Treatment of true bifurcation stenosis by elective stent implantation in parent vessel and non-stent dilatation of side branch: immediate and follow-up results.

Data of 67 consecutive patients who underwent stent implantation in the parent vessel and non-stent dilatation of the side branch of a true bifurcation stenosis was retrospectively analysed. The mean age was 53.2 +/- 9.7 years, with majority (89.6%) being males. Forty-seven (70.1%) lesions involved the bifurcation of left anterior descending artery and its major diagonal branch. The parent vessel was treated using balloon angioplasty in 50 (74.6%), rotational atherectomy in 15 (22.4%) and directional coronary atherectomy in 2 (3.0%) patients. All the patients subsequently received an intracoronary stent in the parent vessel. Depending upon the treatment strategy for the side branch, the patients were divided into two groups: (1) Percutaneous transluminal coronary angioplasty group, which included 37 patients in whom the side branch was dilated by plain balloon angioplasty, and (2) Debulking group, in which 30 patients underwent debulking of the side branch using rotablation or directional coronary atherectomy. Overall, the procedure was successful in 64 (95.6%) patients. One (1.5%) patient developed non-Q wave myocardial infarction during the hospital stay. There were no Q-wave myocardial infarction, need for emergency coronary artery bypass surgery or death. Clinical follow-up of at least six months was available in all patients with a mean duration of 9.5 +/- 3.2 months. Recurrence of symptoms developed in 19 (28.4%) patients. Fourteen (20.9%) patients required target vessel revascularisation, of which 11 (29.7%) belonged to the percutaneous transluminal coronary angioplasty group and 3 (10.0%) to the debulking group, the difference being statistically significant (p = 0.045). The freedom from target vessel revascularisation was 93.1 and 89.4 percent at 6 and 12 months in the debulking group, compared to 78.4 and 68.9 percent at the same time in the percutaneous transluminal coronary angioplasty group. This study thus demonstrates that percutaneous intervention for true bifurcation stenosis with stent implantation in the parent vessel and non-stent dilatation in the side branch provides favourable immediate and follow-up results. Debulking in comparison to plain balloon angioplasty of the side branch results in further improvement in clinical outcome and need for target vessel revascularisation on follow-up.

High speed rotational atherectomy for diffuse in-stent restenosis: short- and mid-term follow-up results.

Between January 1997 to May 1998, 37 consecutive patients underwent high speed rotational atherectomy with adjunctive balloon angioplasty for the management of first-time diffuse variety of in-stent restenosis in the native coronary arteries. Their age ranged from 38 to 71 years (mean 54.3 +/- 9.7 years). All the patients underwent initial stent implantation at moderate to high pressure. Patients were either symptomatic or demonstrated significant ischaemia by non-invasive testing. The median time from the index procedure to in-stent restenosis was 20 weeks (range 9-40 weeks). Majority (78.1%) of lesions were in the territory of left anterior descending coronary artery. The mean lesion length was 24.3 +/- 8.3 mm (range 12-42 mm). Five lesions each (12.2%) were total occlusion and ostial in location. High speed rotational atherectomy was performed using stepped burr technique in majority (90.2%) with the largest burr corresponding to approximately 70 percent of the reference vessel diameter. The initial burr size ranged from 1.5-2.0 mm, final burr was 1.75-2.25 mm and the average number of burrs used per target vessel was 2.2 +/- 0.3 (range 1-3). Adjunctive balloon angioplasty was performed in all (100%) cases using a semi-compliant oversized balloon (balloon-to-artery ratio 1.1:1) inflated at a pressure of 6.5 +/- 2.1 atmospheres (range 4-10). The procedure was successful in all cases without any major complications (death, Q-MI, CABG or repeat PTCA). Over a median follow-up of 10 months, 27 (73%) patients were asymptomatic. Recurrence of clinical events occurred in 10 (27%) patients at median interval of 16 weeks after rotational atherectomy. Angina was controlled on drug therapy in six (16.2%) and target vessel revascularisation was required in three (8.1%) cases. By the Kaplan-Meier estimate, an event-free survival (absence of death, Q-MI, recurrence of angina, target vessel revascularisation) was 97.3, 94.6, 75.7 and 72.6 percent at 1, 3, 6 and 12 months, respectively. Thus, rotational atherectomy using a stepped burr approach for adequate debulking, followed by adjunctive balloon angioplasty is safe with excellent in-hospital results for the treatment of diffuse in-stent restenosis. Although recurrence of symptoms develops in approximately one-fourth of patients on follow-up, it is much less than reported with balloon angioplasty in this subgroup of patients.

Elective stent implantation after optimal debulking for complex coronary lesions: acute and mid-term results.

Between January 1995 to December 1997, 45 patients with complex lesions in coronary arteries were treated by using the strategy of initial debulking with an atherectomy device followed by elective stenting. Their age ranged from 35-73 years (mean +/- SD:53.9 +/- 9.1) and 93.3 percent were males. The lesion morphology was type B1 in 14 (31.1%), B2 in 16 (35.6%) and type C in 13 (28.9%) patients. The choice of atherectomy device, based primarily on the morphology of lesion, was rotational atherectomy in 23 (51.1%) and directional coronary atherectomy in 22 (48.9%) patients. While majority (73.9%) of the lesions treated by rotablation were long, diffuse and calcified, directional atherectomy was preferred for highly eccentric stenoses in large-sized arteries. All patients underwent elective stent implantation after optimal lesion debulking using a mean burr size of 1.74 +/- 0.2mm for rotablation and a 7Fr. atherocath in majority (90.9%) of patients treated by directional coronary atherectomy. Angiographic success was achieved in all, while clinical success was 97.8 percent. One patient died of acute-on-chronic renal failure during hospitalisation. There were no other major in-hospital adverse cardiac events. At a median follow-up of 13 months (range 1-36 months), recurrence of angina developed in 10 (22.7%), out in which target lesion revascularisation was required in 5 (11.4%) and elective coronary artery bypass graft surgery in one (2.2%) patient. The event-free survival as calculated by the Kaplan-Meier method was 85.8 percent at six, 77.2 at 12 71.7 percent at 18 months of follow-up. In conclusion, optimal debulking before stent implantation provides a larger lumen, and thus eliminates sub-acute stent thrombosis in complex coronary lesions. This strategy also resulted in a high incidence of event-free survival and a low frequency of target lesion revascularisation on mid-term follow-up.

Immediate and follow-up clinical outcome after multivessel coronary stenting.

Seventy-two out of 656 patients treated by coronary stenting between January 1995 to May 1997 underwent elective multivessel stenting as a strategy for nonsurgical revascularization in patients with two-vessel (n = 37) and three-vessel (n = 35) disease. Their age ranged from 35 to 77 years (mean: 53.6 +/- 9.2) and the majority (77.8%) were males. The patients were included if the target vessel was more than 2.7 mm in diameter and subserved a moderate to large area of viable myocardium, provided the target lesion was considered approachable by stent. In all, 160 stents were deployed in 146 vessels with a mean of 2.2 stents per patient. The procedure was performed on all the target lesions in one stage in 51(70.8%) and two stages in 21(29.2%) patients. Two-vessel stenting was done in all except 2 patients who received stents in all the three major arteries. Successful deployment of the stent was achieved at the target site in all patients without any major in-hospital complications including subacute stent thrombosis, myocardial infarction (MI), emergency bypass graft surgery (CABG) or death. Clinical follow-up was available in 66(91.6%) patients at a mean of 7.8 +/- 5.5 months. The actuarial survival rates were 98.6, 96.7 and 94.6 percent, respectively at one, 3 and 6 to 12 months after the procedure with an event-free survival (absence of death, MI, recurrence of angina or any revascularization) of 98.5 percent at one, 93 percent at 3, 83.2 percent at 6 and 68.4 percent at 12 months. Only 15(22.7%) patients developed any event and target lesion revascularization was required in 8(12%) patients. In conclusion, multivessel stenting in patients with two- and three-vessel coronary disease is feasible, safe and effective in preventing major in-hospital complications as well as reducing the recurrence of clinical events and need for revascularization on follow-up.