Predictive performance of dual modality of computed tomography angiography and intravascular ultrasound for no-reflow phenomenon after percutaneous coronary stenting in stable coronary artery disease.

Attenuated plaque on intravascular ultrasound (IVUS) and low attenuation plaque on computed tomography angiography (CTA) are associated with no-reflow phenomenon during percutaneous coronary intervention (PCI). However, evaluation by a single modality has been unable to satisfactorily predict this phenomenon. We investigated whether the combination of IVUS and CTA findings can ameliorate the predictive potential for no-reflow phenomenon after stent implantation during PCI in stable coronary artery disease (CAD). A total of 988 lesions of 707 stable CAD patients who underwent coronary CTA before PCI were enrolled. PCI was performed with preprocedural IVUS and stent implantation. As for plaque characters, very low attenuation plaque (CTA v-LAP) whose minimum density was < 0 Hounsfield units on CTA and attenuated plaque (IVUS AP) on IVUS were evaluated. No-reflow phenomenon was observed in 22 lesions (2.2%) of 19 patients (2.7%). Both CTA v-LAP and IVUS AP were much more frequently observed in patients with no-reflow phenomenon. Positive (PPV) and negative predictive values (NPV) and accuracy for prediction of no-reflow were almost equivalent between CTA v-LAP (13.2, 99.6, and 87.0%) and IVUS AP (15.7, 99.8, and 89.0%). The combination of CTA v-LAP and IVUS AP markedly ameliorated PPV (31.7%) without deterioration of NPV (99.7%) and increased the diagnostic accuracy (95.5%). These findings showed that the combination of CTA v-LAP and IVUS AP improved the predictive power for no-reflow phenomenon after coronary stenting in stable CAD patients, suggesting the usefulness of combined estimation by using CTA and IVUS for predicting no-reflow phenomenon during PCI in clinical practice.

A randomized comparison of sirolimus- vs. paclitaxel-eluting stents for treatment of bifurcation lesions by single stent and kissing balloon: results of the SINGLE KISS trial.

BACKGROUND: In the treatment of bifurcation lesions, routine stenting of both branches has thus far failed to demonstrate a clear clinical advantage over a provisional one-stent strategy. On the other hand, large scale data evaluating different stent types for clinical outcomes after one-stent treatment with final kissing inflation (FKI) of bifurcation lesions is also limited. This prospective study evaluated the clinical and angiographic outcomes of paclitaxel-eluting stents (PES) vs. sirolimus-eluting stents (SES) in single crossover main branch stenting followed by FKI in patients with bifurcation lesions. METHODS: We randomized 800 patients with single bifurcation lesions to PES (n=400) and SES (n=400) groups. RESULTS: Crossover rates to the two-stent strategy were low in both groups (PES 1.5%, SES 2.8%; p=0.23). At 1 year, there was no significant difference in the primary endpoint of this study, target lesion revascularization rate (PES 3.8%, SES 3.2%, hazard ratio 0.83; 95% confidence interval 0.39 to 1.76; p=0.62). Stent thrombosis occurred in only 1 case in the SES group after 282 days. At 9 months, a total of 593 patients underwent quantitative coronary measurement. The main branch restenosis rate in the PES group was significantly higher than that of the SES group (PES 12.2%, SES 5.5%; p=0.004), however both groups exhibited similar high side branch restenosis rates (PES 17.2%, SES 19.3%; p=0.6). CONCLUSIONS: In patients with bifurcation lesions, a single stent strategy using PES and SES with FKI indicated similar 1 year clinical outcomes and safety profiles.

Pre-drug-eluting stent debulking of bifurcated coronary lesions.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of plaque debulking by directional coronary atherectomy (DCA) before drug-eluting stent (DES) implantation for bifurcated coronary lesions. BACKGROUND: The introduction of DES significantly reduces restenosis and repeated revascularization. However, percutaneous coronary intervention of bifurcated lesions using DES alone remains challenging regardless of whether simple or complex stenting is used. METHODS: Patients with bifurcated lesions were recruited in this prospective multicenter registry. Pre-DES plaque debulking by DCA was conducted. All patients were scheduled to undergo a 9-month coronary angiography. The primary end point was the 9-month binary angiographic restenosis rate. Secondary end points included procedure-related events and major adverse cardiac events (MACE) at 1 year. RESULTS: A total of 99 patients with bifurcated lesions were enrolled in this registry. Directional coronary atherectomy was performed successfully in all cases without any major procedure-related events. Simple stenting was achieved in all but 2 cases. No in-hospital MACE were observed. The 9-month binary restenosis rates in the main branch and side branch were 1.1% and 3.4%, respectively. Target lesion revascularization was performed in 2 patients (1 for the main branch and the other for the side branch). No deaths, no coronary artery bypass grafting, and no myocardial infarctions were reported in the patients within the first year. CONCLUSIONS: Directional coronary atherectomy before DES implantation can possibly avoid complex stenting. This strategy may provide a good long-term outcome in patients with bifurcated lesions.