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28
COSTA ET AL.
(a)
(c)
(b)
(d)
(C)
Figure 9
(Continued)
T-stenting is used. In these bifurcations the operator is often required to allow the SB stent to
protrude into the MV to ensure appropriate SB ostium coverage. This typically would not be
an issue in T-shaped bifurcations where stent positioning can be ensured without significant
protrusion into the MV. Although the bifurcation angle clearly affects the procedural performance of various double stenting techniques, its effect on clinical outcome need more study.
Dzavik et al. (27)reported that a bifurcation angle morethan 50 degreesis an independent
predictor of major adverse cardiac event (MACE) in patients treated with a crush stent strategy.
In this study, 133 patients treated with crush stenting at a single institution had angiographic
assessment including measurement of the distal bifurcation angle. The mean distal bifurcation
angle was 51.1 ± 15.3 degrees, and patients were divided into two groups on the basis of the
median bifurcationangle (50 degrees). At one year, MACE-free survival was significantly lower
in patients with wider angle (76.2% vs. 93.8%; p = 0.005), including a nonsignificant trend
towards high TLR (12.3% vs. 3.1%; p =0.096). In thisstudy, only 90 of 133 casesunderwent final
kissing-balloon (FKB) inflation, and both FKB and distal angle ≥50 degrees were identified as
significant independent predictors for MACE (HR, 0.22; 95% CI, 0.08–0.56; p = 0.002; and HR,
5.72; 95% CI, 1.83, 17.96; p =0.003; respectively). Importantly, a significant association between
bifurcation angle and FKB for the occurrence of MACE was found (p < 0.0001). Whether
these results reflect the primary role of bifurcation angles in determining the outcome or other
associated factors (such as FKB) is unclear, more studies are needed to settle this issue.
CORONARY ARTERY BIFURCATION LESIONS
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29
IMAGING OF CORONARY BIFURCTION LESIONS
Quantitative Coronary Angiography (QCA)
Accurate analysis of coronary lesions is entirely dependent on the quality of the angiographic
image acquisition including adequate projections to ensure optimal visualization. Previous
studies have attempted to identify the most favorable viewing angles that provide optimal
diagnostic value in terms of assessing stenosis severity, and minimizing vessel foreshortening
and overlap (31). However, such studiesdid not include bifurcations.Angiographic assessment
of coronarybifurcation lesionsis often difficultand incompletebecause ofvessel overlap,limited
(and inaccurate) visualization of the lesion (especially the SB ostium), and the requirement for
multiple views. Current recommended views for optimal bifurcation lesion visualization are
based on heuristic experience and have not been scientifically studied. Optimal visualization of
the SB ostium remains the most critical issue with obvious implications for lesion complexity
assessment and technical decision making, especially for stent positioning when using double
stenting techniques, as relatively high incidence of incomplete SB ostium coverage has been
reported, which has been also associated with restenosis at this location.
As with non-bifurcation lesions when using angiography to image bifurcationsone should
choose the views with best visualization of the target lesion including the most orthogonal
view of the SB ostium with particular attention to avoid vessel overlap and foreshortening.
Current standard image acquisitionprotocol forangiographic analysis innon-bifurcated lesions
require at least two orthogonal views >30 degrees apart. Although optimal visualization of the
bifurcation carina and the SB ostium is sometimes achieved in one single projection, which may
be found in nonstandard views, two or more projections are often required. Table 2 displays
angiographic views commonly utilized for optimal visualization of bifurcation lesions [Fig.
10(A) to 10(I)].
Historically, QCA analysis of bifurcation lesions lacked standarized methodology, and
several pitfalls were identified when standard QCA packages (designed for standard QCA
analysis) were adopted for bifurcation analysis. The major challenge in performing QCA in
bifurcations isto determine the reference diameter atall distinct locations within thebifurcation
segment; incorrectreference determinationwill leadto either overestimationor underestimation
of the stenosisseverity. Inconsistencies in QCA methods andreporting (including not reporting
the exact restenosis location) have occasionally precluded the understanding of the differences
between bifurcation studies (Table 3). Although there were significant differences in baseline
angiographic characteristics,which could partially explain differences inoutcomes among trials
such as Nordic vs. CACTUS (CACTUS included smaller vessels with more severe obstruction),
it isclear that a standardized methodology wasneeded in order to allow consistentcomparisons
of bifurcations trials. The consensus panel of the European Bifurcation Group provides several
recommendations for bifurcation imaging acquisition, analysis, and reporting (Table 4) (29). In
this algorithm, the three segments of the bifurcation are independently analyzed including a
predefinedsubsegmental analysison the basisof theareas ofinterest dependingon thetechnique
and/or device used during PCI (Fig. 11). Because of vessel tapering in bifurcation lesions, pre-,
post-, and follow-up MLD may vary according to location, thus creating systematic under- or
overestimation. Therefore, MLD and percent diameter stenosis postprocedure and at follow-up
should be calculated at each subsegment, and the interpolated reference diameter generated
at each predefined area of interest should be used at each study point (final and follow-up).
Importantly, inpatients withrestenosis, locationof recurrencewould bedocumented. Currently,
there are two dedicated commercial softwares for bifurcation QCA analysis: the Medis Medical
Imaging Systems bifurcation application (QAngio XA V 7.2, Leiden, the Netherlands) and the
CAAS 5 (Pie Medical Bifurcation Imaging software, Maastricht, the Netherlands).
Angiography-based three-dimensional (3-D) vessel reconstruction systems are another
development that may enhancevisualization of coronary vessel anatomy. In bifurcationlesions,
3-D reconstructed images reduce vessel overlap and provide accurate measurements of bifurcation angles and degree of SB ostial involvement (Fig. 12). A preliminary study by Dvir
et al. reported a series of 18 patients with serial pre- and postprocedure 3-D reconstruction
analysis of bifurcation lesions treated with PCI and stenting. In this study, the authors used
the CardiOp-B
TM
3-D reconstruction system (CardiOp-BTM, Paieon Medical Inc., Rosh Ha’ayin,
30
Tab le 2 Recommended Angiographic Projections for Optimize Viewing of Coronary Bifurcations
Target bifurcation Location Common views
LAD/Diagonal Proximal a. RAO 25–35◦/Cranial 30–45
b. Cranial 35–45
◦
◦
c. LAO 25–35◦/Cranial 30–45◦for
LAD/Diagonalis:
d. LAO 30–45
e. RAO 20–30◦/Caudal 20–40
◦
/Caudal 30–45
◦
◦
COSTA ET AL.
Mid/distal a. RAO 25–35◦/Cranial 30–45
b. Cranial 35–45
◦
c. LAO 25–35◦/Cranial 30–45
LCx/OM Proximal a. RAO 20–30◦/Caudal 20–40
b. LAO 30–45◦/Caudal 30–45
c. LAO 25–35◦/Cranial 30–45
Mid a. AP 0
◦
b. RAO 20–30◦/Caudal 20–40
c. LAO 30–45◦/Caudal 30–45
Distal a. AP 0
◦
b. RAO 20–30◦/Caudal 20–40
c. Cranial 35–45
◦
Ramus Proximal a. RAO 20–30◦/Caudal 20–40
b. LAO 30–45◦/Caudal 30–45
c. LAO 25–35◦/Cranial 30–45
RCA Mid (i.e., RCA/AM) a. LAO >30
b. Cranial 20–40
c. RAO 25–45
Distal (i.e., PDA/PLSA) a. LAO 30–45
b. LAO 20–45◦/Cranial 20–40
c. Cranial 20–40
LM Distal (i.e., LAD/LCx) a. AP 0
◦
◦
◦
◦
◦
◦
b. RAO 20–30◦/Caudal 20–40
c. LAO 30–45◦/Caudal 30–45
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Abbreviations
LCx, left circumflex; LM, left main; OM, obtuse marginal; PDA, postero descending artery; PLSA, postero-lateral
side artery; RAO, right anterior oblique; RCA, right coronary artery.
: AM, acute marginal; AP, antero-posterior; LAD, left anterior descending; LAO, left anterior oblique;
Israel) (32). This study showed significant reduction in the distal bifurcation angle from preto postprocedure (71 ± 17 degrees vs. 58 ± 18 degrees; p < 0.001), primarily when double
stenting techniques were used. A previous study also suggested that angle changes from preto post-stent implantation predict late adverse events (28). Reasons for this observation are not
clear, and the existing data are insufficient to make any actionable recommendations in this
regard.
Although standardizing methods of reporting of angiographic analyses of bifurcation
interventions and development of new angiography-based imaging systems arewelcome developments, it is critically important to remember that angiography, at its best, is limited in terms
of providing accurate anatomic information at baseline and postprocedure. Therefore, there
should always be a healthy degree of skepticism regarding insights provided by angiography
and aim to confirm these observations with other imaging modalities.
(a)
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(b)
(c)
(a)
(A)
(b)
(d)
(c)
(d)
(e)
(B)
Figure 10 Series of orthogonal views demonstrating optimized views for coronary bifurcations at different locations: (A) Proximal LAD bifurcation: poorly visualized in a (RA0 23
visualization achieved incranial views, c (RA0 10
bifurcation: not optimal assessment of bifurcation lesion, angle and SB ostium in a (RA0 29
◦
13
/CAU 41◦),C(LA048◦/CAU 30◦); best visualization achieved in d (LAO 8◦/CAU 36◦) and e (LA0 43◦/CAU 29◦).
◦
/CRA 38◦) andd (LA035◦/CR 35◦). (B)Proximal LAD/Diagonalis
◦
/CAU 20◦) and b (LA0 35◦/CAU 33◦); best
◦
/CAU 22◦), b (RA0
Continued on pages 32–34
(
)
32
COSTA ET AL.
(a)
(c)
(b)
(d)
(C)
(a)
(b)
(c)
Figure 10
◦
43
/CRA 32◦); poorly assessed in c (RA0 24◦/CAU 20◦) and d (LA0 28◦/CAU 42◦). (D) Distal LAD bifurcation:
poorly assessed in a (RA0 20◦/CAU 16◦) and d (LA0 36◦/CAU 39◦); lesion best visualized in b (RA0 2◦/CAU 42◦)
and d (LA0 34
(Continued)
◦
/CRA 32◦).
(C) Mid-LAD bifurcation: SB ostium best assessed in a (RA0 3
(D)
(d)
◦
/CRA 39◦) and b (LA0
(a)
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(b)
(c)
(a)
(c)
(d)
(E)
(b)
(d)
(F)
Figure 10
◦
43
) and b (LAO 35◦/CRA 37◦); best visualization in c (RA0 20◦/CAU 25◦) and d (LA0 36◦/CAU 31◦). (F) Ramus
bifurcation: a-–bifurcation not visualized (LAO 36
ostium (RAO 25
D-–best visualization of bifurcation lesion and SB ostium (RAO 30
(Continued)
(E). Proximal LCx bifurcation: bifurcation and SBostium not visualized in a (RA0 18◦/CRA
◦
◦
/CAU 27◦). Distal LCx (i.e., OM) bifurcation: c-–bifurcation not visualized (LAO 50◦/CAU 29◦);
/CAU 32◦); b-–best visualization of bifurcation lesion and SB
◦
/CAU 25◦).
(
Continued
)
34
COSTA ET AL.
(a)
(a)
(a)
(b)
(c)
(G)
(b)
(H)
(b)
(c)
(I)
Figure 10
◦
85
/CAU 5◦), best visualized in c (LAO 58◦/CRA 2◦). (H) Distal RCA bifurcation (i.e., RCA-PDA/PLSA): a (LAO
◦
22
/CAU 2◦); SB ostium best visualized in b (LAO 12◦/CRA 19◦). (I) LM bifurcation: SB ostium not visualized in a
(RAO 20
(Continued)
◦
/CAU 22◦) and b (LAO 85◦/CAU 5◦), best visualized in c (LAO 38◦/CAU 35◦).
(G) Mid-RCA bifurcation: SB ostium poorly visualized in a (RA0 33◦/CAU 6◦) and b (LAO
31
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BBK
30
CACTUS
77
et al.
55
“Mini-
)
Continued
(
(2007)
29
NORDIC
19 20 16.25 14.7 15.8 21.7 20.9
∗∗
17.5
∗∗
3.0 3.0 2.68 2.74 2.85 3.08 3.08
∗∗
3.3
∗∗
7 7 7.20 5.7 5.9 10.4 9.9
2.42 2.36 2.28 2.16 2.30 2.39 2.38
∗∗
∗∗
6.4
2.6
∗∗
∗∗
SES SES SES PES PES SES SES SES SES
53
‡‡
SES
‡‡
SCANDSTENT
36
et al.
52
et al.
“Crush” Crush”
28
(2004)
26
et al.
27
Tab le 3 QCA Parameters Reported in DES Bifurcations Trials
Colombo Tanabe Pan et al. Hoye Moussa Pan et al. Galassi
Studies et al.
Distal vessel −−−−−− − −−2.41 2.63 −−−− −−−
RD, mm 2.6 2.6 2.64 3.0 2.9 2.71 2.87 2.78 2.93 3.3
Stenting Technique Single Double Double Single Double SES/ “Crush” Single Double Single Single SES/ Single Double Single Double
and Device SES SES SES SES SES PES SES BMS
Number of Lesions 23 63 65 50 41 241 120 58 68 207 206 103 102 52 177 173 101 101
Lesion length, mm 12.2 10.8 −−−15.38 18.62 14.4 16.6 18.0
Baseline
Parent Vessel
% DS 64.7 61.7 − 77 74 65.9 69.4 64.4 67.7 −−72 73 68.2 69 68 −−
MLD, mm 0.92 0.99 0.64 0.74 0.76 0.93 0.88 1.01 0.94 −−0.84 0.80 0.90 0.83 0.90 −−
Proximal vessel −−−−−− − −−40 46 −−−− −50.3 47.3
Distal vessel −−−−−− − −−1.18 1.32 −−−− −1.28 1.20
Proximal vessel −−−−−− − −−1.43 1.62 −−−− −1.53 1.63
Proximal vessel −−−−−− − −−2.93 3.00 −−−− −−−
Distal vessel −−−−−− − −−52 50 −−−− −53.4 54.9
Side Branch
Lesion length, mm 5.1 5.5 −−−8.99 12.35 5.4 4.7 6.0
2.1 2.1 1.99 2.5 2.5 2.39 2.36 2.21 2.22 2.6
diameter, mm
Reference
MLD, mm 1.14 0.88 0.61 0.93 0.85 0.89 0.66 1.23 1.27 1.21 1.22 1.00 1.15 1.14 0.83 0.84 1.13 1.11
% DS 46.2 56.8 − 64 65 65.9 72.2 43.4 41.5 46 47 60 56 49.7 61 63 53.1 54.4
Proximal stent −−−−−− − −−2.86 3.04 −−−− −3.22 3.17
MLD, mm 2.65 2.66 2.19 2.75 2.66 2.73 2.82 2.47 2.69 −−2.75 2.76 2.56 2.58 2.71 −−
Final
Parent Vessel
Distal stent −−−−−− − −−13 11 −−−− −7.6 9.3
Proximal stent −−−−−− − −−11 7 −−−− −2.5 3.0
Distal stent −−−−−− − −−2.34 2.50 −−−− −2.77 2.74
Acute gain, mm
% DS 11.7 11.5 − 10 9 13.0 5.9 14.4 13.9 −−9 8 14.7 13 12 −−
Proximal stent −−−−−− − −−− −−−−− −1.69 1.54
Distal stent −− −−− − −−− − −−1.66 1.1 1.47 1.48 1.53
31
BBK
30
CACTUS
77
et al.
55
(2007)
29
“Mini-
NORDIC
SES SES SES PES PES SES SES SES SES
53
‡‡
SES
‡‡
SCANDSTENT
36
)
et al.
52
Continued
et al.
“Crush” Crush”
28
(2004)
26
et al.
27
Colombo Tanabe Pan et al. Hoye Moussa Pan et al. Galassi
0.14 0.28 0.12 −−0.30 − 0.99 0.12 −−0.31 0.60 0.30 0.06 0.14 −−
0.37 0.50 0.31 −−0.41 − 0.03 0.56 −0.04 0.20 0.20 0.36 0.35 0.13 0.29 0.03 0.32
loss, mm
Late lumen
Proximal stent −−−−−− − −−0.00 0.10 −−−− −−0.01 −0.02
Distal stent −−−−−− − −−0.04 0.10 −−−− −0.01 0.08
Side Branch
MLD, mm 1.42 1.59 1.49 1.78 1.73 1.85 − 1.70 1.19 1.52 1.86 1.74 1.58 1.63 1.52 1.66 1.93 1.98
% DS 32.0 29.4 31.0 28 30 30.7 − 28.0 45.1 31 24 29 33 28.4 31 30 18.3 23.4
loss, mm
Late lumen
Distal stent −−−−−− − −−15 15 −−−− −9.9 12.5
Proximal stent −−−−−− − −−11 10 −−−− −3.0 3.6
Distal stent −−−−−− − −−2.29 2.38 −−−− −2.77 2.65
Proximal stent −−−−−− − −−2.86 2.94 −−−− −3.23 3.16
MLD, mm 1.69 2.11 1.80 1.95 2.15 2.26 2.20 1.77 1.73 1.50 2.05 2.03 1.97 2.16 1.65 1.94 1.97 2.30
% DS 23.5 14.4 − 21 12 15.5 10.8 24.5 26.1 34 16 17 17 14.6 27 16 16.6 9.6
Stenting Technique Single Double Double Single Double SES/ “Crush” Single Double Single Single SES/ Single Double Single Double
and Device SES SES SES SES SES PES SES BMS
Studies et al.
Tab le 3 QCA Parameters Reported in DES Bifurcations Trials (
Number of Lesions 23 63 65 50 41 241 120 58 68 207 206 103 102 52 177 173 101 101
Side Branch
Acute gain, mm −−−−−− − −−− −−−1.02 0.81 1.41 0.84 1.19
Angiographic FU
Parent Vessel
% DS 13.1 17.3 22.9 18 23 22.9 − 20.7 42.5 −−20 29 29.8 25 25 −−
MLD, mm 2.51 2.35 2.07 2.50 2.30 2.43 − 2.35 1.68 −−2.45 2.10 1.99 2.19 2.24 −−
13.5
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−− −12.5
28.6
9.4
16.0
3.1
(13/96)
7.3
(12/96)
4.6
6.7
12.2
10.7
(16/56)
5.7
(5/53)
5.1
(25/156)
(34/151)
(3/96)
12.5
(12/96)
9.4
(7/96)
(9/96)
13.2
(7/152)
(20/152)
14.7
(10/150)
(22/150)
2.0
(6/49)
(1/49)
8.9
(6/56)
(10/56)
7.5
(4/53)
(3/53)
11.5
(8/156)
(18/156)
(7/151)
(29/151)
−− −−−
−− −−−
††
73
27
(8/11)
††
33
(2/3)
− 67
13
(4/7)
−− −−−
††
46
(3/11)
††
33
(1/3)
††
38
(1/8)
(0/7)
−− −−−
††
27
(5/11)
††
33
(1/3)
††
40
(3/8)
(4/7)
−− −−−
††
0
(3/11)
††
0
(1/3)
††
25
(4/8)
(3/7)
††
(0/11)
††
(0/3)
††
(2/8)
(0/7)
−− −−−
−− −−−
††
100
100
(10/10)
††
100
(4/4)
94
††
(10/10)
††
(4/4)
††
(17/18)
††
(29/29)
−−−− −−−
Number of lesions with angiographic success at index procedure and
‡
††
33
(6/18)
††
(11/29)
§
Overall 6.1% (N = 4) restenosis in PV including 1 in-stent, 2 proximal edge, and 1 distal
Double stenting technique used in 55% in SES and in
‡‡
−−22.5
#
4.9 28.3 4.6
3.5
(13/115)
9.1
10.0
14.8 43.4 19.2
8.7
(4/115)
(10/115)
25.3
(47/186)
(17/186)
(6/40)
(4/40)
15.0
−− 57
(4/4)
−− 43
−− 0
−− − −100
(0/4)
(0/4)
77
−−100
(10/13)
(34/47)
−− 38
(10/13)
(0/13)
Defined as ostium 5 mm plus balloon-treated area in the side branch.
†
Some lesions had stenosis in more than one location.
††
By visual estimation.
∗∗
5
2
−− − 11.3
22.7
(10/44)
)
‡
28.0
(14/50
)
‡
(3/16
∗
Overall lesion 18.7
Restenosis, % (N)
9.1
5.7
4.8
Parent Vessel
(1/?)
(4/44)
13.6
(3/53)
21.8
(1/21)
14.2
Side Branch
(2/?)
(6/44)
(12/55)
(3/21)
Restenosis location, % (N = total
Parent Vessel
number of restenosis in each vessel)
−− − 100
75
§
−
§
In-stent −
(3/4)
−− − 0
−− − 0
−− 72
0
(1/4)
(0/4)
25
§
§
−
§
§
Proximal stent −−−−−− − −− 0
Distal stent −−−−−− − −−57
Proximal edge −
83
92
−
Distal edge −
Ostium 5 mm 100
Side Branch
−− − 0
−− − 77
0
(6/6)
(5/6)
100
92
(11/12)
(11/12)
(3/3)
(3/3)
100
†
segment
In-stent/injured
Distal edge − 8
(0/6)
(1/12)
Percentage of overall population with angiographic follow-up.
∗
Clinical restenosis.
#
No systematic angiographic FU available.
angiographic follow-up (angiographic success defined as attainment of <50% residual stenosis in both branches).
53% in BMS. BMS =bare metal stents; DS = diameter stenosis; FU =follow-up; MLD = minimum lumen diameter; PES =paclitaxel-eluting stents; RD =reference diameter; SES = sirolimus-eluting stents.
edge.
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