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Scheme of stent configuration before and after the POT. A Before the POT, immediately after MV stenting according to distal MV reference. The malapposition remained in the proximal MV (middle panel, triangles). Jailed struts covered on the SB ostium (lower panel). B Optimal POT. The POT balloon is located with the distal marker in the carina (upper panel, arrow). The malapposition in the proximal MV is reduced (middle panel). The jailed struts are enlarged uniformly, which facilitates the optimal GWR to the distal cell (lower panel, red cell). C Suboptimal POT. The POT balloon is located more proximally (upper panel, arrow). The stent apposition is improved in the POT-treated site (middle panel). However, the enlargement of jailed struts is obtained only in the proximal cell, which induces suboptimal GWR to the proximal cell and increase of ISA at the bifurcation (lower panel)
Source publication
Aim
We sought to investigate the efficacy of the proximal optimization technique (POT) on crossover stenting followed by side branch (SB) dilation under optical coherence tomography guidance in a multicenter registry study.
Methods and results
A total of 135 bifurcation lesions in 134 patients were divided into POT (n = 52) and non-POT groups (n =...
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Citations
... Previous studies have reported the efficacy of POT on clinical outcomes [6,7]. However, no merit has been documented in other reports [8,9]. Therefore, a recent EBC document and previous studies discussed the technical aspect of POT and argued that this technique is probably less simple than theorized [1,5,10]. ...
... For optimal POT balloon positioning, the inner edge of the distal radio-opaque marker has been recommended to be placed just under the carina [5]. A too-distal position of POT induces overstretching in the distal MV and carina shift, whereas a too-proximal position of POT and relatively small balloon to proximal MV lead to unfavorable deformation of the stent-side cell for eventual re-wiring [1,9]. In our study, although the POT balloon was aimed to be placed accurately, difficulty in identifying the carina due to overlapping of the branches or foreshortening and an inadequate smaller balloon size relatively in the proximal MV (shown in Supplementary Table 1) according to the angiographyguidance might be related to the suboptimal POT. ...
Background:
The impact of coronary bifurcation angle (BA) on incomplete stent apposition (ISA) after crossover stenting followed by side branch (SB) intervention has not been established.
Methods:
A total of 100 crossover stentings randomly treated with proximal optimization technique followed by short balloon dilation in the SB (POT-SBD group, 48 patients) and final kissing balloon technique (KBT group, 52 patients) were analyzed in the PROPOT trial. Major ISA with maximum distance > 400 μm and its location was determined using optical coherence tomography before SB intervention and at the final procedure. The BA was defined as the angle between the distal main vessel and SB. Optimal POT was determined when the difference in stent volume index between the proximal and distal bifurcation was greater than the median value (0.86 mm3/mm) before SB intervention.
Result:
Major ISA was more frequently observed in the POT-SBD than in the KBT group (35% versus 17%, p < 0.05). In the POT-SBD group, worsening ISA after SBD was prominent at the distal bifurcation. The BA was an independent predictor of major ISA (odds ratio 1.04, 95% confidence interval 1.00-1.07, p < 0.05) with a cut-off value of 59.5° (p < 0.05). However, the cases treated with optimal POT in the short BA (<60°) indicated the lowest incidence of major ISA. In the KBT group, BA had no significant impact.
Conclusion:
A wide BA has a potential risk for the occurrence of major ISA after POT followed by SBD in coronary bifurcation stenting.
... The average percentage of incomplete stent apposition per lesion at bifurcation was lower in the 3D-OCT guidance arm than that in the angiography guidance arm (19.5 ± 15.8% vs 27.5 ± 14.2%, p = 0.008). The feasibility of the online 3D-OCT system was 98.2% in contrast to 89.9% in the older Murasato et al. [18] study using offline 3D OCT system [19]. Moreover, 3D OCT reconstruction of coronary bifurcation enables computational flow dynamics, simulation of flow velocity and pressure (fractional flow reserve) [18]. ...
... The feasibility of the online 3D-OCT system was 98.2% in contrast to 89.9% in the older Murasato et al. [18] study using offline 3D OCT system [19]. Moreover, 3D OCT reconstruction of coronary bifurcation enables computational flow dynamics, simulation of flow velocity and pressure (fractional flow reserve) [18]. ...
Coronary bifurcation is defined by the European Bifurcation Consensus as a coronary artery stenosis adjacent to the origin of a significant side branch. Its anatomy is composed of 3 different segments: proximal main vessel, distal main vessel and side branch. Coronary artery bifurcation lesions are encountered in approximately 15–20% of all percutaneous coronary interventions and constitute a complex subgroup of lesions characterized by lower procedural success rates and higher rates of adverse outcomes. In recent years, a growing focus in the European and Japanese bifurcation club meetings has been the emerging role of intravascular imaging, in guiding successful bifurcation percutaneous coronary interventions (PCI). In this review we will present the main ways optical coherence tomography (OCT) can be used to improve outcomes during bifurcation PCI.
... However, inappropriate distal positioning of the POT balloon bears the risk of distal MV overstretch and carina shift to the SB. On the other hand, incorrect proximal positioning may lead to stent malapposition and underexpansion near the carina [17]. The present analysis demonstrated that 7 POT could be a source of additional ostial SB stenosis, due to ostial stretch in elliptical fashion [11]. ...
Background:
Percutaneous coronary interventions (PCI) of bifurcation lesions poses a technical challenge with a high complication rate. Kissing balloon inflation (KBI) and proximal optimization technique (POT) are used to correct bifurcation carina after stenting. However, both may still lead to uncomplete strut apposition to the side branch (SB) lateral wall. Proposed herein, is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and KBI called proximal optimization with kissing balloon inflation (POKI).
Methods:
Bench and in-vivo evaluations were performed. For the bench visualization bifurcated silicone mock vessel was used. The POKI technique was simulated using a 3.5 mm POT balloon. For the in-vivo evaluation patients with angiographic bifurcation lesions in a native coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm, SB diameter ≥ 2.0 mm, and percentage diameter stenosis (%DS) more than 50% in the main vessel (MV) were included. Provisional stenting was the default strategy.
Results:
In total 41 vessels were evaluated. The target vessel was left main in 9 (22.0%) patients, left anterior descending artery - in 26 (63.4%), left circumflex artery - in 4 (9.8%) and right coronary artery - in 2 (4.9%). The predominant type of bifurcation was Medina 1-1-1 (61.8%). Baseline proximal MV DS% was 60.0 ± 23.7%, distal MV DS% - 58.8 ± 28.9% and SB DS% 53.0 ± 32.0%. The application of POKI was feasible in 41 (100%) of the vessels. Post-PCI residual DS at proximal MV was 11.5 ± 15.4%, distal MV - 6.6 ± 9.3%, and SB - 22.9 ± 28.5%. Both procedural and angiographic success was 100%.
Conclusions:
POKI is a novel stent-optimization technique for bifurcation lesions. It showed excellent feasibility and success rate both in bench and in-vivo evaluation.
... (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.) [13,14]. Despite these techniques, when the most distal stent link is in contact with the rim of the carina, consensus report on the use of OCT in CBLs by European and Japanese Bifurcation Club recommended that a second distal compartment is considered as the optimal cell, and in the presence of multiple second distal compartment, the larger compartment should be selected [15]. ...
Background
The jailing strut configuration with link-free and distal guidewire recrossing (LFD) at the side branch orifice (SBO) reduces incomplete stent apposition (ISA) after kissing balloon technique (KBT) in crossover stenting of coronary bifurcation lesions (CBLs). However, data regarding vascular healing after KBT are lacking. We investigated vascular healing 9 months after crossover stenting followed by KBT with optical coherence tomography (OCT) guidance in a prospective multicenter registry.
Methods
Fifty-nine patients with CBLs (LFD, 35 patients; non-LFD, 24 patients) were studied. The jailing configuration of the SB and the wire-recrossing position, incidence of ISA and uncovered struts, and neointima unevenness score (NUS) in the main vessel (MV) after 9 months were determined by off-line 3D-OCT in the core laboratory.
Results
The ISA rate was significantly higher at the SB ostium and distal MV after KBT in the non-LFD group, compared to the LFD group. After 9 months, incidence of ISA (18.3 ± 18.2 vs. 6.0 ± 8.7%, p < 0.01) and uncovered struts (8.7 ± 9.9 vs. 4.7 ± 7.3 %, p = 0.08) were higher at the SB ostium with higher SB restenosis in the non-LFD group. In distal MV, NUS was significantly higher (3.1 ± 1.1 vs. 2.5 ± 0.6, p < 0.05). In true-CBLs, an increase in uncovered struts and ISA rate was prominent in the proximal MV and opposite SB. No differences were observed in the 9-month clinical outcomes.
Conclusion
Visualization of the wire recrossing point and the SB-jailing strut pattern by OCT plays an important role to optimize the KBT in CBL stenting, resulting in favorable mid-term vascular healing.
... A recent multicenter registry investigated the efficacy of POT on crossover stenting under optical coherence tomography (OCT) guidance and showed that pre-POT (POT before MV stenting) provided no benefits such as reduction of incomplete strut apposition around the bi- Table 4. QCA measurements between two treatments after propensity score matching. furcation or no increased success of guide wire re-crossing into the optimal cell [23]. In addition to POT-alone, POT can be used before or/and after FKBD or isolated SB dilation in different sequences, resulting in several combinations of POTAs (e.g., S-POT, K-POT, POT-S-rePOT, POT-K-rePOT), all of which, especially the re-POT, have been well accepted and recommended by the 11th and 12th consensuses of the European Bifurcation Club [1,2]. ...
Background: A simple stenting strategy with provisional side-branch (SB) stenting or crossover stenting has been recommended as the default approach for most coronary bifurcation lesions (CBLs). The proximal optimization technique (POT) and POT-associated techniques (POTAs) were introduced to optimize the ostium of SB. However, these techniques are unable to remove the jailed struts or completely diminish vessel damage. In this study we developed a novel branch ostial optimization technique (BOOT) and assessed its efficacy and safety by a propensity score matching comparison (PSM) with POT-associated techniques (POTA). Methods: From June 2016 to March 2018, a total of 203 consecutive patients with true CBLs were treated with BOOT (50 patients) or POTA stenting (153 patients). We performed PSM to correct for confounders from clinical and lesion characteristics. The primary endpoint was cumulative major adverse cardiac events (MACE) at 12 months including cardiac death, non-fatal myocardial infarction, and target vessel/lesion revascularization (TVR/TLR) or target vessel/lesion thrombosis (ST). Results: After PSM, there were 43 patients in each group. Follow-up coronary angiography was performed in 77 (89.5%) patients. At 12 months, the angiographic restenosis rate was significantly different between the BOOT group and the POTA group after PSM (proximal main branch: 20.01 ± 11.33% vs. 26.81 ± 14.02%, p = 0.003; distal main branch: 18.07 ± 3.71% vs. 23.44 ± 10.78%, p = 0.006; side branch: 23.53 ± 10.12% vs. 39.01 ± 10.29%, p < 0.001, respectively). The incidence of MACE at 12 months was not different between the BOOT group before PSM (8.0% vs. 11.8%, p = 0.604), but less frequent after PSM (4.7% vs. 23.3%, p = 0.026) when compared with the POTA group, mainly due to TVR/TLR (2.3% vs. 20.9%, p = 0.015). Conclusions: In patients with CBLs, BOOT is feasible for optimization of the SB ostium and may be superior to POTAs in terms of the angiographic measurements and long-term clinical outcomes at 12 months follow-up.
... 8,9 Introduction of proximal optimization technique (POT) at the much larger proximal LM vessel is mandatory, to avoid unacceptable stent-vessel gap and later stent thrombosis. 10 UPLMPCI is a unique complex high risk-percutaneous coronary intervention (PCI) and require a special technique such as a double kissing crush or a culotte in the true bifurcation or provisional main branch stent implantation for non-true bifurcation (NTB). The operator's skill is essential and directly reflect the initial result. ...
An 81-year-old Vietnamese man presented with worsening angina, with previous coronary angiography and intravascular ultrasonography findings with ostial left anterior descending artery (LAD) narrowing. He flew to our center for a second opinion. We offered intracoronary optical coherence tomography (OCT) evaluation for the measurement of critical ostial LAD, minimal lumen area (MLA). Provisional stent implantation to left main (LM) bifurcation (MEDINA 0,1,0) with dedicated self-apposing stent was performed with good angiographic result and mid-term follow up without major adverse event.
... 8 Similarly, a retrospective analysis of the efficacy of POT in the SB-treated cases of the 3D Optical Coherence Tomography (OCT) Bifurcation Registry reported no significant differences in the incomplete strut apposition or success rate of optimal SB guidewire re-crossing before SB dilation (SBD) between the POT-and non-POT-treated groups. 9 Although precise positioning of the POT balloon with distal marker at the carina is recommended, its geographical miss to the proximal led to insufficient stent expansion in the bifurcation 9 and that to the distal enhanced the risk of SB ostial narrowing. 10,11 Furthermore, we previously conducted a prospective randomized study to evaluate the proximal optimization technique in coronary bifurcation lesions (PROPOT). ...
... 8 Similarly, a retrospective analysis of the efficacy of POT in the SB-treated cases of the 3D Optical Coherence Tomography (OCT) Bifurcation Registry reported no significant differences in the incomplete strut apposition or success rate of optimal SB guidewire re-crossing before SB dilation (SBD) between the POT-and non-POT-treated groups. 9 Although precise positioning of the POT balloon with distal marker at the carina is recommended, its geographical miss to the proximal led to insufficient stent expansion in the bifurcation 9 and that to the distal enhanced the risk of SB ostial narrowing. 10,11 Furthermore, we previously conducted a prospective randomized study to evaluate the proximal optimization technique in coronary bifurcation lesions (PROPOT). ...
... similar or could be further improved. In another study with OCT examination, POT-induced dilation varied with an average proximalto-distal bifurcation expansion ratio of 1.2-1.5 among the attending institutes, wherein incomplete strut apposition was more likely to occur in the institute presenting with a lower value (inappropriate POT).9 Although the POT balloon was encouraged to be located accurately in this study,12 difficulty in the identification of the carina due to overlapping of the branches or foreshortening in the angiography and inadequate balloon size selection under angiography might have affected the results. ...
Objective:
We investigated the effect of proximal optimization technique (POT) on coronary bifurcation stent failure (BSF) in cross-over stenting by comparing with the kissing balloon technique (KBT) in a multicenter randomized PROPOT trial.
Background:
POT is recommended due to increased certainty for optimal stent expansion and side branch (SB) wiring.
Methods:
We randomized 120 patients treated with crossover stenting into the POT group, which was followed by SB dilation (SBD), and the KBT group. Finally, 52 and 57 patients were analyzed by optical coherence tomography before SBD and at the final procedure, respectively. Composite BSF was defined as a maximal malapposition distance of >400 μm, or malapposed and SB-jailed strut rates of >5.95% and >21.4%, respectively.
Results:
Composite BSF before SBD in the POT and KBT groups was observed in 29% and 26% of patients, respectively. In the POT group, differences in stent volumetric index between the proximal and distal bifurcation (odds ratio [OR] 60.35, 95% confidential interval [CI] 0.13-0.93, p = 0.036) and between the proximal bifurcation and bifurcation core (OR: 3.68, 95% CI: 1.01-13.40, p = 0.048) were identified as independent risk factors. Composite BSF at final in 27% and 32%, and unplanned additional procedures in 38% and 25% were observed, respectively. Composite BSF before SBD was a risk factor for the former (OR: 6.33, 95% CI: 1.10-36.50, p = 0.039) and the latter (OR: 6.43, 95% CI: 1.25-33.10, p = 0.026) in the POT group.
Conclusion:
POT did not result in a favorable trend in BSF. Insufficient expansion of the bifurcation core after POT was associated with BSF.
... Jailed strut rate at the bifurcation core, the secondary endpoint, was 16.1% and 14.7% (p=0.44) by pre-SBD OCT and 9.9% and 7.6% (p=0. 16) by final OCT in the POT and KBT groups, respectively (Central illustration, Figure 5). Lumen area, stent area, and stent eccentricity index in final OCT were not significantly different between the POT and KBT groups ( Table 4). ...
... A previous study using the bench test suggested appropriate POT balloon positioning is essential to avoid a carina shift [15]. Inappropriate distal location of the POT balloon risks distal MV overstretch and carina shift to the SB, while inappropriate proximal location may lead to stent malapposition and underexpansion around the carina [16] (Figure 6). Nonetheless, in daily clinical practice, visualisation of the actual part of the carina by angiography is difficult due to foreshortening or vessel overlap. ...
Background:
Clinical implications of proximal optimisation technique (POT) for bifurcation lesions have not been investigated in a randomised controlled trial.
Aims:
This study aimed to investigate whether proximal optimisation technique (POT) is superior in terms of stent apposition compared with the conventional kissing balloon technique (KBT) in real-life bifurcation lesions using optical coherence tomography (OCT).
Methods:
A total of 120 patients from 15 centres were randomised into two groups: POT followed by side branch dilation or KBT. Finally, 57 and 58 patients in the POT and KBT groups, respectively, were analysed. OCT was performed at baseline, immediately after wire recrossing to the side branch, and at the final procedure.
Results:
The primary endpoint was the rate of malapposed struts assessed by the final OCT. The rate of malapposed struts did not differ between the POT and KBT groups (in-stent proximal site: 10.4% vs. 7.7%, p=0.33; bifurcation core: 1.4% vs. 1.1%, p=0.67; core's distal edge: 6.2% vs. 5.3%, p=0.59). More additional treatments were required among the POT group (40.4% vs. 6.9%, p<0.01). At 1-year follow-up, only one patient in each group underwent target lesion revascularisation (2.0% vs. 1.9%).
Conclusions:
POT followed by side branch dilation did not show any advantages over conventional KBT in terms of stent apposition, however, the excellent mid-term clinical outcomes were observed in both strategies.
... POT can provide symmetric adequate stent expansion in the proximal MV with appropriate widening of the jailed struts at the SB ostium, which facilitates optimal guide wire re-crossing to the distal cell for the SB dilation [25,26]. Both JBC and KBC experts realized the efficacy of the POT and performed it with higher frequency. ...
The coronary bifurcation intervention varies among countries due to the differences in assessment of lesion severity and treatment devices. We sought to clarify the difference in basic strategy between South Korea and Japan. A total of 19 and 32 experts from Korean (KBC) and Japanese Bifurcation Clubs (JBC), respectively, answered a survey questionnaire concerning their usual procedure of coronary bifurcation intervention. JBC experts performed less two-stent deployment in the left main (LM) bifurcation compared to KBC experts (JBC vs. KBC: median, 1–10% vs. 21–30%, p < 0.0001) instead of higher performance of side branch dilation after cross-over stenting in both LM (60% vs. 21%, p = 0.001) and non-LM bifurcations (30% vs. 5%, p = 0.037). KBC experts more frequently performed proximal optimization technique (POT) in non-LM bifurcation (41–60% vs. 81–99%, p = 0.028) and re-POT in both LM (1–20% vs. 81–99%, p = 0.017) and non-LM bifurcations (1–20% vs. 81–99%, p = 0.0003). JBC experts more frequently performed imaging-guided percutaneous coronary intervention, whereas KBC experts more often used a pressure wire to assess side branch ischemia. JBC experts used a rotablator more aggressively under the guidance of optical coherence tomography. We clarified the difference in the basic strategy of coronary bifurcation intervention between South Korea and Japan for better understanding the trend in each country.
... Advances in OCT imaging processing now facilitate real-time analysis of stent-vessel interactions and precise location of guidewire crossing through stent side cells into the side-branch (SB). In particular, a recent study documented that the position of "link" struts across SB ostia, a phenomenon that cannot be controlled by the operator during stent implantation, is associated with incomplete stent apposition after kissing (8). After stenting, the assessment of adequate stent expansion and "landing", together with the recognition of edge dissections may guide further PCI optimization (5). ...
The 15th European Bifurcation Club (EBC) meeting was held in Barcelona in October 2019 and it facilitated a renewed consensus on coronary bifurcation lesions (CBL) and unprotected left main (LM) percutaneous interventions. Bifurcation stenting techniques continue to be refined, developed and tested. It remains evident that provisional approach with optional side-branch treatment utilising T, T and small protrusion (TAP) or culotte continue to provide flexible options for the majority of CBL patients. Debate persists regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment. In more complex CBL, especially when involving the LM, adoption of dedicated 2-stent techniques should be considered. Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and challenges. When using 2-stent techniques, failure to perform a final kissing inflation is regarded as a technical failure, since it may jeopardize clinical outcome. The development of novel technical tools and drug regimens deserve attention. In particular, intra-coronary imaging, bifurcation simulation, drug-eluting balloon technology and tailored anti-platelet therapy are identified as promising tools to enhance clinical outcomes. In conclusion, the evolution of a broad spectrum of bifurcation PCI components have resulted from studies extending from bench testing to randomised controlled trials. However, further advances are still needed to achieve the ambitious goal of optimizing the clinical outcomes for every patient undergoing PCI on a CBL.
