provisional" stenting technique (second stent on the SB placed, after the MB stenting, only in case of suboptimal or inadequate result) remained the prevailing approach, several two-stent techniques emerged (crush) or were re-introduced (V, T, culottes) to allow stenting in both branches when needed. At the present time, only few randomized studies and some observational reports specifically addressed the issue of bifurcation lesion treatment with sirolimus-eluting stents (SES). It is still not clear yet which is the better strategy between the provisional approach and stenting both branches when dealing with a bifurcation lesion which has a stenosis in the SB suitable for stenting. Moreover, no study has so far addressed which is the best strategy to use among the several techniques reported in the literature when both branches are intentionally stented from the outset. Finally, the introduction of dedicated stents for different types of bifurcations, with specific stent designs to provide good deliverability, secured access to the side branch, complete coverage of the lesion site without double/triple layers of stent struts, thus incorporating the benefits of drug elution and ensuring drug availability to all diseased surfaces, may further facilitate the conquest of one of the most challenging areas in interventional cardiology.

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Restenosis rates and late lumen loss at 6 month angiographic follow-up following double stenting with the “crush” (black bars) vs T stenting (white bars) techniques with and without kissing balloon post-dilatation in the main branch (Panel A) and in the side branch (Panel B). Values are expressed as number (%) or mean (SD). NS, not statistical significant 8 (adapted from Lee et al Heart 2006; 92(3): 371–376)
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fig2: Restenosis rates and late lumen loss at 6 month angiographic follow-up following double stenting with the “crush” (black bars) vs T stenting (white bars) techniques with and without kissing balloon post-dilatation in the main branch (Panel A) and in the side branch (Panel B). Values are expressed as number (%) or mean (SD). NS, not statistical significant 8 (adapted from Lee et al Heart 2006; 92(3): 371–376)

Mentions: Tanabe et al (Tanabe et al 2004) reported on the outcome of a small series of 58 patients with 65 de novo bifurcations, part of the “Rapamycin-Eluting Stent Evaluation At Rotterdam Cardiology Hospital” (RESEARCH) registry, (Lemos et al 2004) treated with SES in both the main and the side branches with one of the following techniques: T (63%), culottes (8%), kissing stents (3%), or “crush” (26%). Kissing balloon inflation was performed in only 31% of cases. At 6 months, MACE occurred in 10.3% of cases, with a TLR rate of 8.6%, and no episodes of MI or stent thrombosis. Angiographic 6-month follow-up was performed in 44 lesions: restenosis occurred in 10 of them (22.7%), and in particular in 4 lesions in the MB (9.1%) and in 6 in the SB (13.6%). The restenosis rate for the SB was 16.7% following T-stenting vs 7.1% with all the other stent techniques. Once again after the use of the T-stenting technique SB restenosis were mostly located at the ostium (5 of the 6 cases of SB restenosis). In a report by our group, (Ge et al 2006) the “crush” technique with FKB was associated with a significant reduction of SB restenosis rate (8.6% vs 26.5%, p = 0.04) when compared to the T stenting technique (Figure 2).


Drug eluting stents: focus on Cypher sirolimus-eluting coronary stents in the treatment of patients with bifurcation lesions.

Chieffo A, Aranzulla TC, Colombo A - Vasc Health Risk Manag (2007)

Restenosis rates and late lumen loss at 6 month angiographic follow-up following double stenting with the “crush” (black bars) vs T stenting (white bars) techniques with and without kissing balloon post-dilatation in the main branch (Panel A) and in the side branch (Panel B). Values are expressed as number (%) or mean (SD). NS, not statistical significant 8 (adapted from Lee et al Heart 2006; 92(3): 371–376)
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2291332&req=5

fig2: Restenosis rates and late lumen loss at 6 month angiographic follow-up following double stenting with the “crush” (black bars) vs T stenting (white bars) techniques with and without kissing balloon post-dilatation in the main branch (Panel A) and in the side branch (Panel B). Values are expressed as number (%) or mean (SD). NS, not statistical significant 8 (adapted from Lee et al Heart 2006; 92(3): 371–376)
Mentions: Tanabe et al (Tanabe et al 2004) reported on the outcome of a small series of 58 patients with 65 de novo bifurcations, part of the “Rapamycin-Eluting Stent Evaluation At Rotterdam Cardiology Hospital” (RESEARCH) registry, (Lemos et al 2004) treated with SES in both the main and the side branches with one of the following techniques: T (63%), culottes (8%), kissing stents (3%), or “crush” (26%). Kissing balloon inflation was performed in only 31% of cases. At 6 months, MACE occurred in 10.3% of cases, with a TLR rate of 8.6%, and no episodes of MI or stent thrombosis. Angiographic 6-month follow-up was performed in 44 lesions: restenosis occurred in 10 of them (22.7%), and in particular in 4 lesions in the MB (9.1%) and in 6 in the SB (13.6%). The restenosis rate for the SB was 16.7% following T-stenting vs 7.1% with all the other stent techniques. Once again after the use of the T-stenting technique SB restenosis were mostly located at the ostium (5 of the 6 cases of SB restenosis). In a report by our group, (Ge et al 2006) the “crush” technique with FKB was associated with a significant reduction of SB restenosis rate (8.6% vs 26.5%, p = 0.04) when compared to the T stenting technique (Figure 2).

Bottom Line: The introduction of drug-eluting stent (DES) has remarkably improved the outcome in bifurcation lesions compared to BMS, resulting in lower adverse events and main branch (MB) restenosis rates.Furthermore, although the "provisional" stenting technique (second stent on the SB placed, after the MB stenting, only in case of suboptimal or inadequate result) remained the prevailing approach, several two-stent techniques emerged (crush) or were re-introduced (V, T, culottes) to allow stenting in both branches when needed.Moreover, no study has so far addressed which is the best strategy to use among the several techniques reported in the literature when both branches are intentionally stented from the outset.

View Article: PubMed Central - PubMed

Affiliation: Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy.

ABSTRACT
Coronary bifurcations represent a challenging lesions subset and account for up to 15% of all current PCI. Regardless of the stenting technique used, however, restenosis rate after bare metal stent (BMS) is high, especially at the ostium of the side branch (SB). The introduction of drug-eluting stent (DES) has remarkably improved the outcome in bifurcation lesions compared to BMS, resulting in lower adverse events and main branch (MB) restenosis rates. Furthermore, although the "provisional" stenting technique (second stent on the SB placed, after the MB stenting, only in case of suboptimal or inadequate result) remained the prevailing approach, several two-stent techniques emerged (crush) or were re-introduced (V, T, culottes) to allow stenting in both branches when needed. At the present time, only few randomized studies and some observational reports specifically addressed the issue of bifurcation lesion treatment with sirolimus-eluting stents (SES). It is still not clear yet which is the better strategy between the provisional approach and stenting both branches when dealing with a bifurcation lesion which has a stenosis in the SB suitable for stenting. Moreover, no study has so far addressed which is the best strategy to use among the several techniques reported in the literature when both branches are intentionally stented from the outset. Finally, the introduction of dedicated stents for different types of bifurcations, with specific stent designs to provide good deliverability, secured access to the side branch, complete coverage of the lesion site without double/triple layers of stent struts, thus incorporating the benefits of drug elution and ensuring drug availability to all diseased surfaces, may further facilitate the conquest of one of the most challenging areas in interventional cardiology.

Show MeSH
Related in: MedlinePlus