Fate of stent-related side branches after coronary intervention in patients with in-stent restenosis
Fernando Alfonso, MD, PhD, FESCa,
Carlos Hernández, MDa,
María José Pérez-Vizcayno, MDa,
Rosana Hernández, MD, PhD, FESCa,
Antonio Fernández-Ortíz, MD, PhD, FESCa,
Javier Escaned, MD, PhD, FESCa,
Camino Bañuelos, MD, FESCa,
Manel Sabaté, MD, PhDa,
Marcelo Sanmartín, MDa,
Cristina Fernández, MDa and
Carlos Macaya, MD, PhD, FESCa
a Interventional Cardiology Unit, Cardiovascular Institute, San Carlos University Hospital, Madrid, Spain
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Figure 1 Angiogram in the left anterior oblique projection with cranial angulation showing a restenosed stent in the proximal left anterior descending coronary artery (a). The distal part of the stent spanned a disease-free septal branch (Type B) and a diagonal branch (arrow) with ostial involvement (Type A). After treatment (b) a good angiographic result was obtained in the left anterior descending coronary artery (parent vessel); the septal branch remained patent but the diagonal branch became occluded (asterisk). This occlusion was clinically silent. The six-month angiogram (c) revealed an adequate angiographic result on the left anterior descending coronary artery and patency (reappearance) of the diagonal branch (arrow).
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Figure 2 Left panel. Angiogram in the right anterior oblique projection revealing a severe stenosis in the mid-left anterior descending coronary artery. (a) De novo lesion. (b) After initial stenting. (c) Stent restenosis (before treatment). (d) Immediately after treatment of in-stent restenosis (index procedure). (e) At six-month follow-up. A large diagonal branch and two small septal perforator side branches are always visualized. Right panel. Angiogram in the left anterior oblique projection with cranial angulation in a patient with a tight lesion in the proximal left anterior descending coronary artery (a to e, timing same as above). A diagonal branch—with severe ostium involvement—remained patent after initial stenting, occluded (without clinical sequelae) during treatment of in-stent restenosis (asterisk) and reappeared at follow-up (arrow).
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Figure 3 Flow diagram illustrating the occurrence of side-branch (SB) occlusion in relation to location (top) and SB classification (bottom). RVB = right ventricular branch; PL = posterolateral branch; ST = stent.
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Figure 4 Clinical, procedural, and angiographic predictors of side-branch (SB) occlusion (top) and of SB flow deterioration (bottom). Crude (unadjusted) relative risks (RR) and confidence intervals (CI) are displayed in a logarithmic scale. Adj RR = adjusted relative risks; Ad Hoc = procedures performed during the diagnostic coronary angiogram; Ostial-D = ostial disease in the SB; R Length = restenosis length (studied per 1 mm of increment); B/A Ratio = balloon/artery ratio using quantitative angiography (>1.13, upper tertile); Device = use of any device different from balloon angioplasty; angle = adverse takeoff angulation of the SB; MLD = minimal lumen diameter of the parent vessel after intervention (per 1 mm of increment); ST1 = during initial stenting.
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