Bifurcation coronary lesions represent a significant proportion of percutaneous coronary intervention (PCI) procedures and are often technically challenging with both lower procedural success rates and higher adverse event rates than those observed in non-bifurcation lesions. Conventional techniques used to treat bifurcation lesions, including provisional stenting and various two-stent approaches, have several shortcomings. Dedicated bifurcation stents such as the Cappella Sideguard® have been developed to overcome the problems associated with the current available techniques. This review focuses on the utility of the nitinol Sideguard stent in the treatment of bifurcation lesions and discusses the benefits of its trumpet-shaped design, self-expanding properties and low-profile delivery system. Treatment of bifurcation lesions using the Sideguard stent is straightforward and not subject to some of the limitations associated with conventional PCI techniques. Several trials are currently on the way to assess the safety and clinical efficacy of this very promising stent platform.
Acknowledgment: The authors acknowledge the help of Jon VanZile in the preparation of this manuscript.
Support: The publication of this article was funded by Cappella Medical.
Bifurcation coronary lesions, percutaneous coronary intervention, stenting, Cappella Sideguard, nitinol Sideguard stent, low-profile delivery system
Farzin Fath-Ordoubadi is a paid consultant for Cappella Medical. Mamas A Mamas has no conflicts of interest to declare.
January 30, 2011 |
February 24, 2011 |
Interventional Cardiology Review, 2011;6(1):25-27
Farzin Fath-Ordoubadi, Manchester Heart Centre, Manchester Royal Infirmary, Manchester, M13 9PT, UK. E: Farzin.email@example.com
Bifurcation lesions account for 15–20% of all percutaneous coronary intervention (PCI) cases performed, representing about half a million cases annually.1 But PCI treatment for bifurcation coronary disease has historically yielded less satisfactory results than conventional stenting. The procedure is often technically challenging and has been associated with both lower procedural success rates and higher adverse event rates than observed in non-bifurcation lesions.2,3 When dealing with bifurcation disease, clinicians confront a host of challenges, including the angle of the bifurcation, a wide variety of ostial shapes and sizes, differences among lesion/vessel sizes and shapes and technical challenges unique to bifurcation lesions.
Interventional cardiologists have tried to confront these challenges in a number of ways, including provisional stenting and various dual-stent approaches using conventional straight stents adapted for ad hoc techniques. The current favoured technique is provisional stenting, which involves primary treatment of the main branch (MB) with a stepwise approach for treating the side-branch (SB) vessel. Studies such as the British Bifurcation Coronary study (BBC-1) have confirmed that provisional stenting is associated with a decreased composite end-point rate of mortality, myocardial infarction (MI) and target-vessel failure (TVF) compared with the more complicated dual-stent options.4
However, the benefit observed in the BBC-1 study was mainly achieved through a reduction in peri-procedural MI (3.6% versus 11.2%) as defined by cardiac enzyme release. There were comparable rates of target vessel failure and mortality in both treatment arms. Similar results have been observed in the Coronary bifurcations: application of the crushing technique using sirolimus-eluting stents (CACTUS) trial, which compared a dual-stent ‘crushing’ technique with provisional stenting. This trial demonstrated similar target lesion revascularisation (TLR)/target vessel revascularisation (TVR) and mortality rates in both treatment arms. Unlike BBC-1, however, it showed no difference in MI rates between the two cohorts.5
Provisional stenting has gained widespread acceptance, primarily due to technical simplicity rather than improvements in clinical outcomes, but significant challenges are still associated with the technique. During implantation, there is the risk of prolapsing plaque from the MB into the SB and carina shift, resulting in deterioration of the SB lumen. Clinical management and resolution of a compromised or obstructed SB can often be time consuming and is not always possible to rectify.