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Practical based approach to left main bifurcation stenting.

Ahn JM, Lee PH, Park SJ - BMC Cardiovasc Disord (2016)

Bottom Line: However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise.In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches.Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Korea. drjmahn@gmail.com.

ABSTRACT
Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method.

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Related in: MedlinePlus

Provisional approach for distal left main stenosis. Coronary angiography showed a “true” LM bifurcation lesion (Medina 1.1.1) (a) while intravascular ultrasound revealed very minimal disease at the ostium of the left circumflex artery (b). Provisional single stenting was performed (c), with the final angiogram showing an acceptable result without side branch compromise (d)
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Fig1: Provisional approach for distal left main stenosis. Coronary angiography showed a “true” LM bifurcation lesion (Medina 1.1.1) (a) while intravascular ultrasound revealed very minimal disease at the ostium of the left circumflex artery (b). Provisional single stenting was performed (c), with the final angiogram showing an acceptable result without side branch compromise (d)

Mentions: The provisional approach is a single-stent strategy that allows the positioning of a second stent, if required (Fig. 1). Similar to non-LM bifurcations, several studies reported that, compared with two-stent techniques, the provisional one-stent approach for distal LM bifurcation was associated with more favorable outcomes, including lower risks of major adverse cardiac events [4–6], death [6], myocardial infarction [5, 6], and target vessel revascularization [5–7] (Table 1). In addition, the provisional one-stent approach was found to reduce the risk of stent thrombosis [6, 7]. Based on these results, the provisional one-stent approach has been preferred in the treatment of LM bifurcation stenosis [8], with more than 60 % of patients with LM bifurcation in real-world practice treated using the provisional one-stent technique [5]. However, all previous studies were observational, suggesting the need for randomized controlled studies to properly evaluate the superiority of the provisional approach over double stenting in patients with LM bifurcation disease.Fig. 1


Practical based approach to left main bifurcation stenting.

Ahn JM, Lee PH, Park SJ - BMC Cardiovasc Disord (2016)

Provisional approach for distal left main stenosis. Coronary angiography showed a “true” LM bifurcation lesion (Medina 1.1.1) (a) while intravascular ultrasound revealed very minimal disease at the ostium of the left circumflex artery (b). Provisional single stenting was performed (c), with the final angiogram showing an acceptable result without side branch compromise (d)
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4759961&req=5

Fig1: Provisional approach for distal left main stenosis. Coronary angiography showed a “true” LM bifurcation lesion (Medina 1.1.1) (a) while intravascular ultrasound revealed very minimal disease at the ostium of the left circumflex artery (b). Provisional single stenting was performed (c), with the final angiogram showing an acceptable result without side branch compromise (d)
Mentions: The provisional approach is a single-stent strategy that allows the positioning of a second stent, if required (Fig. 1). Similar to non-LM bifurcations, several studies reported that, compared with two-stent techniques, the provisional one-stent approach for distal LM bifurcation was associated with more favorable outcomes, including lower risks of major adverse cardiac events [4–6], death [6], myocardial infarction [5, 6], and target vessel revascularization [5–7] (Table 1). In addition, the provisional one-stent approach was found to reduce the risk of stent thrombosis [6, 7]. Based on these results, the provisional one-stent approach has been preferred in the treatment of LM bifurcation stenosis [8], with more than 60 % of patients with LM bifurcation in real-world practice treated using the provisional one-stent technique [5]. However, all previous studies were observational, suggesting the need for randomized controlled studies to properly evaluate the superiority of the provisional approach over double stenting in patients with LM bifurcation disease.Fig. 1

Bottom Line: However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise.In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches.Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Poongnap-dong, Songpa-gu, Seoul, 138-736, Korea. drjmahn@gmail.com.

ABSTRACT
Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing the chosen technique than the choice of method.

Show MeSH
Related in: MedlinePlus