| (PART 1) Double kissing in Mini-Culotte stenting: Insights from Micro-CT of bench testingBackground: Double kissing Mini-Culotte(DK-mini-Culotte) stenting is based on Mini-Culotte stenting, a kissing balloon inflation is added before the main vessel stent implanted, so there are double kissing balloon inflations in this stenting technique. Though DK-mini-Culotte stenting and Mini-Culotte stenting both have shown good clinical outcomes, the morphologic characteristics of implanted stents in these two stenting techniquesare still unclear.Objectives:This study is to evaluate the effects of double kissing balloon inflation in Mini-Culotte stenting for the morphologic characteristics of implanted stents.Methods: DK-mini-Culotte stenting and Mini-Culotte stenting were performed in two types of silicone bifurcated phantoms with diameter differences of 0.5mm(Model 1: n=4, respectively) and 1.25mm(Model 2: n=4, respectively) of branch vessels. The procedures were recorded by a high resolution digital videorecorder, and all stent phantoms were scanned by Micro-CT. Special software was used to get the three-dimensional reconstruction images for these stent phantoms. The malapposition, deformation, misdistribution of struts and residual stenosis of stents were observed by qualitative methods, and measurement indicators such as diameter stenosis, area stenosis of side branch ostial(SBO AS), metal carina length(MCL), maximum distance of malapposed struts for wall facing SB ostial(MDMS for WFSBO) were analyzed byquantitative methods.Results:Qualitative analysis: As compared to the DK-mini-Culotte stenting, Mini-Culotte stenting was associated with more obvious struts malapposition, deformation and misdistribution, more struts covered atthe SBO of the phantoms, and more severe circular stent under-expansion at the main vessel stents facing SBO. Quantitative analysis: In the Model 1, the MCL(0.25±0.13 mm VS0.55±0.15mm), SBO AS(4.65%±3.24% VS 12.5%±3.93%) and MDMS for WFSBO(0.27±0.08 mm VS 0.49±0.15mm) were all lower in the DK-mini-Culotte stenting group that those in the Mini-Culotte stenting group(all P<0.05); In Model 2, all these parameters of MCL(0.21±0.47 mm VS 0.47±0.12mm), SBO AS(5.13%±3.37% VS 15.00%±6.18%) and MDMS for WFSBO(0.32±0.13 mm VS 0.68±0.10mm) were also lower in DK-mini-Culotte stenting group, as compared with Mini-Culotte stenting group(all P<0.05). The results of factorial analysis showed MDMS for WFSBO trended to be shorter in Model 1(F=4.226,P=0.062). Conclusions:DK-mini-Culotte stenting was associated withbetter morphologic characteristics of stent phantoms when compared with Mini-Culotte stenting, so the clinical outcomes of DK-mini-Culotte stenting may be more superior.(PART 2) Comparison of DK-mini-Culotte stenting versus other two-stent techniques for unprotected left main true bifurcation lesionsBackground:DK-mini-Culotte stenting is a new two-stent technique. It has been shown that DK-mini-Culotte stenting was associated with good clinical outcomes, but whether this stenting is suitable for unprotected left main true bifurcation lesions is still unclear.Objectives:To compare the 1-year clinical outcomes between DK-mini-Culotte stenting and other two-stent techniques for unprotected left main true bifurcation lesions, so as to increase new clinical evidences for DK-mini-Culotte stenting.Methods: This study was a retrospective observational cohort study. There were 113 consecutive patients with unprotected left main true bifurcation lesions in this clinical study. These patients were all subjected to coronary angiography and PCI with two-stent techniques in our hospital, there were 20 patients in the DK-mini-Culotte group and 93 patients in the other two-stent group. The primary clinical endpoint was major adverse cardiovascular events(MACE), which including cardiac death, myocardial infarction, and target vessel revascularization(TVR). The secondary endpoints were stent thrombosis, restenosis, and the individual components of MACE.Results: Though the cumulative event rate of MACE in the DK-mini-Culotte group was numerically lower than that in the other two-stent group, but the difference was no statistical significance(5.0% VS 12.9%,P=0.308). The MACE in DK-mini-Culotte group was mainly caused by TVR for the restenosis of left circumflex(5.0%), and the incidence of TVR between the two groups was no statistical difference(5.0% VS 6.5%). The results of quantitative coronary angiography(QCA): the mean stenosisextent ofleft circumflexat 12-monthsangiographic follow-upwas lower in the DK-mini-Culotte group compared with other two-stent group(21.33% ± 17.53% VS 33.84% ± 22.14%, P=0.028); though the rate of restenosis(≥50%) ofleft circumflex was numerically lower in the DK-mini-Culotte group than that in the other two-stent group, which was no statistical difference(16.7% VS 22.8%, P=0.755).Conclusions:For unprotected left main true bifurcation lesions,DK-mini-Culotte stenting was associated with good clinical outcomes, and lower stenosis extent ofleft circumflexat 12-months angiographic follow-up,so DK-mini-Culotte stenting may be aneffective stenting technique to treatunprotected left main true bifurcation lesions.(PART 3) Comparison of percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main true bifurcation lesionsBackground: As for the treatment strategies of unprotected left main lesions, coronary artery bypass grafting(CABG) is the first recommendation in the current guideline. However, along with the development of stentquality and stenting strategies, more and more patients with left main lesions have been treated with percutaneous coronary intervention(PCI).Objectives: The aim of this study is to compare the 1-year clinical outcomes of PCI and CABG for unprotected left main true bifurcation lesions in the real world. Methods: This study was a retrospective observational cohort study. Propensity score(PS) adjustment and propensity score matching(PSM) were applied in this study to correct the selective bias of observational study. There were 276 consecutive patients with unprotected left main true bifurcation lesions in this cohort study.They were all received coronary angiography, CABG(n=68) or PCI(n=208) with drug eluting stent(DES) in our hospital. The primary clinical endpoint was major adverse cardiac and cerebrovascular events(MACCE), which including all-cause death, myocardial infarction, stroke and target vessel revascularization(TVR).Results: Therewas no statistical difference between the PCI and CABG groups in the cumulative event rate of MACCE(12.5% VS 19.1%, P=0.163), the PS adjusted hazard ratio(HR) was 0.77(95%CI: 0.37-1.63; P=0.498). Though both death(2.4% vs. 8.8%, P=0.018) and a composite safety endpoint of death, myocardial infarction, or stroke(7.7% vs. 17.6%, P=0.019) were observed less frequently after PCI than after CABG, after PS adjustment, PCI was no longer associated with significantly lower risk of death(PS-adjusted HR: 0.41, 95% CI: 0.11-1.61; P=0.203) or thecomposite of death, myocardial infarction, or stroke(PS-adjusted HR: 0.59, 95% CI: 0.25-1.37; P=0.219). After PSM, there were both 58 patients in the PCI and CABG groups, the baseline characteristics were no statistical differences between the two groups, cumulative event rate of MACCE in the PCI group was still not inferior than thatin the CABG group(12.1% VS 13.8%), the PS adjusted HR was 0.90(95% CI: 0.33-2.48; P=0.498), and the secondary endpoints between the two groups were all similar(all P>0.05). For subgroup analysis, cumulative event rate of MACCE was no any statistical difference between the PCI and CABG groups in each subgroup.Conclusions:For the treatment of unprotected left main true bifurcation lesions,PCI with DES was associated with comparable 1-year clinical outcomes compared to CABG, so PCI may be an effective alternative revascularization strategy for these lesions. |
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