Wire bias modification with reverse orbital atherectomy for safer rotational atherectomy in calcified bifurcation.

Although debulking devices are very useful in modifying calcified plaques, their effectiveness is highly dependent on wire bias. In particular, in eccentric calcified bifurcation lesions, wire bias tends to be poor and needs to be corrected for adequate lesion preparation. A 67-year-old man was diagnosed with exertional angina pectoris. Coronary angiography showed a highly calcified eccentric lesion from the left main trunk to the left anterior descending artery. The patient refused coronary artery bypass surgery, therefore we decided to treat this complex bifurcation lesion with percutaneous coronary intervention. Initially, we performed reverse orbital atherectomy (OA) and sifted the guide wire position into the calcified plaque successfully. We continued with rotational atherectomy (RA) using a 2.0 mm burr and were able to obtain sufficient lumen without complications. Finally, the lesion was dilated with a cutting balloon and a drug-coated balloon to obtain a stent-like result. This case demonstrates that wire bias modification with reverse OA enables us to perform more aggressive and effective RA safely in eccentric calcified bifurcation lesions. This combination atherectomy can become an attractive approach in eccentric calcified bifurcation lesions. Learning objective: Atherectomy devices are helpful for lesion modification in calcified lesions but their effectiveness is highly dependent on wire bias. If the wire bias can be intentionally moved to an optimal position, it can be a very effective procedure in the treatment of calcified lesions. Wire bias modification by reverse ablation with orbital atherectomy that we have demonstrated enables subsequent aggressive rotational atherectomy and this combination atherectomy can be an attractive approach in eccentric calcified lesions.

Impact of Medina classification on clinical outcomes of imaging-guided coronary bifurcation stenting.

Background: Intracoronary imaging improves clinical outcomes after stenting of complex coronary bifurcation lesions (CBLs), but the impact of Medina classification-based CBL distribution on outcomes of imaging-guided bifurcation stenting is unclear. Methods: In this integrated analysis of four previous studies, in which all CBLs were treated with drug-eluting stents under intravascular ultrasound or optical coherence tomography guidance, the distribution of 763 CBLs was assessed using angiographic Medina classification. Major adverse cardiac events (MACE), including target lesion revascularization (TLR), myocardial infarction, stent thrombosis, and cardiac death, were investigated at 1-year follow-up. Results: The most and least prevalent Medina subtypes were 0-1-0 (27.9 %) and 0-0-1 lesions (2.8 %). The most and least frequent MACE/TLR rates were 18.2 %/18.2 % for 0-0-1 lesions and 4.1 %/2.8 % for 0-1-0 lesions. Risks were higher for 0-0-1 lesions than for 0-1-0 lesions for both MACE (hazard ratio [HR]: 4.04, 95 % confidence interval [CI]: 1.21-13.45, p = 0.02) and TLR (HR: 6.19, 95 % CI: 1.69-22.74, p = 0.006). MACE rates were similar for true and non-true CBLs excluding 0-0-1 lesions (8.2 % and 5.9 %, HR 1.54, 95 % CI: 0.86-2.77, p = 0.15), while MACE (HR: 3.25, 95 % CI: 1.10-9.63, p = 0.03) and TLR (HR: 4.24, 95 % CI: 1.38-12.96, p = 0.01) risks were higher for 0-0-1 lesions. Conclusions: This integrated analysis of imaging-guided bifurcation stenting demonstrated similar clinical outcomes in true and non-true CBLs, except for 0-0-1 lesions, which had a significantly higher risk of MACE/TLR.

Impact of coronary bifurcation angle on stent malapposition in a randomized comparison between proximal optimization technique followed by side branch dilatation and kissing balloon inflation.

Background: The impact of coronary bifurcation angle (BA) on incomplete stent apposition (ISA) after crossover stenting followed by side branch (SB) intervention has not been established. Methods: A total of 100 crossover stentings randomly treated with proximal optimization technique followed by short balloon dilation in the SB (POT-SBD group, 48 patients) and final kissing balloon technique (KBT group, 52 patients) were analyzed in the PROPOT trial. Major ISA with maximum distance > 400 µm and its location was determined using optical coherence tomography before SB intervention and at the final procedure. The BA was defined as the angle between the distal main vessel and SB. Optimal POT was determined when the difference in stent volume index between the proximal and distal bifurcation was greater than the median value (0.86 mm3/mm) before SB intervention. Result: Major ISA was more frequently observed in the POT-SBD than in the KBT group (35% versus 17%, p < 0.05). In the POT-SBD group, worsening ISA after SBD was prominent at the distal bifurcation. The BA was an independent predictor of major ISA (odds ratio 1.04, 95% confidence interval 1.00-1.07, p < 0.05) with a cut-off value of 59.5° (p < 0.05). However, the cases treated with optimal POT in the short BA (<60°) indicated the lowest incidence of major ISA. In the KBT group, BA had no significant impact. Conclusion: A wide BA has a potential risk for the occurrence of major ISA after POT followed by SBD in coronary bifurcation stenting.

Impact of quantitative flow ratio on graft function in patients undergoing coronary artery bypass grafting.

Recent studies showed that preoperative functional assessment with fractional flow reserve (FFR) could predict a long-term patency of arterial bypass grafts in patients with coronary artery bypass grafting (CABG). Quantitative flow ratio (QFR) is a novel angiography-based approach to estimate FFR. This study aimed to investigate whether preoperative QFR could discriminate arterial bypass function at 1 year after surgery. The PRIDE-METAL registry was a prospective, multicenter observational study that enrolled 54 patients with multivessel coronary artery disease. By protocol, left coronary stenoses were revascularized by CABG with arterial grafts, whereas right coronary stenoses were treated with coronary stenting. Follow-up angiography at 1 year after surgery was scheduled to assess arterial graft patency. QFR was performed using index angiography by certified analysts, blinded to bypass graft function. The primary end point of this sub-study was the discriminative ability of QFR for arterial graft function, as assessed by receiver-operating characteristic curve. Among 54 patients enrolled in the PRIDE-METAL registry, index and follow-up angiography was available in 41 patients with 97 anastomoses. QFR were analyzed in 35 patients (71 anastomoses) with an analyzability of 85.5% (71/83). Five bypass grafts were found to be non-functional at 1 year. The diagnostic performance of QFR was substantial (area under the curve: 0.89; 95% confidence interval: 0.83 to 0.96) with an optimal cutoff of 0.76 to predict functionality of bypass grafts. Preoperative QFR is highly discriminative for predicting postoperative arterial graft function.Trial registration: Clinical.gov reference: NCT02894255.

Physiological Approach for Coronary Artery Bifurcation Disease: Position Statement by Korean, Japanese, and European Bifurcation Clubs.

Coronary artery bifurcation lesions are frequently encountered in cardiac catheterization laboratories and are associated with more complex procedures and worse clinical outcomes than nonbifurcation lesions. Therefore, anatomical and physiological assessment of bifurcation lesions before, during, and after percutaneous coronary intervention is of paramount clinical importance. Physiological assessment can help interventionalists appreciate the hemodynamic significance of coronary artery disease and guide ischemia-directed revascularization. However, it is important to understand that the physiological approach for bifurcation disease is more important than simply using physiological indexes for its assessment. This joint consensus document by the Korean, Japanese, and European bifurcation clubs presents the concept of a physiological approach for coronary bifurcation lesions, as well as current knowledge, practical tips, pitfalls, and future directions of applying physiological indexes in bifurcation percutaneous coronary intervention. This document aims to guide interventionalists in performing appropriate physiology-based assessments and treatment decisions for coronary bifurcation lesions.

Rewiring to the dissected branch along the jailed balloon (Real JAB technique)-A novel rewiring technique for the dissected branch in bifurcation lesion-case report.

Guidewire recrossing into the branch through the stent strut is difficult when that branch was injured or occluded after stenting in the true bifurcation lesion. A 72-year-old man with chronic total occlusion in both mid-left anterior descending coronary artery (LAD) and 2nd diagonal branch (D) was admitted to our hospital. We put a 2.25 × 38 mm drug-eluting stent from the LAD to the D with culotte stenting. However, the LAD occluded after stenting. Although we tried to recross, it was impossible because the guidewire migrated subintimal space which was caused by guidewire manipulation. So, we advanced a 2.25 mm balloon catheter on the 1st guidewire which had already been placed outside of the stent in the LAD, and inflated it at bifurcation to compress the subintimal space. Subsequently, we advanced another guidewire through the strut along the surface of the balloon catheter. Immediately after the deflation of the balloon, the guidewire slipped into the distal LAD without resistance. Large branch occlusion after stenting is a serious complication in true bifurcation treatment. Our new bailout technique is effective for recrossing a guidewire into the dissected branch to preserve it. .

Effect of proximal optimization technique on coronary bifurcation stent failure: Insights from the multicenter randomized PROPOT trial.

OBJECTIVE: We investigated the effect of proximal optimization technique (POT) on coronary bifurcation stent failure (BSF) in cross-over stenting by comparing with the kissing balloon technique (KBT) in a multicenter randomized PROPOT trial. BACKGROUND: POT is recommended due to increased certainty for optimal stent expansion and side branch (SB) wiring. METHODS: We randomized 120 patients treated with crossover stenting into the POT group, which was followed by SB dilation (SBD), and the KBT group. Finally, 52 and 57 patients were analyzed by optical coherence tomography before SBD and at the final procedure, respectively. Composite BSF was defined as a maximal malapposition distance of >400 µm, or malapposed and SB-jailed strut rates of >5.95% and >21.4%, respectively. RESULTS: Composite BSF before SBD in the POT and KBT groups was observed in 29% and 26% of patients, respectively. In the POT group, differences in stent volumetric index between the proximal and distal bifurcation (odds ratio [OR] 60.35, 95% confidential interval [CI] 0.13-0.93, p = 0.036) and between the proximal bifurcation and bifurcation core (OR: 3.68, 95% CI: 1.01-13.40, p = 0.048) were identified as independent risk factors. Composite BSF at final in 27% and 32%, and unplanned additional procedures in 38% and 25% were observed, respectively. Composite BSF before SBD was a risk factor for the former (OR: 6.33, 95% CI: 1.10-36.50, p = 0.039) and the latter (OR: 6.43, 95% CI: 1.25-33.10, p = 0.026) in the POT group. CONCLUSION: POT did not result in a favorable trend in BSF. Insufficient expansion of the bifurcation core after POT was associated with BSF.

Validation of the newly introduced CASTLE Score for predicting successful CTO recanalization.

BACKGROUND: The new EuroCTO CASTLE Score was validated against the widely adopted Japanese Multicenter CTO Registry (J-CTO) score in predicting technical success in percutaneous coronary intervention (PCI) for coronary chronic total occlusions (CTO). METHODS: A total of 463 patients treated by CTO PCI were included in a retrospective analysis. Result: The mean CASTLE score was 2.23 ± 1.1 and J-CTO score was 2.84 ± 1.0. The overall technical success rate was 83.2%. At 30 days follow up, a primary composite safety endpoint showed a low proportion of stent thrombosis (0.2%) and re-hospitalization (0.4%). Moreover, an improvement of clinical symptoms was found in 83% of patients. Receiver operating characteristic analysis (ROC) demonstrated a comparable overall discriminatory performance in predicting technical outcome: CASTLE score, area under the ROC curve (AUC) 0.668, 95% CI: 0.606-0.730; J-CTO score AUC 0.692, 95% CI: 0.631-0.752; Comparison of AUCs: p = 0.324. Those findings were even consistent in more complex procedures CASTLE Score ≥ 4 and J-CTO score ≥ 3: CASTLE Score AUC 0.514, 95% CI: 0.409-0.619; J-CTO score, AUC 0.617, 95% CI: 0.493-0.741; Comparison of AUCs: p = 0.211. Furthermore, increasing score values are accompanied by a longer examination and fluoroscopy time, more contrast medium and a higher dose area product. CONCLUSION: Compared to the widely accepted J-CTO score, the new introduced EuroCTO CASTLE score demonstrated a comparable overall discriminatory performance in predicting technical outcomes in CTO PCI.

Difference in basic concept of coronary bifurcation intervention between Korea and Japan. Insight from questionnaire in experts of Korean and Japanese bifurcation clubs.

The coronary bifurcation intervention varies among countries due to the differences in assessment of lesion severity and treatment devices. We sought to clarify the difference in basic strategy between South Korea and Japan. A total of 19 and 32 experts from Korean (KBC) and Japanese Bifurcation Clubs (JBC), respectively, answered a survey questionnaire concerning their usual procedure of coronary bifurcation intervention. JBC experts performed less two-stent deployment in the left main (LM) bifurcation compared to KBC experts (JBC vs. KBC: median, 1-10% vs. 21-30%, p < 0.0001) instead of higher performance of side branch dilation after cross-over stenting in both LM (60% vs. 21%, p = 0.001) and non-LM bifurcations (30% vs. 5%, p = 0.037). KBC experts more frequently performed proximal optimization technique (POT) in non-LM bifurcation (41-60% vs. 81-99%, p = 0.028) and re-POT in both LM (1-20% vs. 81-99%, p = 0.017) and non-LM bifurcations (1-20% vs. 81-99%, p = 0.0003). JBC experts more frequently performed imaging-guided percutaneous coronary intervention, whereas KBC experts more often used a pressure wire to assess side branch ischemia. JBC experts used a rotablator more aggressively under the guidance of optical coherence tomography. We clarified the difference in the basic strategy of coronary bifurcation intervention between South Korea and Japan for better understanding the trend in each country.

Prospective multicenter registry of hybrid coronary artery revascularization combined with non-saphenous vein graft surgical bypass and percutaneous coronary intervention using everolimus eluting metallic stents (PRIDE-METAL study).

The concept of hybrid coronary revascularization (HCR) combines the advantages of coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to improve the treatment of patients with complex multivessel disease. This study aimed to investigate a 1-year clinical follow-up of a prospective multicenter registry of HCR combined with non-saphenous vein graft surgical bypass and PCI using everolimus-eluting metallic stents (the PRIDE-METAL study). From June 2016 to June 2018, a total of 54 patients with multivessel coronary disease from six Japanese institutes were enrolled in this study. The primary endpoint of the study was the occurrence of major adverse cardiovascular event (MACE; all-cause death, myocardial infarction, stroke, and repeat revascularization) at 1 year. Three patients declined before complete HCR, and two patients were lost by the 1-year follow-up. All-cause mortality at 30 days and at 1 year was 0% and 4.1%, respectively. The rates of myocardial infarction, repeat revascularization, stroke, and MACE were 0% at 30 days, and 0%, 2.0%, 2.0%, and 8.2% at 1-year follow-up, respectively. No occlusion of arterial bypass graft at the 30-day follow-up was observed, and was observed in 1.7% at the 1-year follow-up. HCR was safe and feasible and associated with a low risk of MACE at the 1-year follow-up. Further validation in multicenter and randomized studies is needed.

Impact of Optimal Preparation Before Drug-Coated Balloon Dilatation for De Novo Lesion in Patients With Coronary Artery Disease.

BACKGROUND: Drug eluting stent (DES) remain several problems, including stent thrombosis, stent fracture and neoatherosclerosis. Stent-less Percutaneous coronary intervention (PCI) using a drug coated balloon (DCB) is a stent-less strategy, and several trials have supported the efficacy of DCB. However, the optimal preparation before using DCB was uncertain. The aim of this study was to investigate the optimal preparation for plaque oppression/debulking before DCB dilatation for de novo coronary artery lesion. METHODS: A total 936 patients were treated using DCB from 2014 to 2017 at our institution. Among them, we analyzed 247 patients who underwent PCI using DCB alone for de novo lesion. The primary end point of this study was target lesion failure (TLF). RESULTS: The area under the receiver operating characteristic (ROC) curve (AUC) was used to determine the optimal cutoff value of % plaque area to predict TLF. ROC curve analysis revealed plaque area ≥ 58.5% (AUC, 0.81) were associated with TLF. Eligible 188 patients were divided into 2 groups (plaque area ≥ 58.5% [n = 38] and <58.5% [n = 150]) according to IVUS data before using DCB. TLF was significantly higher in plaque area ≥ 58.5% group than in <58.5% group (P < 0.01). Multivariable analysis selected plaque area ≥ 58.5% as an independent predictor of TLF (hazard ratio 7.59, P < 0.01). CONCLUSIONS: Lesion preparation achieving plaque area < 58.5% was important in stent-less PCI using DCB.

Verification of the differences of scoring effect in current scoring balloons.

The characteristics of each scoring balloon seem to be different because material or configuration of scoring element in each device is unique. The aim of this study is to clarify the difference of scoring effect among 3 different scoring devices. We prepared 3 different scoring devices [Wolverine™ Cutting Balloon™ (CB), ScoreFlex™ NC (SF), NSE Alpha™ (NSE), n = 5 respectively. Balloon diameter is 3 mm and 2 types of silicone tubes with different elasticity [140 kPa (tube S) and 576 kPa (tube H), respectively. Inner diameter is 3 mm]. We dilated each balloon in each silicone tube with nominal pressure (NP) and 20 atmosphere (HP) and took a picture using a micro CT. We measured penetration depth of all scoring elements into silicone tube wall and calculated their percentage using the following formula; penetration depth/original scoring element height × 100. We also observed the deformation of scoring element during balloon inflation in each device. Scoring element of CB cut deeper into both tubes significantly than SF and NSE at both pressure (40.5% vs 25.1% and 16.8% at NP and 86.1% vs 33.5% and 29.1% at HP in tube S, p < 0.01, respectively, 62.6% vs 33.5% and 17.0% at NP and 93.3% vs 45.1% and 36.5% at HP in tube H, p < 0.01, respectively). Although no deformation of scoring element was recognized in CB, some deformations were observed in 50% of NSE and 40% of SF (p = 0.0377). Scoring balloon with sharp and firmly fixed scoring elements like CB may show definite scoring effect.

The Effect of Aggressive Wire Recanalization in Calcified Atheroma and Dilatation (ARCADIA) Technique in Eccentric Calcified Lesion of No-stenting Zone.

PURPOSE: The endovascular approach for eccentric calcified lesions of the no-stenting zone is challenging. This study aimed to investigate the effect of a novel technique for these lesions. METHODS: We performed EVT for severe and eccentric calcified lesions using the technique, which is presented previously and named aggressive wire recanalization in calcified atheroma and dilatation (ARCADIA). In brief, a guidewire is passed to the residual lumen firstly. Next, another guidewire is advanced into and cross through the calcified plaque and returned to the distal original lumen with intravascular ultrasound (IVUS) guided. The calcified plaque is dilated by using a scoring-balloon or non-compliant balloon. RESULTS: Consecutive 14 peripheral artery disease patients with isolated and eccentric calcification in a no-stenting zone were treated using ARCADIA technique between January 2018 and March 2020. In IVUS data, lumen cross-section area was significantly increased from 5.2 ± 2.0 mm2 to 18.1 ± 6.9 mm2 (p < 0.01), lumen area was expanded roundly evaluating as symmetry index from 0.45 ± 0.09 to 0.81 ± 0.12 (p < 0.01). There were no distal embolization and perforation after ARCADIA technique. One-year target lesion revascularization occurred in only 2 cases. The primary patency of 1 year was 85.7%. CONCLUSION: ARCADIA technique is safe and appropriate, and can be 1 option to treat for eccentric calcified lesions of the no-stenting zone as an optimal wire crossing method.

The importance of side branch preservation in the treatment of chronic total occlusions with bifurcation lesions.

OBJECTIVES: The aim of this study was to identify the predictive factors for suboptimal result in side branch (SB) in chronic total occlusion (CTO) bifurcation lesions and clinical outcomes of patients with suboptimal result in SB. BACKGROUND: There is little evidence on the optimal strategy for bifurcation lesions in CTO. METHODS: We retrospectively reviewed 314 consecutive bifurcation lesions in CTO with SB ≥ 2.5 mm in 3 hospitals from March 2010 to June 2018. Patients were divided into the two groups based on the suboptimal SB treatment (SST) and optimal SB treatment (OST) groups. The baseline characteristics, procedural and clinical outcomes were compared between the two groups. This study also evaluated the predictors of suboptimal result in SB. RESULTS: Suboptimal result in SB occurred in 47 cases. Presence of stenosis in SB, bifurcations located within the occluded segment and sub-intimal tracking at SB ostium was an independent predictor of suboptimal result in SB. The cumulative incidence of target lesion revascularization (TLR) in all lesions was not significantly different between the two groups, however, TLR in right coronary artery (RCA) was significantly higher in the SST group. In the Cox regression analysis, suboptimal result in SB in RCA and sub-intimal tracking were independent predictors of TLR for MB. In patients with bifurcations located within the occluded segment, usage of two-stent technique was significantly lower in the SST group. CONCLUSIONS: Meticulous procedures are required for SB preservation to improve not only SB prognosis but also MB, especially in RCA.

Percutaneous coronary intervention in side branch coronary arteries: Insights from the Japanese nationwide registry.

BACKGROUND: Performance of percutaneous coronary intervention (PCI) in side-branch vessels (SB-PCI) has not been fully investigated despite the technical advancement of PCI. METHODS: We investigated 257,492 patients registered in the Japanese nationwide PCI registry from January to December 2018; 199,767 (78%) underwent PCI for major vessel PCI (MV-PCI), 21,555 (8.4%) underwent SB-PCI, and 24,862 (9.6%) underwent PCI for both vessels (SB + MV-PCI). The frequencies of primary composite adverse events, defined as in-hospital mortality and procedural complications (i.e., peri-procedural myocardial infarction, tamponade, new-onset cardiogenic shock, stent thrombosis, emergent surgery, and bleeding), and PCI for restenotic lesions were investigated. Their association with institutional frequency of each PCI was also investigated. RESULTS: Fewer drug-eluting stents (66% vs. 86%) and more drug-coated balloons (23% vs. 9%) were used in SB-PCI than in MV-PCI (p < 0.001). Pre-procedure non-invasive testing was similarly performed in SB-PCI and MV-PCI (57% vs. 61%). The composite endpoint was observed in 0.7%, 1.9%, and 2.2% of the SB-PCI, SB + MV-PCI, and MV-PCI groups, respectively (p < 0.001). Institutional frequency of SB-PCI was inversely associated with the composite-endpoint risk for all PCI procedures (odds ratio 1.37, 95% confidence interval 1.04-1.81 in the lowest tertile, with reference to the middle tertile, p = 0.02). Frequency of PCI for restenotic lesions was also inversely associated with the institutional frequency of MV-PCI (p < 0.001). CONCLUSION: SB-PCI was performed safely with a low frequency of acute complications, and higher SB-PCI frequency presented a lower risk of in-hospital adverse events, albeit with a cost of an increase in PCI for restenotic lesions.

Ischemic/bleeding event after short dual-antiplatelet therapy in patients with high bleeding risk: Sub-analysis of the MODEL U-SES study.

BACKGROUND: This analysis aimed to evaluate the clinical impact of high bleeding risk (HBR) on adverse events after percutaneous coronary intervention (PCI). METHODS: We retrospectively analyzed 1695 patients in the MODEL U-SES study, which was a multicenter, open-label, prospective observational study evaluating safety of 3-month dual antiplatelet therapy (DAPT) after Ultimaster stent (Terumo Corporation, Tokyo, Japan) implantation at 65 sites in Japan. Patients were divided into 2 groups (HBR/Non-HBR) according to modified Academic Research Consortium-HBR criteria. Ischemic/thrombotic event (cardiovascular death, myocardial infarction, ischemic stroke, and stent thrombosis) and bleeding event (Bleeding Academic Research Consortium 3 or 5) at 1 year were evaluated. RESULTS: Of 1695 patients, 840 patients were categorized as HBR and 855 patients were Non-HBR. One-year follow-up was completed in 95.3%. During 1-year follow-up, ischemic/thrombotic events were observed in 31 cases (1.8%) and bleeding events occurred in 21 cases (1.2%). Presence of HBR was significantly associated with higher incidence of ischemic/thrombotic events as compared to Non-HBR (adjusted hazard ratio, 0.16; 95% confidence interval, 0.05 to 0.50), whereas the incidence of bleeding events did not reach statistical significance between HBR and Non-HBR. In comparison of monotherapy after DAPT, P2Y12 inhibitor monotherapy after DAPT had comparable ischemic/thrombotic and bleeding events with aspirin monotherapy after DAPT in both HBR and Non-HBR. CONCLUSION: In contemporary PCI practice, nearly half of patients had HBR and presence of HBR significantly increased risk of ischemic/thrombotic events. Both aspirin and P2Y12 inhibitor monotherapy following short DAPT had low and comparable ischemic/bleeding events.

Proximal optimisation technique versus final kissing balloon inflation in coronary bifurcation lesions: the randomised, multicentre PROPOT trial.

BACKGROUND: Clinical implications of the proximal optimisation technique (POT) for bifurcation lesions have not been investigated in a randomised controlled trial. AIMS: This study aimed to investigate whether POT is superior in terms of stent apposition compared with the conventional kissing balloon technique (KBT) in real-life bifurcation lesions using optical coherence tomography (OCT). METHODS: A total of 120 patients from 15 centres were randomised into two groups - POT followed by side branch dilation or KBT. Finally, 57 and 58 patients in the POT and KBT groups, respectively, were analysed. OCT was performed at baseline, immediately after wire recrossing to the side branch, and at the final procedure. RESULTS: The primary endpoint was the rate of malapposed struts assessed by the final OCT. The rate of malapposed struts did not differ between the POT and KBT groups (in-stent proximal site: 10.4% vs 7.7%, p=0.33; bifurcation core: 1.4% vs 1.1%, p=0.67; core's distal edge: 6.2% vs 5.3%, p=0.59). More additional treatments were required among the POT group (40.4% vs 6.9%, p<0.01). At one-year follow-up, only one patient in each group underwent target lesion revascularisation (2.0% vs 1.9%). CONCLUSIONS: POT followed by side branch dilation did not show any advantages over conventional KBT in terms of stent apposition; however, excellent midterm clinical outcomes were observed in both strategies.

Pulmonary lymphangitic carcinomatosis secondary to ureteral cancer.

BACKGROUND: Pulmonary lymphangitic carcinomatosis (PLC) is a metastatic lung disease of malignant tumors that spread through pulmonary lymphatic vessels. Although prompt diagnosis and specific treatment of PLC are required due to the poor prognosis associated with this disease, it is often challenging to determine the primary cancer site. CASE PRESENTATION: A 67-year-old Japanese woman presented to our hospital with a 10-day history of cough and dyspnea on exertion. Chest radiography and computed tomography (CT) revealed diffuse nodular opacities with interlobular septal thickening. Both bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) revealed carcinoma cells with unknown origin. Contrast-enhanced CT depicted a mass in the right ureter with hydronephrosis, and retrograde urography showed a narrowing of the right ureter. Urine cytology from her right ureter via ureteral catheter also revealed atypical cells, highly suggestive of malignancy. Immunohistochemical examination of lung specimens via TBLB showed results consistent with lung metastasis of ureteral cancer. Therefore, we arrived at a diagnosis of PLC secondary to ureteral cancer. CONCLUSIONS: This case encouraged multidisciplinary discussion and a whole-body examination, including TBLB with immunohistochemistry, to determine the origin of PLC.