Gender-based disparities in outcomes of coronary bifurcation stenting in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis.

INTRODUCTION: Around 15-20% of lesions necessitating percutaneous coronary interventions (PCI) are attributed to coronary bifurcation lesions. We aim to study gender-based differences in PCI outcomes among bifurcation stents. METHODS: 3 studies were included after thorough systematic search using MEDLINE (EMBASE and PubMed). CRAN-R software using the Metabin module was used for statistical analysis. Pooled odds ratios (OR) were calculated using the random effect model and the Mantel-Haenszel method, with a 95% confidence interval (CI) used to determine statistical significance. Heterogeneity was assessed using Higgins I2. RESULT: Women exhibited a higher risk of in-hospital mortality (OR 0.67, 95% CI 0.58-0.76, I2 = 0%, P < 0.0001), post-procedural bleeding (OR 0.53, 95% CI 0.47-0.6, I2 = 0%, P < 0.0001) and post-procedure stroke (OR 0.72, 95% CI 0.52-1.0, I2 = 0%, P < 0.06) as compared to men. However, there were no significant differences in terms of myocardial infarction (OR 0.84, 95% CI 0.22-3.27, I2 = 49.4%, P < 0.80) and cardiac tamponade (OR 0.63, 95% CI 0.06; 5.72, I2 = 0%, P < 0.6821) in both groups. CONCLUSION: Our study reveals a noteworthy increase in in-hospital mortality in women, which could be attributed to a higher rate of major bleeding, advanced age, increased co-morbidities, and complex pathophysiology of the lesion in comparison to men. Further studies are required to gain a better understanding of the precise mechanisms thus enhancing procedural outcomes.

Unintended Deformation of Stents During Bifurcation PCI: An OCTOBER Trial Substudy.

BACKGROUND: Unintended deformation of implanted coronary stents can lead to loss of coronary access, stent thrombosis and coronary events during follow-up. The incidence, mechanisms and clinical outcomes of unintended stent deformations (USD) during complex bifurcation stenting are not well characterized. OBJECTIVES: In a prespecified analysis of the OCTOBER (European Trial on Optical Coherence Tomography Optimized Bifurcation Event Reduction) trial, we aimed to: 1) determine the incidence and characterize mechanisms of USD identified by optical coherence tomography (OCT); and 2) evaluate physician's detection and correction of accidental abluminal rewiring and USD. METHODS: OCT scans were analyzed for accidental abluminal rewiring and USD. When USD was identified, the plausible mechanism was determined by analysis of all procedural OCT scans and the corresponding angiograms. RESULTS: USD was identified by the core lab in 9.3% (55/589) of OCT-guided cases. Accidental abluminal rewiring was the cause in 44% (24/55), and guide catheter collision was the cause in 40% (22/55) of cases. USD was found in 18.5% of all cases with left main bifurcation percutaneous coronary intervention. The total incidence of abluminal rewiring was 33 in 32 OCT-guided cases (5.4%) and was corrected by physicians in 18 of 33 appearances (54.5%). The 2-year major adverse cardiac event rate for patients with untreated USD (n = 30) was 23.3%, whereas patients with confirmed or possibly corrected USD (n = 25) had no events during follow-up. CONCLUSIONS: USD was associated with adverse procedural complications and cardiac events during follow-up when not identified and corrected. The predominant mechanisms were undetected abluminal rewiring and guide catheter collision. Left main bifurcation percutaneous coronary intervention was a particular risk with USD detected in 18.5% of cases.

Simultaneous stent implantation for pulmonary artery bifurcation stenosis in infants.

OBJECTIVES: Pulmonary artery (PA) bifurcation stenosis often requires simultaneous stent placement, which may be technically challenging. Limited data exist regarding this practice in infants. We aim to report the procedural outcomes and safety of bifurcation stent placement in infants. METHODS: We performed a single-center retrospective review of infants younger than 12 months who underwent simultaneous stent placement for PA bifurcation stenosis from January 1, 2001 through December 31, 2019. RESULTS: Seventeen infants underwent simultaneous PA bifurcation stent placement. The median age was 6.4 months (1.1-10.1 months), and weight was 5.8 kg (3-10.6 kg). Nine (52.9%) patients had had prior PA intervention. Most stents were placed in central PAs (28, 82.4%), followed by lobar branches (6, 17.6%). All patients received pre-mounted stents. The peak gradient across each branch decreased from 47.4 ± 16 to 18.7 ± 13 mm Hg (P less than .0001). The right ventricle to systemic systolic pressure ratio decreased from systemic (1.0 ± 0.3) to just over half systemic (0.58 ± 0.2) (P = .0001). The minimum vessel diameter increased from 3.6 ± 1.5 to 6.0 ± 1.9 mm (P less than .0001). There were 4 (23.5%) patients with high severity adverse events. There were no procedure-related deaths. The median follow-up period was 83.8 months (5.3 months-19.4 years). All patients had subsequent PA re-intervention at a median time of 8.1 months (2.9 months-8.8 years), and median time to re-operation was 19.1 months (2.9 months-7.5 years). CONCLUSIONS: Simultaneous PA stent placement is an effective strategy for relief of bifurcation stenosis in infants. Future transcatheter interventions are necessary to account for patient growth, but may delay the need for re-operation.

Percutaneous Coronary Intervention for Left Main Chronic Total Occlusion: Unprotected or Protected Case?

A 60-year-old male with chronic obstructive pulmonary disease and active smoking was admitted for positive treadmill test. He reported exertional chest pain 4 months ago; however, since then he had been symptom free. Echocardiography showed severe anteroseptal and mild inferoposterior hypokinesia, preserved wall thickness and moderately reduced left-ventricular ejection fraction. Coronary angiography revealed non-calcified chronic total occlusion (CTO) of the left main (LM) with microchannel toward the left circumflex artery (Cx). Oligosymptomatic or asymptomatic patients with unprotected LM-CTO are rarely encountered.

Multimodal Imaging of a Culotte Bifurcation Procedure in the Left Main Coronary Artery of a Perfusion-Fixed Human Heart: Step-by-Step with Serial Micro-CT Analyses.

Percutaneous coronary intervention can be a high-risk procedure that would benefit from optimizing device-tissue interactions between stents and coronary vessels. Using a perfusion-fixed human heart with coronary artery disease, we performed a percutaneous coronary intervention of the left main coronary artery bifurcation. This heart was perfused and multimodal imaging was utilized to view the procedure with direct visualization, fluoroscopy, and optical coherence tomography (OCT). We followed the European Bifurcation Club's guidelines to perform a single-stent bifurcation before transitioning to a two-stent Culotte technique. After each procedural step, the heart was removed from the perfusion apparatus and transferred to a micro-CT scanner to obtain unique scans. We conducted apposition analyses of the computational 3D models from micro-CT DICOM datasets, and compared them to the results from direct visualization and commercial OCT's Apposition Indicator software. Additional measurements of resulting coronary anatomic expansions were taken to determine the potential roles of each step in improving procedural outcomes. Micro-CT images show stent deformation during a percutaneous coronary intervention (provisional to Culotte bifurcation procedure) in an isolated diseased human heart.

Success rate and influencing factors of a balloon-push technique: A new technique to remove side branch-jailed struts under three-dimensional optical coherence tomography guidance.

BACKGROUND: Kissing balloon inflation with distal guide wire recross can cause severe stent deformation depending on the stent link location with respect to the carina. The balloon-push technique, by which an inflated balloon is forced into the SB from the proximal main vessel (MV), is a feasible way to remove jailed struts without causing severe stent deformation. AIMS: We investigated the procedural success rate, patterns of jailed strut removal at side branch (SB) orifices, factors related to failure of jailed strut removal, and follow-up angiogram results of the balloon-push technique. METHODS: Between September 2015 and December 2020, 51 bifurcation stenting cases in which the balloon-push technique was used were enrolled. Based on three-dimensional optical coherence tomography images, strut removal with 1 stent crown length was defined as successful. Strut removal patterns were classified into two types: parallel-slide type (stent struts shifted distally into the MV lumen without inversion) and under-carina type (stent struts shifted distally under the carina with strut inversion or strut slide). RESULTS: Procedural success was attained in 39 cases (success rate: 76.5%). Parallel-slide type and under-carina type occurred in 43% and 33% of cases, respectively. Factors related to failure were trifurcation lesions and a smaller pushed balloon-SB artery ratio compared with those in success cases (0.95 ± 0.18 vs. 1.10 ± 0.22, p = 0.032). Follow-up angiography was performed in 37 cases, and 2 cases had binary in-stent restenosis. CONCLUSIONS: Removal of jailed struts with the balloon-push technique was feasible, without severe stent deformation, in bifurcation stentings.

Coronary Bifurcation Stenting: Review of Current Techniques and Evidence.

BACKGROUND: Coronary bifurcation stenting constitutes 20% of all PCI performed. Given the extensive prevalence of bifurcation lesions, various techniques have sought to optimally stent the bifurcation to improve revascularization while also decreasing rates of stent thrombosis and lesion recurrence. Advanced techniques, such as planned two-stent approaches, have been shown to have improved outcomes but also require fluoroscopy and procedure time, posing an economic argument as well as a patient-outcome one. OBJECTIVE: Because of the many strategies posited in the literature, it becomes essential to objectively evaluate evidence from randomized controlled trials and meta-analyses to help determine the optimal stenting strategy. METHODS: We reviewed the clinical evidence on the efficacy of coronary bifurcation stenting. RESULTS: In this paper, we review the most recent randomized controlled trials and meta-analyses on the efficacy of various stenting techniques and advances in stenting technologies published to gauge the current state of understanding and chart where the field is heading. CONCLUSION: Bifurcation stenting is a maturing problem in the field of interventional cardiology that is adapting to the needs of the patients and advances in technology.

Novel use of the double kissing crush technique to stent complex pulmonary artery stenosis in a child with Alagille syndrome.

Coronary bifurcation lesions and treatment with two-stent techniques have been developed, including the double kissing (DK) crush technique. The use of this technique in children or noncoronary vessels, including pulmonary arteries, has not been described. We present a 12-year-old girl with Alagille syndrome, a ventricular septal defect (VSD), and complex bilateral pulmonary artery (PA) stenoses who is status post six catheterizations for PA angioplasty and stenting to improve her marked right ventricular hypertension. With collaboration between the congenital and structural teams, she successfully underwent the DK crush technique for a complex lesion in her PA. This improved pulmonary flow and allowed for successful surgical VSD closure.

DES Selection for Left Main and Coronary Bifurcation Stenting.

Coronary bifurcation lesions present a challenging lesion subset regarding procedural complexity and worse patient outcomes as compared to simple lesions. Drug eluting stents (DES), as the current standard of care for percutaneous myocardial revascularization, have tubular design and uniform diameter, and therefore, need to be subjected to a standardized set of procedural modifications, to optimally fit and reconstruct underlying bifurcation anatomy. Since contemporary DES have various design platforms, with diverse mechanical properties, we must be aware of the device's favorable characteristics and limitations, to ensure maximal procedural safety and success. This is especially true for bifurcation lesion stenting, during which device integrity will often be eventually tested by undergoing specific procedural steps, such as proximal balloon optimization, kissing-balloon inflations, or even intentional stent crushing. In this review we address the design characteristics of contemporary DES, their bifurcation-specific experimental testing data, and reported clinical results, in an attempt to provide relevant information and help in device selection for bifurcation stenting procedures.

[Airway stenting in patients with complex benign tracheobronchial stenosis]. / Odnomomentnoe endoprotezirovanie trakhei i glavnykh bronkhov pri rubtsovom stenoze.

Tracheal and bronchial stenting is actively used for cancer and benign airway stenosis. This procedure is common in patients with advanced cancer. Stenting ensures breathing and availability of early chemo- and radiotherapy without the need for tracheostomy. This procedure is less common in patients with benign tracheal stenosis. In this case, isolated tracheal or bronchial stenting is performed. Complex tracheobronchial stenosis is extremely rare and creates significant difficulties. We present 3 cases of tracheobronchial stenting for cicatricial stenosis. In each case, stenosis was dilated with a rigid bronchoscope or balloon dilatation. Then, a silicone stent was installed. Resection with an appropriate anastomosis was contraindicated due to advanced pathological process. Thus stenting was regarded as a palliative operation. The follow-up periods were 9 months, 3 and 10 years. Each patient underwent inhalation therapy, endoscopy and repeated stenting if necessary.

Percutaneous coronary artery intervention in unprotected left main coronary artery disease: one-year outcome Egyptian registry.

BACKGROUND: Left main coronary artery lesions are associated with jeopardy of an outsized area of the myocardium, causing a high incidence of morbidity and mortality. Optimal treatment of coronary bifurcation anatomy remains highly debatable, whether by provisional or two-stent technique. This prospective observational study was designed to investigate the one-year clinical outcomes of unprotected left main coronary artery disease revascularization by percutaneous coronary intervention in a "real-world" setting among Egyptian patients in a prospective single-center registry (at Ain Shams University Hospitals). RESULTS: This study included 163 patients who underwent PCI to LM lesions between May 1, 2020, and the end of April in Ain Shams University hospitals. Patients were dichotomized into two groups according to their intended stenting technique, whether provisional or two-stent technique. A total of 142 underwent provisional stenting while 21 were designated for the two-stent technique, mainly DK crush (double kissing). Among the patients with intended provisional stenting, 34 patients underwent the TAP technique. Patients were followed up for the primary endpoints, at the in-hospital setting, at 30 days, and after 1 year. In-hospital death was encountered in 6.34% of cases undergoing provisional stenting, among which 5.36% were due to a cardiovascular cause. Total MACCE was found to be 2.96% in the provisional stenting group versus 4.76% in the two-stent group. Overall, MACCE at 1 year was found to be 22.31% in the provisional group and 30% in the two-stent group (p-value0.57). TVF was recognized in 10% of cases treated by provisional stenting and 30% of cases treated by the two-stent technique (p-value 0.023). CONCLUSIONS: LM coronary artery lesions treatment by PCI is considered a safe and beneficial solution. Provisional stenting is the preferred approach bearing in mind that bail-out procedures may be sought in case the SB needs further treatment. Adjunctive assessment by IVUS or FFR may help achieve better outcomes, and efforts should be performed to facilitate their feasibility.

Two-Step V-Stenting and Simultaneous Kissing Stent via 6F Guides: Simple Just Got Simpler.

V-stenting (VS) and simultaneously kissing stents (SKS) upfront 2-stent strategies for treating large diameter bifurcations and especially distal left main coronary artery (LMCA) disease. Former teaching suggests that the minimal requirements for VS and SKS requires 8F guiding catheters or 7.5F sheathless guide. Presented is the "2-Step refinement" of SKS and VS that can be executed via conventional 6F guide without any additional equipment. In view of the simplicity and suitability for unstable subjects with acute coronary syndromes; "2 Step SKS and VS" should be in the armamentarium of all advanced interventionalists.

Single versus Double Stenting in NSTEMI Patients with Complex Left Main Bifurcation Disease.

Background: Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long-term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods: We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results: Four hundred and forty-five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow-up of 37.1 months (IQR 22.1-39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions: Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long-term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2-stent strategy.

Clinical Outcomes and OCT Analysis After Culotte Stenting With 2nd- and 3rd-Generation Everolimus-Eluting Stents: Two-Year Follow-Up of the CELTIC Bifurcation Study.

PURPOSE: The aim of this study was to provide 2-year clinical outcomes for patients with Medina 1,1,1 bifurcation lesions treated with a culotte technique, comparing Synergy and Xience drug eluting stent (DES) platforms. A sub-group analysis of 9-month Optical Coherence Tomography (OCT) was performed to assess stent healing. METHODS: A total of 170 patients with non-left main stem Medina 1,1,1 lesions, were randomized to treatment with Synergy or Xience DES. The primary outcome was a composite of death, myocardial infarction, stroke, target vessel failure, stent thrombosis and angiographic restenosis. Qualitative and quantitative analyses of 30 bifurcations were carried out on OCT images taken at 9-month follow-up. RESULTS: After 2 years, the primary outcome had occurred in 17.7% of patients in the Synergy group and 18.8% of patients in the Xience group. The non-inferiority test was met (p = 0.0055). MACCE occurred in 7.3% of all patients by 2 years. OCT analysis found smaller stent and lumen areas in patients treated with Synergy stents. There was a higher proportion of malapposed struts in patients treated with Xience stents. CONCLUSIONS: The first report of the CELTIC bifurcation study demonstrated a low MACCE rate after 9 months. There was little accrual of events after this timepoint. There was no difference in clinical outcomes between the platforms tested. OCT analysis demonstrated excellent healing of both platforms.

Gender-related differences in clinical outcomes after either single or double left main bifurcation stenting.

We sought to examine the impact of gender differences in clinical outcomes at 3 years also comparing the role of double versus single stenting approach for the treatment of coronary unprotected LM bifurcation lesions. We retrospectively analyzed both the procedural and medical data of patients referred to our hub center for complex LM bifurcation disease, treated using Crossover provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT) techniques between January 1st, 2008 and May 1st 2018. The main outcome of the study was to evaluate the association between gender and target lesion failure (TLF) based on the different stenting technique used. Five hundred and sixty-seven patients (251 females, mean age 70.0 ± 10 years, mean Syntax score 31.6 ± 6.3) were evaluated. Crossover, T or TAP, culotte and NIT techniques were performed in 171 (30.1%), 61 (10.7%), 98 (17.2%) and 237 (41.8%) patients, respectively with no differences in baseline and peri-procedural items among gender. At a mean follow-up of 37.1 ± 10.8 months (range 22.1-39.3 moths), the overall TLF rate, cardiovascular mortality and stent thrombosis were 12.1%, 3.1% and 1.0%, respectively. Female gender was associated with an increased rate of major bleeding when treated with double stent strategy (p = 0.02). No gender difference in TLF was noted among gender, independently from the stenting approach used. Among patients with ULM bifurcation disease undergoing PCI, TLF rates were not different between genders at 3-year follow-up either using a single or double stent technique.

Gender-based outcomes of coronary bifurcation stenting: A report from the National Readmission Database.

BACKGROUND: There is a paucity of data focusing on women's outcomes after percutaneous coronary interventions (PCI) for coronary bifurcation lesions (CBLs). METHODS: Patients who received PCI for CBLs in the context of acute coronary syndrome (ACS) during the period of 01 October 2015- 31 December 2017, were identified from the United States National Readmission Database. The primary endpoint of this study was in-hospital major adverse events (MAEs). The secondary endpoints were in-hospital mortality, vascular complications, major bleeding, post-procedural bleeding, need for blood transfusion, severe disability surrogates (non-home discharge and need for mechanical ventilation), resources utilization surrogates (length of stay and cost of hospitalization), and 30-day readmission rate. A 1:1 propensity score matching was used to compare the outcomes between women and men. RESULTS: A total of 25,050 (women = 7,480; men = 17,570) patients were included in the current analysis. After propensity score matching, women had higher in-hospital MAEs (7 vs 5.2%, p < .01), major bleeding (1.8 vs 0.8%, p < .01), post-procedural bleeding (6.1 vs 3.4%, p < .01), need for blood transfusion (6.4 vs 4.2%, p < .01), non-home discharges (10.2 vs 7.1%; p < .01), longer length of hospital stay (3 days [IQR 2-6] vs. 3 days [IQR 2-5], p < .01) and higher 30-day readmission rate compared to men (14.2 vs. 11.5%, p < .01). CONCLUSIONS: Among all-comers who received PCI for CBLs in the context of ACS, women suffered higher MAEs and 30-day readmission rates compared to their men' counterparts. The higher MAEs in the women were mainly driven by higher postprocedural bleeding rates and the need for blood transfusion.

Differential Factors for Predicting Outcomes in Left Main versus Non-Left Main Coronary Bifurcation Stenting.

BACKGROUND: No large-scale study has compared the clinical and angiographic predictors of cardiovascular events in patients with left main bifurcation (LMB) and non-LMB stenting after second-generation DES implantation. Herein, we investigated differential clinical and angiographic factors for predicting outcomes in LMB versus non-LMB stenting. METHODS: A total of 2648 patients with bifurcation lesions treated with second-generation DESs from the retrospective patient cohort were divided into an LMB group (n = 935) and a non-LMB group (n = 1713). The primary outcome was the 7-year incidence of target lesion failure (TLF), defined as the composite of cardiac death, myocardial infarction, and target lesion revascularization. RESULTS: The incidence of TLF was 9.8%. Those in the LMB group were associated with a higher risk of TLF (14.2% versus 7.5%, p < 0.001) than those in the non-LMB group. Regarding the LMB group, independent predictors of TLF were chronic kidney disease (CKD), reduced left ventricular ejection fraction (LVEF), and two-stenting. Regarding the non-LMB group, CKD, reduced LVEF, old age, diabetes, and small diameter of the main vessel stent were independent predictors of TLF. CONCLUSIONS: The two-stent strategy could potentially increase TLF for the LMB lesions, and achieving the maximal diameter of the main vessel stent could result in better clinical outcomes for non-LMB lesions.

Balloon Deflection Technique to Facilitate Stent Delivery in Impassable Situations During Percutaneous Coronary Intervention.

BACKGROUND: Long and multiple lesions especially in the background of tortuous coronary artery often require multiple stents. The entry and passage of another stent through an already deployed stent becomes challenging because of poorly expanded stent struts, calcified tissue, underlying tortuosity, highly angulated takeoff of the vessel, and lack of coaxiality. It can be facilitated by balloon deflection technique (BDT) where balloon at proximal edge of main vessel stent over a buddy wire helps to deflect second stent either distally or into side branch by blocking potential dead. METHODS: The present retrospective, single-center study included 16,189 consecutive patients who underwent percutaneous coronary intervention (PCI) either through transfemoral or transradial route from January 2014 to August December 2019 at LPS Institute of Cardiology, GSVM Medical College, Kanpur, UP, India where BDT was used in situation of impassable stent among 37 patients. RESULTS: The mean age of patients was 75.4 ± 6.5 years. The commonest clinical presentation was chronic coronary syndrome (n = 19; 51.3%) followed by non-ST-segment elevation myocardial infarction (NSTEMI) (n = 9; 24.4%), ST-segment elevation myocardial infarction (STEMI) (n = 5; 13.5%), and unstable angina (UA) (n = 10; 10.8%). Type B2 lesion was commonest (45.9%) followed by type C (35.2%) and B1 (18.9%). The commonest indication for BDT was angulation (n = 10; 27.1%) followed by tortuosity (n = 9; 24.3%), chronic total occlusion (n = 8; 17.9%), calcification (n = 7; 18.9%), and distally located lesion (n = 3; 8.1%). The left circumflex artery (LCX) was the most commonly intervened artery (n = 16; 43.2%) followed by left anterior descending (n = 11; 29.7%) and right coronary artery (n = 10; 27.1%). Mean diameter and mean length of stents were 3.3 ± 0.9 mm and 18 ± 6 mm respectively. The mean diameter and mean length of deflection balloon were 3 ± 0.5 mm and 20 ± 5 mm respectively. Lesions were modified using aggressive pre-dilatation in all cases while 19.4% of lesion required cutting balloon for additional modification. Additional wire as buddy wire was used in 54% of cases while wire in main vessel acted as buddy wire in dedicated bifurcation stenting. Stent implantation was successful in 36 cases with success rate of 97.3%; while in one case, stent could not be delivered using BDT. Stent was finally delivered using GuideZilla mother-in-child catheter. Overall failure rate was 2.7% which was contributed by extreme tortuosity, angulation, and severe calcification. CONCLUSIONS: In selected cases of impassable lesions; the deflection balloon technique may provide a simple, convenient, and inexpensive solution without further need of additional hardwares except a buddy wire and a balloon.

Local fluid dynamics in patients with bifurcated coronary lesions undergoing percutaneous coronary interventions.

Although the coronary arteries are uniformly exposed to systemic cardiovascular risk factors, atherosclerosis development has a non-random distribution, which follows the local mechanical stresses including flow-related hemodynamic forces. Among these, wall shear stress plays an essential role and it represents the major flow-related factor affecting the distribution of atherosclerosis in coronary bifurcations. Furthermore, an emerging body of evidence suggests that hemodynamic factors such as low and oscillating wall shear stress may facilitate the development of in-stent restenosis and stent thrombosis after successful drug-eluting stent implantation. Drug-eluting stent implantation represents the gold standard for bifurcation interventions. In this specific setting of interventions on bifurcated lesions, the impact of fluid dynamics is expected to play a major role and constitutes substantial opportunity for future technical improvement. In the present review, available data is summarized regarding the role of local fluid dynamics in the clinical outcome of patients with bifurcated lesions.