European Heart Journal Advance Access originally published online on January 31, 2007
European Heart Journal 2007 28(4):433-442; doi:10.1093/eurheartj/ehl539
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The clinical outcome of percutaneous treatment of bifurcation lesions in multivessel coronary artery disease with the sirolimus-eluting stent: insights from the Arterial Revascularization Therapies Study part II (ARTS II)
1 Thoraxcenter, Ba 583, Erasmus Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
2 EMO Centro Cuore Columbus and San Raffaele Hospital, Milan, Italy
3 Institut Cardiovasculaire Paris Sud, Massy, France
4 Lanarkshire Acute Hospitals, Glasgow, UK
5 Chaim Sheba Medical Center, Tel Hashomer, Israel
6 Azienda Ospedaliera Ospedali Riunitit di Bergamo, Bergamo, Italy
7 Klinikum Augsburg, Augsburg, Germany
8 Institute of Cardiology Warsaw, Warsaw, Poland
9 Kerckhoff Klinik, Kardiologie, Bad Nauheim, Germany
10 Cardialysis, B.V., Rotterdam, The Netherlands
11 Cordis Corporation, Miami Lakes, FL, USA
Received 15 May 2006; revised 13 January 2007; accepted 22 January 2007; online publish-ahead-of-print 31 January 2007.
* Corresponding author. Tel: +31 10 463 5260; fax: +31 10 436 9154. E-mail address: p.w.j.c.serruys{at}erasmusmc.nl
See page 383 for the editorial comment on this article (doi:10.1093/eurheartj/ehl252)
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Abstract |
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Aims Little is known about the impact of treating bifurcations on the overall outcome of multivessel coronary artery disease treated with stenting. This analysis was made to investigate the 1 year clinical outcome of the treatment of bifurcation lesions using sirolimus-eluting stents (SES) in patients with multivessel disease.
Methods and results Among a total of 607 patients (2160 lesions) in the Arterial Revascularization Therapies Study part II (ARTS II), there were 324 patients in whom at least one bifurcation lesion was treated (465 lesions). Patients with bifurcations were compared with those without bifurcations in terms of baseline characteristics and major adverse cardiac and cerebrovascular events (MACCE). Patients with ‘true’ (200 patients) vs. ‘partial’ bifurcations (124 patients) and usage of a one- (263 patients) vs. two-stent strategy (61 patients) were also evaluated. The bifurcation group was associated with more complex lesion and procedural characteristics than the non-bifurcation group. However, there was no significant difference in 1 year MACCE rates between the bifurcation group and the non-bifurcation group (13.3 vs. 11.0%, P = 0.46). MACCE in patients with true bifurcations was 13.0 vs. 13.7% for partial bifurcations (P = 0.87) and 14.1 vs. 9.8% for one- vs. two-stent strategy (P = 0.53).
Conclusions In this trial without angiographic follow-up, the presence of bifurcations did not affect 1 year outcomes after SES implantation. The outcomes in true vs. partial bifurcations and using one vs. two stents were similar when the treatment strategies were left to the operator's discretion.
Key Words: Bifurcation lesion • Multivessel disease • Stent • Sirolimus • Multicentre trial
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Introduction |
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Percutaneous coronary intervention (PCI) in bifurcation lesions remains problematic. Even in the modern era of PCI with stent implantation, treatment of bifurcations is hampered by a higher event rate1–3 and requires longer procedure time, more radiation exposure, and higher volumes of contrast material4 compared with non-bifurcation lesions. The interventional approach is more complicated and may include initial adjunctive debulking, double guidewire placement, re-crossing of stent struts towards the side branch (SB), and final kissing balloon inflation. Therefore, in the treatment of multivessel disease, bifurcation lesions can become a crucial obstacle to complete revascularization, with a potentially negative impact on long-term outcomes.
Numerous pivotal randomized trials have now shown that PCI using drug-eluting stents (DES) significantly reduces the need for repeat revascularization in patients with coronary artery disease.5–8 The efficacy of sirolimus-eluting stents (SES) in multivessel disease9,10 and bifurcation lesions11,12 has recently been reported. Nevertheless, these trials have focused on the treatment of single-discrete lesions with relatively simple morphology.5–7 In spite of this recent progress, the presence of bifurcation lesions in multivessel disease may still be seen as a reason to prefer surgical revascularization. Interestingly, a retrospective angiographic analysis of 158 coronary bypass operations revealed that multivessel stenting would have been technically feasible in 77 (49%) of patients with bifurcation lesions.13 However, the practical impact of DES utilization on bifurcation lesions in patients with multivessel disease has not been assessed.
The objective of the analysis of the Arterial Revascularization Therapies Study part II (ARTS II)14,15 was to investigate the 1 year clinical outcome of patients with bifurcation lesions treated with SES and to compare it with the outcome of non-bifurcation lesions, without having mandated or pre-specified a particular treatment strategy.
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Patient population
Principal inclusion and exclusion criteria of the ARTS II study have been described previously.14,15 Clinical manifestations of coronary artery disease were stable angina (Canadian Cardiovascular Society class I, II, III, or IV), unstable angina (Braunwald class IB, IC, IIB, IIC, IIIB, or IIIC), or silent myocardial ischaemia.14,15 Patients were required to have multivessel disease, with a need for treatment of the left anterior descending (LAD) artery and at least one other significant lesion (> 50% diameter stenosis by visual estimate) in another major epicardial coronary artery.14,15 Patients with any previous coronary intervention, left main coronary disease, overt congestive heart failure, or a left ventricular ejection fraction of < 30% were excluded. A total of 607 patients with 2160 lesions were treated with SES. The patient selection and recruitment procedures and associated patient numbers were described in the main manuscript.15 All 607 patients gave written informed consent. Of these patients, 602 were treated with PCI, and the remaining five patients underwent bypass surgery. Finally, 1 year follow-up analyses were performed in 601 patients (99.0%). In this analysis, bifurcation lesions were defined as a lesion
50% diameter stenosis involving a main branch (MB) and/or contiguous SB with a diameter of 2.0 mm by visual estimate. An SB was required to be within a distance that was less than three times the diameter of the reference vessel of the SB measured from the branching point. ‘True’ bifurcation lesions were defined as lesions with significant stenoses present in both the MB and the ostium of the SB. ‘Partial’ bifurcation lesions were defined as lesions in which a branch vessel did not have significant ostial stenosis. The SYNTAX Score was used to classify the lesions in more detail (Figure 1).16 Both the MB and the SB needed to have at least a Thrombolysis in Myocardial Infarction (TIMI) flow grade 1 pre-procedure. A total of 324 patients with 465 bifurcation lesions met the criteria for inclusion in this analysis (210 patients with one bifurcation lesion; 114 patients with two or more bifurcation lesions) and were compared with the remaining 283 patients without bifurcations. We also analysed two additional subgroups on the basis of lesion morphology and stenting strategy and compared (i) 200 patients with at least one true bifurcation vs. 124 with only partial bifurcations and (ii) 263 patients treated with a one-stent strategy (stenting only MB or SB) in any of the bifurcations vs. 61 treated with a two-stent strategy (stenting in both branches) in at least one of the bifurcations.
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Procedure
All the lesions were treated with an SES (Cypher®; Cordis Corp., Johnson & Johnson, Warren, NJ, USA) with a diameter of 2.5–3.5 mm and a length of 13–33 mm, without restriction on the total length of stents implanted in an overlapping manner. The decision to choose a specific strategy of stent implantation in the bifurcation lesions was left to the operators' discretion: one-stent strategy, or two-stent strategy using any of the four main techniques (T-, V-, culotte-, and crush-stenting techniques).17,18 Recommendations concerning the antiplatelet regimen have been described previously.14,15
Angiographic analysis of bifurcation lesions
The following baseline lesion and procedural characteristics were evaluated by angiography: plaque distribution; take-off angle of the SB; stenting techniques; significant stenosis ( 50% diameter stenosis) remaining in the SB left post-procedure in true bifurcations; significant plaque shift ( 50% diameter stenosis) into the SB (or MB) in partial bifurcations; final kissing balloon inflation; angiographic success in lesion, MB, as well as SB; persistent major dissection in SB after procedure; and final TIMI flow grade in SB.
Plaque distribution was described on the basis of SYNTAX Score bifurcation lesion types.16 Take-off angle of SB was measured as the angle between MB distal to the branching point and SB by visual assessment in a non-foreshortened projection (Figure 1). Significant plaque shift was defined as 50% diameter stenosis in ostia of SBs (or MBs) subsequent to stenting in partial bifurcations. Angiographic success was defined as a residual stenosis of <50% of the luminal diameter by visual assessment with TIMI 3 flow in the MB, SB, or lesion (both branches).
Endpoints and clinical definitions
The primary endpoint of this analysis was freedom from any major adverse cardiac and cerebrovascular event (MACCE) at 30 days and 1 year, defined as death from any cause, cerebrovascular accident, documented non-fatal myocardial infarction, and any revascularization by percutaneous intervention or surgery after the index procedure. Because this analysis does not compare patients undergoing PCI using SES (ARTS II) with the historical surgical cohort in ARTS I,15,19 the incidence of myocardial infarction was determined as follows: in the first 7 days after the intervention, a definite diagnosis of myocardial infarction was made if there was documentation of new abnormal Q-waves (according to the Minnesota code) and either a ratio of serum creatine kinase MB (CK-MB) isoenzyme to total cardiac enzyme that was greater than 0.1 or a CK or CK-MB value that was three times the upper limit of normal,20 whereas five times the upper limit of normal was used as the diagnostic threshold in the main report of this study14,15,19 to enable comparison with the surgical cohort. Serum CK and CK-MB isoenzyme concentrations were measured 6, 12, and 18 h after the intervention. Apart from MACCE, we reported the occurrence of stent thrombosis at bifurcation lesions, which was defined as either angiographic documentation of a complete occlusion (TIMI flow 0 or 1) or angiographic documentation of a flow-limiting thrombus (TIMI flow 1 or 2). Stent thrombosis was categorized depending on the timing of occurrence into acute (peri-procedure), subacute (post-procedure to 30 days), and late (>30 days).
Statistical analysis
Patients with bifurcation lesions (bifurcation group) were compared with those without bifurcation lesions (non-bifurcation group) with respect to clinical, lesion, and procedural characteristics, as well as the freedom from MACCE. Additional subgroup comparisons were also performed between patients with true vs. partial bifurcations and between patients treated with the one-stent vs. two-stent strategy. Continuous variables were expressed as mean ± SD. Categorical variables were presented as frequency (%). Patient demographics and procedural characteristics of the groups were compared with the Student's t-test and with the 
2 test or the Fisher's exact test for categorical variables. Kaplan–Meier analyses and survival rates between groups were compared using the log-rank test. A two-sided P-value < 0.05 was considered statistically significant. Analyses were performed using SAS version 8.02 (SAS Institute, Inc., Cary, NC, USA).
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Baseline patient demographics and clinical characteristics: the non-bifurcation group vs. the bifurcation group
Table 1 shows the patient baseline demographics and clinical characteristics of the non-bifurcation and the bifurcation groups. None of the clinical characteristics except for family history differed between the non-bifurcation and the bifurcation groups.
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Overall lesion and procedural characteristics: the non-bifurcation group vs. the bifurcation group
The bifurcation group had more extensive disease and more complex lesion characteristics compared with the non-bifurcation group [diffuse lesion, P < 0.001 (95% CI 2.8–8.2); type C lesion, P = 0.008 (95% CI 1.1–6.9)] (Table 2). There was a concomitant increase in procedural complexity in the bifurcation group as reflected by a higher number of stents implanted [P < 0.001 (95% CI 0.5–1.0)], longer total stent length per patient [P < 0.001 (95% CI 10.5–20.6)], or longer procedural time [P < 0.001 (95% CI 9.4–23.0)] (Table 2).
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Thirty day and 1 year outcomes and incidence of stent thrombosis: the non-bifurcations vs. the bifurcations
MACCE and the incidence of stent thrombosis at 30 days and at 1 year are shown in Table 3. The MACCE rate at each time point was not significantly different between the bifurcation group and the non-bifurcation group (6.2 vs. 4.2% at 30 days, P = 0.36; 13.3 vs. 11.0% at 1 year, P = 0.46).
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Five stent thromboses (subacute four and late one) occurred in the bifurcation group vs. two (one subacute and one late) in the non-bifurcation group up to 1 year. Among the five events in the bifurcation group, four subacute thromboses (two patients on day 1; one on day 22; one on day 28) were related to bifurcation lesions and one late thrombosis developed in a non-bifurcation lesion. Of these four bifurcation lesions, three were stented only in the MB. The remaining one stent thrombosis was associated with a lesion treated with stenting in both the LAD artery and the diagonal branch (provisional T-stenting without kissing balloon inflation). One patient who had never been placed on aspirin therapy developed subacute thrombosis 22 days after the index PCI.
Baseline and procedural characteristics: true vs. partial bifurcations and one-stent vs. two-stent strategy
In terms of patient characteristics, only hypertension was significantly more frequent in patients with true vs. partial bifurcations (Table 4). Patients with true bifurcations and two-stent strategy also had a significantly higher number of lesions than the corresponding companion subgroup. Patients treated with two-stent strategy had more complex procedural characteristics with longer procedural time, a higher number and longer length of stents used than those with one stent (P < 0.001). The procedural characteristics did not differ between patients with true or partial bifurcations except for the number of stented lesions (3.6 vs. 3.2, P = 0.002) (Table 4).
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Thirty day and 1 year outcome: true vs. partial bifurcations and one-stent vs. two-stent strategy
There was no difference in any of the endpoints that were evaluated between the two groups, including stent thrombosis (Table 5).
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Lesion and procedural demographics of 465 bifurcation lesions
Table 6 summarizes lesion and procedural characteristics of the 465 bifurcation lesions. Figure 2 delineates the profile of the 465 lesions. Lesions located in the LAD/diagonal branching point were the most frequent. True bifurcations (types D, F, and G, Figure 1) accounted for 52.5% (244/465). Overall, a double guidewire technique was used in 39.8% (185/465), whereas in true bifurcations, the use was 53.7% (131/244). The other technical aspects, such as the use of two-stent strategy and final kissing balloon, are described in Figure 2.
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The angiographic success (<50% residual stenosis) of the MB was 98.1% (456/465), whereas the SB angiographic success rate was only 51.2% (238/465). Nevertheless, the final patency of the SB with TIMI 3 flow was 92.9% (432/465). In the non-true bifurcations (types A, B, C, and E, Figure 1), significant narrowing of the SB was present after the procedure in 28.5% (63/221), whereas the percentage was 64.3% (157/244) in the SB of true bifurcations.
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Discussion |
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The main findings of this analysis are (i) SES implantation to treat bifurcation lesions in patients with multivessel disease yields similar outcomes as in those with non-bifurcation lesions; (ii) there is no difference in outcome between patients with true bifurcation lesions and partial bifurcation lesions and in patients treated with a one-stent vs. two-stent strategy; (iii) these excellent results were obtained despite the fact that many SBs were left with a significant narrowing at the end of the procedure.
Bifurcation lesions in multivessel disease
The expanded use of PCI to multivessel disease has raised the issue of how to handle complex lesions in terms of complete revascularization. The restenosis risk of patients with multivessel interventions is higher if a companion lesion develops restenosis, regardless of the presence or absence of conventional patient risk factors or lesion complexity.21 The existence of inter-lesion dependence for the risk of restenosis in multilesion stenting has been hypothesized.21 However, the impact of bifurcation lesions in multivessel intervention remains to be determined.
A few studies in the bare metal stent era demonstrated that treatment of bifurcation lesions resulted in a lower success rate and higher late adverse event rate than non-bifurcation lesions.1–3 However, these studies included not only multivessel intervention but also single-vessel treatment (target lesion per patient, 1.4),2,3 and stents were only used in 70% of patients.1–3 Because patients in the present study underwent multivessel treatment with SES as a default strategy, these results may not be directly comparable with those of previous studies.1–3 Nevertheless, in the light of the promising results from major randomized trials,5,6 it could be hypothesized that the SES could potentially equalize the treatment risk between patients with bifurcation lesions and those without bifurcation lesions.
Changing impact of bifurcation lesions in DES era
Our findings seem to contradict a number of prior studies12,22–24 evaluating DES in bifurcation lesions where a high target lesion revascularization (TLR) rate was found for the SB and in many instances when two stents were implanted. We believe that a number of the TLRs reported in these studies12,22–24 were triggered by the stenoses detected during protocol-mandated angiographic follow-up. The ARTS I and ARTS II studies are clinical outcome trials without any mandatory angiographic investigation at follow-up, thereby reflecting the natural course of the disease and its treatment and avoiding the so-called ‘oculo-stenotic reflex’, as illustrated in the BENESTENT II trial.25 This reflex may be even more pronounced when treating bifurcation lesions.2 The fact that residual stenoses in the SB were left untreated and did not result in recurrent angina or other clinical events at follow-up speaks to the benign nature of these persisting SB stenoses. This view is supported by the findings that only 51% of the SBs had an optimal result after the procedure (Table 6). Moreover, according to a fractional flow reserve analysis, it appears that many of the SB lesions that seem to be angiographically significant may not be haemodynamically significant.26 It is also worth noting that our results were obtained with a conservative usage of a two-stent strategy, even in true bifurcations. We cannot ignore the fact that this approach accepts a certain level of incomplete revascularization on many SBs, which were probably correctly judged by the interventionalists as being clinically unimportant, provided that they showed TIMI 3 flow (92.9%) (Table 6). Therefore, even the concept of ‘incomplete revascularization’ needs to be revisited.
It is also worth noting that the threshold criteria for enzyme elevation used to define non-Q-wave myocardial infarction applied in this analysis, namely three times CK or CKMB elevation, are similar to that used routinely in other studies.22–24 However, it is more sensitive than five times CK or CKMB elevation described in the ARTS I and II original protocols14,15,19 that was used to enable comparison of the results of PCI with surgery for multivessel disease.19
The occurrence of stent thrombosis did not differ between the bifurcation and non-bifurcation groups. Three out of the four bifurcation lesions that developed stent thrombosis had a poor angiographic result at the end of the procedure (only one bifurcation achieved lesion success). Recently, bifurcation lesions were reported as one of the independent predictors of stent thrombosis of DES.27,28 The relatively small number of patients evaluated in this analysis and the low overall frequency of thromboses in this study do not allow for any definitive statement with respect to these observations by other investigators.
Study limitation
Given the strong trend towards a higher incidence of MI in the bifurcation group (P = 0.08), this subanalysis may have been underpowered to demonstrate the potential adverse impact of bifurcation lesion treatment in multivessel disease when using a DES. More than 1000 patients with bifurcations were required to show only 3% difference of adverse cardiac event rate compared with those without bifurcations even in bare metal stent era.2 The present analysis is a post hoc subanalysis of non-randomized subgroups of bifurcations and non-bifurcations. Therefore, no power or sample size calculation could be performed.
Operators treated most lesions using a one-stent strategy (85.4% of bifurcations) without SB protection (application of double guidewire in 39.8% of the lesions) and adjunctive debulking (rotablation in only three lesions). In order to save procedural and radiation time or contrast media for multivessel treatment, it is likely that operators tended to choose or prefer the simplest treatment strategy. Thus, it is largely an analysis of the success of a one-stent strategy rather than a comparison of different treatment strategies for treating bifurcation lesions with SES. However, the strategy of using a single wire may not necessarily have been appropriate even though complications related to SB occlusion were quite infrequent. A more liberal usage of two wires in true bifurcations might have resulted in an ever lower complication rate.
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Conclusions |
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This analysis of treating bifurcation lesions in multivessel disease with SES showed that these lesions were associated with increased procedural complexity but not with more adverse events compared with non-bifurcation lesions. In contemporary interventional practice, when operators are allowed to decide the best strategy to employ, which resulted in a conservative implantation of two stents, no difference in outcome was found among different types of bifurcations. The suboptimal angiographic results in the SB did not increase the risk of MACCE. However, this result may warrant further investigation in a larger, appropriately designed study in the light of the trend towards a higher rate of myocardial infarction in the bifurcation group.
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Acknowledgements |
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This study was supported by Cordis Corporation, a Johnson & Johnson Company. A complete list of investigators and committees of the ARTS II has been previously reported.15 We are indebted to Brian G. Firth, Marco Valgimigli, and Neville Kukreja for their careful review of the manuscript and constructive comments, and to Héctor M. García-García for his assistance with statistical analysis. H.-P.S., K.W., and D.J.D. are employees of Cordis.
Conflict of interest: none declared.
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References |
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- Al Suwaidi J, Yeh W, Cohen HA, Detre KM, Williams DO, Holmes DR Jr. (2001) Immediate and one-year outcome in patients with coronary bifurcation lesions in the modern era (NHLBI Dynamic Registry). Am J Cardiol 87:1139–1144.[CrossRef][Web of Science][Medline]
- Garot P, Lefevre T, Savage M, Louvard Y, Bamlet WR, Willerson JT, Morice MC, Holmes DR Jr. (2005) Nine-month outcome of patients treated by percutaneous coronary interventions for bifurcation lesions in the recent era. A report from the Prevention of Restenosis with Tranilast and its Outcomes (PRESTO) trial. J Am Coll Cardiol 46:606–612.
[Abstract/Free Full Text] - Wilensky RL, Selzer F, Johnston J, Laskey WK, Klugherz BD, Block P, Cohen H, Detre K, Williams DO. (2002) Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry). Am J Cardiol 90:216–221.[CrossRef][Web of Science][Medline]
- Bernardi G, Padovani R, Morocutti G, Vano E, Malisan MR, Rinuncini M, Spedicato L, Fioretti PM. (2000) Clinical and technical determinants of the complexity of percutaneous transluminal coronary angioplasty procedures: analysis in relation to radiation exposure parameters. Catheter Cardiovasc Interv 51:1–9 (discussion 10).[CrossRef][Web of Science][Medline]
- Morice MC, Serruys PW, Sousa JE, Fajadet J, Ban Hayashi E, Perin M, Colombo A, Schuler G, Barragan P, Guagliumi G, Molnar F, Falotico R. (2002) A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 346:1773–1780.
[Abstract/Free Full Text] - Moses JW, Leon MB, Popma JJ, Fitzgerald PJ, Holmes DR, O'Shaughnessy C, Caputo RP, Kereiakes DJ, Williams DO, Teirstein PS, Jaeger JL, Kuntz RE. (2003) Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 349:1315–1323.
[Abstract/Free Full Text] - Stone GW, Ellis SG, Cox DA, Hermiller J, O'Shaughnessy C, Mann JT, Turco M, Caputo R, Bergin P, Greenberg J, Popma JJ, Russell ME. (2004) A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med 350:221–231.
[Abstract/Free Full Text] - Stone GW, Ellis SG, Cannon L, Mann JT, Greenberg JD, Spriggs D, O'Shaughnessy CD, DeMaio S, Hall P, Popma JJ, Koglin J, Russell ME. (2005) Comparison of a polymer-based paclitaxel-eluting stent with a bare metal stent in patients with complex coronary artery disease: a randomized controlled trial. JAMA 294:1215–1223.
[Abstract/Free Full Text] - Lemos PA, Serruys PW, van Domburg RT, Saia F, Arampatzis CA, Hoye A, Degertekin M, Tanabe K, Daemen J, Liu TK, McFadden E, Sianos G, Hofma SH, Smits PC, van der Giessen WJ, de Feyter PJ. (2004) Unrestricted utilization of sirolimus-eluting stents compared with conventional bare stent implantation in the ‘real world’: the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. Circulation 109:190–195.
- Orlic D, Bonizzoni E, Stankovic G, Airoldi F, Chieffo A, Corvaja N, Sangiorgi G, Ferraro M, Briguori C, Montorfano M, Carlino M, Colombo A. (2004) Treatment of multivessel coronary artery disease with sirolimus-eluting stent implantation: immediate and mid-term results. J Am Coll Cardiol 43:1154–1160.
[Abstract/Free Full Text] - Tanabe K, Hoye A, Lemos PA, Aoki J, Arampatzis CA, Saia F, Lee CH, Degertekin M, Hofma SH, Sianos G, McFadden E, Smits PC, van der Giessen WJ, de Feyter P, van Domburg RT, Serruys PW. (2004) Restenosis rates following bifurcation stenting with sirolimus-eluting stents for de novo narrowings. Am J Cardiol 94:115–118.[Web of Science][Medline]
- Colombo A, Moses JW, Morice MC, Ludwig J, Holmes DR Jr, Spanos V, Louvard Y, Desmedt B, Di Mario C, Leon MB. (2004) Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation 109:1244–1249.
- Griffiths H, Bakhai A, West D, Petrou M, De Souza T, Moat N, Pepper J, Di Mario C. (2004) Feasibility and cost of treatment with drug eluting stents of surgical candidates with multi-vessel coronary disease. Eur J Cardiothorac Surg 26:528–534.
[Abstract/Free Full Text] - Serruys PW, Lemos PA, van Hout BA. (2004) Sirolimus eluting stent implantation for patients with multivessel disease: rationale for the Arterial Revascularisation Therapies Study part II (ARTS II). Heart 90:995–998.
[Free Full Text] - Serruys PW, Ong ATL, Morice MC, de Bruyne B, Colombo A, Macaya C, Richardt G, Fajadet J, Hamm C, Dawkins K, O'Malley J, Bressers M, Donohoe D. (2005) Arterial Revascularization Therapies Study part II—sirolimus-eluting stents for the treatment of patients with multivessel de novo coronary artery lesions. Eurointervention 1:147–156.
- Sianos G, Morel MA, Kappetein P, Morice MC, Colombo A, Dawkins K, van den Brand M, van Dyck N, Russell ME, Mohr F, Serruys PW. (2005) The SYNTAX score: an angiographic tool grading the complexity of coronary artery disease. Eurointervention 1:219–227.
- Louvard Y, Lefevre T, Morice MC. (2004) Percutaneous coronary intervention for bifurcation coronary disease. Heart 90:713–722.
[Free Full Text] - Iakovou I, Ge L, Colombo A. (2005) Contemporary stent treatment of coronary bifurcations. J Am Coll Cardiol 46:1446–1455.
[Abstract/Free Full Text] - Serruys PW, Unger F, Sousa JE, Jatene A, Bonnier HJ, Schonberger JP, Buller N, Bonser R, van den Brand MJ, van Herwerden LA, Morel MA, van Hout BA. (2001) Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease. N Engl J Med 344:1117–1124.
[Abstract/Free Full Text] - Smith SC Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, Gibbons RJ, Alpert JP, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russell RO. (2001) ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines)—executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (committee to revise the 1993 guidelines for percutaneous transluminal coronary angioplasty). J Am Coll Cardiol 37:2215–2239.
[Free Full Text] - Kastrati A, Schomig A, Elezi S, Schuhlen H, Wilhelm M, Dirschinger J. (1998) Interlesion dependence of the risk for restenosis in patients with coronary stent placement in multiple lesions. Circulation 97:2396–2401.
- Pan M, de Lezo JS, Medina A, Romero M, Segura J, Pavlovic D, Delgado A, Ojeda S, Melian F, Herrador J, Urena I, Burgos L. (2004) Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy. Am Heart J 148:857–864.[CrossRef][Web of Science][Medline]
- Ge L, Airoldi F, Iakovou I, Cosgrave J, Michev I, Sangiorgi GM, Montorfano M, Chieffo A, Carlino M, Corvaja N, Colombo A. (2005) Clinical and angiographic outcome after implantation of drug-eluting stents in bifurcation lesions with the crush stent technique importance of final kissing balloon post-dilation. J Am Coll Cardiol 46:613–620.
[Abstract/Free Full Text] - Ge L, Tsagalou E, Iakovou I, Sangiorgi GM, Corvaja N, Airoldi F, Chieffo A, Montorfano M, Michev I, Colombo A. (2005) In-hospital and nine-month outcome of treatment of coronary bifurcational lesions with sirolimus-eluting stent. Am J Cardiol 95:757–760.[CrossRef][Web of Science][Medline]
- Serruys PW, van Hout B, Bonnier H, Legrand V, Garcia E, Macaya C, Sousa E, van der Giessen W, Colombo A, Seabra-Gomes R, Kiemeneij F, Ruygrok P, Ormiston J, Emanuelsson H, Fajadet J, Haude M, Klugmann S, Morel MA. (1998) Randomised comparison of implantation of heparin-coated stents with balloon angioplasty in selected patients with coronary artery disease (Benestent II). Lancet 352:673–681.[CrossRef][Web of Science][Medline]
- Koo BK, Kang HJ, Youn TJ, Chae IH, Choi DJ, Kim HS, Sohn DW, Oh BH, Lee MM, Park YB, Choi YS, Tahk SJ. (2005) Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol 46:633–637.
[Abstract/Free Full Text] - Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G, Airoldi F, Chieffo A, Montorfano M, Carlino M, Michev I, Corvaja N, Briguori C, Gerckens U, Grube E, Colombo A. (2005) Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA 293:2126–2130.
[Abstract/Free Full Text] - Kuchulakanti PK, Chu WW, Torguson R, Ohlmann P, Rha SW, Clavijo LC, Kim SW, Bui A, Gevorkian N, Xue Z, Smith K, Fournadjieva J, Suddath WO, Satler LF, Pichard AD, Kent KM, Waksman R. (2006) Correlates and long-term outcomes of angiographically proven stent thrombosis with sirolimus- and paclitaxel-eluting stents. Circulation 113:1108–1113.
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