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Aims: The aim of this study was to assess the efficacy and safety of percutaneous reintervention in patients who underwent aortic coarctation stenting at an early age., Methods and Results: From 1993 to 2018, 177 patients with aortic coarctation were treated with stent implantation at our centre; 33 of them were treated at less than 12 years of age and required reintervention because of their rate of growth. The average age of the patients at the first and second procedure was 6±3 years and 19±7 years, respectively. At the reintervention procedure, 15 (45%) patients were treated with balloon re-expansion, and 18 (55%) were treated with re-stenting. Success was obtained in 30 patients (91%). The gradient across the coarctation changed from 22±10 mmHg to 6±6 mmHg, while the minimal lumen diameter increased from 9±6 mm to 15±3 mm. There were eight occlusions of the femoral artery (after the first procedure), and two covered stents were needed because of femoral bleeding. The mean follow-up time after the second procedure was 5±4 years. A third procedure was required only in three patients (9%)., Conclusions: Patients with aortic coarctation treated with stent placement at an early age can be successfully re-treated after the completion of their somatic growth.

Introduction and Objectives: There is little evidence on the optimal strategy for bifurcation lesions in the context of a coronary chronic total occlusion (CTO). This study compared the procedural and mid-term outcomes of patients with bifurcation lesions in CTO treated with provisional stenting vs 2-stent techniques in a multicenter registry., Methods: Between January 2012 and June 2016, 922 CTO were recanalized at the 4 participating centers. Of these, 238 (25.8%) with a bifurcation lesion (side branch ≥ 2mm located proximally, distally, or within the occluded segment) were treated by a simple approach (n=201) or complex strategy (n=37). Propensity score matching was performed to account for selection bias between the 2 groups. Major adverse cardiac events (MACE) consisted of a composite of cardiac death, myocardial infarction, and clinically-driven target lesion revascularization., Results: Angiographic and procedural success were similar in the simple and complex groups (94.5% vs 97.3%; P=.48 and 85.6% vs 81.1%; P=.49). However, contrast volume, radiation dose, and fluoroscopy time were lower with the simple approach. At follow-up (25 months), the MACE rate was 8% in the simple and 10.8% in the complex group (P=.58). There was a trend toward a lower MACE-free survival in the complex group (80.1% vs 69.8%; P=.08). After propensity analysis, there were no differences between the groups regarding immediate and follow-up results., Conclusions: Bifurcation lesions in CTO can be approached similarly to regular bifurcation lesions, for which provisional stenting is considered the technique of choice. After propensity score matching, there were no differences in procedural or mid-term clinical outcomes between the simple and complex strategies., (Copyright © 2017 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Introduction and Objectives: The use of the jailed guidewire technique is highly useful when treating bifurcation lesions by provisional stenting. However, at the time of withdrawal, the guidewire can suffer damage and even fracture. The aim of this study was to evaluate structural damage in both polymer-coated and nonpolymer-coated jailed guidewires., Methods: Between January 2011 and December 2012, an observational study was conducted using stereoscopic microscopy to evaluate 135 jailed guidewires (45 nonpolymer-coated and 90 polymer-coated) previously used in the percutaneous treatment of bifurcation lesions. Damage after withdrawal was classified as mild, moderate, or severe., Results: Age and sex distributions were similar in both groups of patients treated with polymer-coated and nonpolymer-coated guidewires. However, operators selected polymer-coated guidewires more frequently when treating more complex bifurcations and in diabetic patients. Some type of microscopic damage was observed in 25 of the guidewires analyzed (18%). Paradoxically, damage was more common in nonpolymer-coated guidewires (53.0% vs 1.1%; P<.001). None of the guidewires suffered complete fracture., Conclusions: Coronary guidewires that are jailed during the treatment of bifurcations using provisional stenting often suffer nonsevere microscopic damage. Although polymer-coated guidewires were used in more complex bifurcation lesions, paradoxically, they were damaged less frequently., (Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: This study sought to determine whether several anatomic or evolving characteristics of the coarctation may create challenging conditions for treatment., Background: Stent repair of coarctation of aorta is an alternative to surgical correction., Methods: We analyzed our 21-year experience in the percutaneous treatment of complex coarctation of aorta. Adverse conditions for treatment were as follow: 1) complete interruption of the aortic arch (n = 11); 2) associated aneurysm (n = 18); 3) complex stenosis (n = 30); and 4) the need for re-expansion and/or restenting (n = 21). Twenty patients (33%) belonged to more than 1 group. Ten interruptions were type A and 1 was type B. The mean length of the interrupted aorta was 9 ± 11 mm. The associated aneurysms were native in 8 patients and after previous intervention in 10 patients. Aneurysm shapes were fusiform in 8 patients and saccular in 10. The following characteristics defined complex stenosis as long diffuse stenosis, very tortuous coarctation, or stenosis involving a main branch or an unusual location. Patients previously stented at an early age, required re-expansion and/or restenting after reaching 16 ± 5 years of age., Results: Two patients had died by 1-month follow-up. The remaining 58 patients did well and were followed-up for a mean period of 10 ± 6 years. Late adverse events occurred in 3 patients (5%). All remaining patients are symptom-free, with normal baseline blood pressure. Imaging techniques revealed good patency at follow-up without associated aneurysm or restenosis. The actuarial survival free probability of all complex patients at 15 years was 92%., Conclusions: Stent repair of complex coarctation of aorta is feasible and safe. Initial results are maintained at later follow-up., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: To analyse the ultrasound anatomy of bifurcation lesions {1,1,0},{0,1,0} and {1,0,0} of the Medina classification in order to identify predictors of angiographic side branch (SB) damage after main branch (MB) stenting., Methods and Results: One hundred and ten patients with Medina classification bifurcation lesions of {1,1,0},{0,1,0} and {1,0,0} were recruited. An intravascular ultrasound study (IVUS) was performed on the MB before treatment, after stent implantation and after SB intervention. A quantitative analysis was conducted in combination with a qualitative study of the carina morphology and plaque distribution. Ostial SB damage (an increase of the percentage of ostial stenosis by QCA ≥30%) was observed in 51 lesions (48%) after MB stenting. The baseline IVUS identified a carina with a spiky morphology ("eyebrow" sign) in 51 bifurcations. In 41 out of 51 bifurcations with this sign, ostial SB damage was induced after stenting the MB due to carina shift (p<0.01). Narrower angiographic angles were associated with the presence of the "eyebrow" sign (62º±23º vs. 76º±24º, p<0.05). Plaque located at the carina was associated with a lower rate of ostial SB damage (29%) when compared with those lesions with no plaque exhibiting at the carina (51%), p<0.05., Conclusions: The "eyebrow" sign is a powerful predictor of ostial SB damage after stent implantation in the MB in bifurcation coronary lesions without plaque involving the SB.

Provisional side-branch stenting is currently the most widely accepted percutaneous technique for the treatment of bifurcation lesions. However, abrupt closure of the side branch may occur after main vessel stent implantation. Resolving side-branch stenosis under these conditions may pose major technical difficulties. We describe a new technique to resolve uncrossable side-branch occlusion following main-vessel stent implantation during provisional side-branch stenting. The technique consists of using the jailed wire to dilate the occluded side branch. We first use a low profile, 1.25-mm diameter balloon catheter. A regular balloon is then inflated through the same wire to open the side branch, crushing the proximal part of the main vessel stent. At this point, a second stent is implanted at the side-branch, finishing the procedure as an inverted crush stenting. The described strategy may be useful in cases of uncrossable side-branch occlusion causing severe hemodynamic impairment that cannot be swiftly managed with conventional methods., (Copyright © 2010 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)

Introduction and Objectives: The plaque distribution patterns in coronary bifurcation lesions are not well understood. It has been speculated that carina is free of plaque partly because of high wall shear stress providing an atheroprotective effect. To study plaque distribution with intravascular ultrasound (IVUS) in the coronary bifurcation and the prevalence of carina involvement., Methods: IVUS study was performed on 195 coronary bifurcation lesions in the main vessel (MV) and on 91 in the side branch (SB). Plaque at the carina was considered when its thickness was > 0.3mm. Plaque burden was measured at different levels: proximal reference, distal, carina and at the point of minimal lumen area (MLA)., Results: The prevalence of plaque at the carina was 32%. Its thickness was 0.8 (0.36) mm, less than that observed at the counter-carina [1.22 (0.54) mm; P<.01]. The prevalence was higher (52%) when the MLA point was distal to the carina. The plaque at the carina was associated with a lower incidence of damage at the SB ostium after stenting the MV (32% vs 54%; P<.04)., Conclusions: The carina is not immune to atherosclerosis, showing plaque at this level in one third of the bifurcations. The incidence of plaque is higher in those bifurcations with the MLA point distal to the carina and seems to be associated with a lower incidence of damage to the SB ostium., (Copyright © 2010 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.)