European Heart Journal Advance Access originally published online on February 28, 2008
European Heart Journal 2008 29(6):726-732; doi:10.1093/eurheartj/ehn045
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Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using fractional flow reserve
1 Division of Cardiology, Department of Internal Medicine, Seoul National University College of Medicine, Cardiovascular Center and Cardiovascular Research Institute, Seoul National University Hospital, Yongon-dong 28, Jongno-gu, Seoul 110-744, Republic of Korea
2 Heart Center, Bundang Seoul National University Hospital, Gyeonggi-do, Republic of Korea
3 Ajou University School of Medicine, Gyeonggi-do, Republic of Korea
Received 26 March 2007; revised 8 January 2008; accepted 17 January 2008; online publish-ahead-of-print 28 February 2008.
* Corresponding author. Tel: +82 2 2072 2226, fax: +82 2 766 8904, Email: hyosoo{at}snu.ac.kr
See page 704 for the editorial comment on this article (doi:10.1093/eurheartj/ehn054)
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Abstract |
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Aims: This study was performed to evaluate the functional outcomes of fractional flow reserve (FFR)-guided jailed side-branch (SB) intervention strategy.
Methods and results: One hundred and ten patients treated by provisional strategy were consecutively enrolled and SB FFR was measured in 91 patients. SB intervention was allowed when FFR was <0.75. FFR measurement was repeated after SB intervention and at 6-month follow-up angiography. In 26 of 28 SB lesions with FFR <0.75, balloon angioplasty (SB balloon/artery ratio = 0.84 ± 0.14) was performed and FFR 
0.75 was achieved in 92% of the lesions although the mean residual stenosis was 69 ± 10%. During follow-up, there were no changes in SB FFR in lesions with (0.86 ± 0.05 to 0.84 ± 0.01, P = 0.4) and without SB angioplasty (0.87 ± 0.06 to 0.89 ± 0.07, P = 0.1). Functional restenosis (FFR <0.75) rate was only 8% (5/65). When clinical outcomes of these patients were compared with 110 patients with similar bifurcation lesions treated without FFR-guidance, there was no difference in 9-month cardiac event rates (4.6 vs. 3.7%, P = 0.7) between the two groups.
Conclusion: In conclusion, FFR-guided SB intervention strategy resulted in good functional outcomes.
Key Words: Bifurcation • Physiology • Stents • Angioplasty • Restenosis
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Introduction |
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Even in the era of drug-eluting stents, bifurcation lesions remain as one of the most challenging lesion subsets in the field of coronary intervention.1–6 The provisional side-branch intervention strategy (provisional strategy) is preferred for most bifurcation lesions because no previous study has shown the benefit of systematic two stenting over this strategy.1–4,7–9 During the application of the provisional strategy, the operator needs to decide whether to dilate the jailed side branch after main branch stent implantation and whether a stent should be implanted after balloon angioplasty. Although various angiographic or flow criteria are currently used in the decision making for side-branch interventions, none of these has been validated yet. Moreover, angiographic evaluation alone is sometimes inaccurate and does not reflect the functional severity of lesions, especially in ostial or complex lesions.10–12 Therefore, a better evaluation modality for such complex interventions is warranted.
Fractional flow reserve (FFR) is an easily obtainable physiological parameter that is stenosis specific and reflects both the degree of stenosis and the myocardial territory supplied by the specific artery.13–15 Our previous study using FFR showed that physiological evaluation of jailed side-branch lesions is feasible and angiographic evaluation overestimates the functional severity of these lesions.12 However, as most of the lesions were treated by operators' discretion and follow-up FFR measurement was not performed, the information on functional and clinical outcomes of FFR-guided side-branch intervention strategy could not be evaluated.
We performed this study to evaluate the changes in functional significance of jailed side-branch lesions after intervention and the functional outcomes of FFR-guided jailed side-branch intervention strategy for bifurcation lesions.
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Methods |
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Patient selection
FFR-guided side-branch intervention group (FFR group)
Patients with de novo, coronary bifurcation lesions with jailed side branches after successful drug-eluting stent implantation at the main branches were prospectively and consecutively enrolled. Four operators were involved in FFR-guided side-branch intervention strategy (B.-K.K., H.-J.K., Y.-S.C., and W.-Y.C.). Jailed side branches needed to have an ostial stenosis >50%, vessel size >2 mm, vessel length >40 mm, and lesion length <10 mm by visual estimation. Patients were excluded if any one of the following was present: ST elevation myocardial infarction, left main stenosis, totally occluded lesion, angiographically visible thrombus, significant lesion within the main branch proximal to the stented segment, significant distal lesion (diameter stenosis >50%) at a side branch, regional wall motion abnormalities of the stented artery and jailed side-branch segments, left ventricular ejection fraction
40%, primary myocardial disease, serum creatinine 2 mg/dL, predilatation of side branch before the main branch stent implantation, or contraindications to adenosine.
Conventional intervention group (conventional group)
Conventional group patients were selected from our intervention database from June 2004 among the patients who underwent coronary intervention by the operators not involved in FFR-guided strategy. Selection criteria were a non-left main de novo bifurcation lesion with side-branch lesion length <10 mm. Exclusion criteria were the same as the FFR group.
This study was approved by the Institutional Review Board of Seoul National University Hospital, and all patients gave informed consent to participate in the study.
Study procedure
Coronary stenting of the main branch was performed with standard interventional techniques using drug-eluting stents. After successful stenting, 200 µg of nitroglycerine was administered and a reference image was obtained. In the FFR group, pressure measurement was performed using a 0.014 inch pressure guide wire (PressureWire, Radi Medical Systems, Uppsala, Sweden) as previously described.12,15 The pressure wire was passed through the struts of the stent and FFR was measured at 5 mm distal to the jailed side-branch ostial stenosis to assess the severity of stenosis. Then pressure wire was pulled back and FFR was measured at main branch to evaluate the influence of the proximal lesion. Hyperaemia was induced with both intracoronary bolus administration (80 µg) and intracoronary continuous infusion (240 µg/min) of adenosine.16 The lower FFR value at each site was used in the analysis. The same method of adenosine administration was used at post-intervention and follow-up FFR measurements. Lesions with an FFR <0.75 were considered to have functionally significant stenosis and side-branch balloon dilatation was allowed only for these lesions. It was recommended to use a smaller balloon than the side-branch vessel diameter. After kissing balloon inflation, FFR was measured again at the same site and further intervention was only recommended when FFR was <0.75 after kissing balloon dilatation. In the conventional group, the decision to treat the side-branch lesion and the method of intervention were all up to the operators' discretion.
Clinical follow-up was performed at 1 month after stent implantation, and every 2–3 months thereafter. Adverse cardiac events were defined as cardiac death, myocardial infarction, or target vessel revascularization during the follow-up period. Follow-up coronary angiography and FFR measurement were planned 6 months after the procedure.
Quantitative coronary angiography (Quantcor QCA, version 4.0, Pie Medical Imaging, the Netherlands) was performed by a single experienced technician, who was blinded to the FFR value. It was performed before and after the procedure and at the time of angiographic follow-up. Minimal luminal diameter, lesion length, and reference vessel diameter of both branches were measured. Bifurcation lesions were classified according to Lefevre's classification.7
Statistical analysis
Data are presented as mean ± standard deviation for continuous variables and as frequency for categorical variables. Comparisons of continuous variables were performed using the Student's or paired t-test. Analyses of discrete variables were performed using the 
2 test or Fisher's exact test where appropriate. Serial changes of FFR in lesions with kissing balloon inflation were analysed using a mixed model. The assumed covariance structure was compound symmetry which made the best fit for the data. The Bonferroni correction was performed for post-hoc comparisons. When there were multiple side branches in a target lesion, only the first branch was included in the analyses. Statistical analyses were performed using SPSS, version 11.0. All tests were two-sided and a P-value of <0.05 was considered statistically significant. As this was not a randomized study to compare the outcome of two different strategies, sample size calculation to establish a powered analysis was not performed. The investigators thought that 110 patients would be enough to provide valuable information on the functional outcomes of FFR-guided strategy.
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Results |
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In the FFR group, 110 patients were consecutively enrolled from 373 patients with bifurcation lesions from June 2004 to January 2006 and FFR was successfully measured in 91 patients (Figure 1). Among those, 10 patients had been also included in our previous study.12 Side-branch access failure with a pressure wire occurred in four lesions among 95 lesions tried. After main branch stent implantation, mean FFR was 0.81 ± 0.12 at the jailed side branches and 0.96 ± 0.04 at the main branches. Mean percent stenosis of jailed side-branch lesions was 79 ± 11% and 28 lesions were functionally significant. Twenty-six lesions among 28 lesions with FFR <0.75 underwent side-branch intervention and all were treated by kissing balloon inflation and all side-branch balloon inflation was done over the pressure wire. However, side-branch intervention was not performed in any of functionally insignificant lesions. Clinical, angiographic, and procedural characteristics are shown in Table 1.
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Fractional flow reserve changes during follow-up
Angiographic follow-up was performed in 76 of 89 available patients (85%). There was one case of non-cardiac death and one follow-up loss. Mean duration between the intervention and follow-up angiography was 6.7 ± 1.2 months (range: 5–11 months, median: 6 months). Among 76 lesions with angiographic follow-up, FFR was successfully measured in 65 lesions (86%). FFR measurement was not attempted in four lesions with significant main branch stenosis and there were two cases of wiring failure during radial approach. Figure 2 shows the changes of FFR in each lesion. There were no significant changes in FFR during follow-up at both main and side branches [0.96 ± 0.04 to 0.96 ± 0.04 for main branch (P = 0.9), 0.87 ± 0.06 to 0.87 ± 0.09 for side branch (P = 0.4), Table 2]. In lesions without kissing balloon inflation, FFR change during follow-up was 0.01 ± 0.05. When the symptomatic status according to the follow-up side-branch FFR was analysed, 5% (3/60) of patients with functionally patent side branch and 20% (1/5) of those with functional restenosis had new or worsening angina during follow-up (P = 0.3).
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Fractional flow reserve changes after kissing balloon inflation
In 26 lesions with kissing balloon inflation, mean side-branch balloon/artery ratio was 0.84 ± 0.14. Post-kissing balloon inflation FFR could not be measured in one lesion due to wire failure. FFR was significantly increased from 0.65 ± 0.08 to 0.85 ± 0.07 (n = 25, P < 0.001) after kissing balloon inflation. The percent stenosis of jailed side-branch lesion was decreased from 83 ± 11 to 69 ± 10% after kissing balloon inflation and 32% (8/25) of the lesions still had
75%. However, FFR 0.75 was achieved in 92% (23/25) of the lesions after single kissing balloon inflation. No further intervention was performed in the other two lesions. Follow-up FFR was available in 21 lesions with kissing balloon inflation and acute functional gain was maintained during follow-up (Figure 3). However, there was a trend towards more functional late loss in lesions with kissing balloon inflation (
FFR: –0.02 ± 0.09) than in those without (FFR: 0.01 ± 0.05) (P = 0.09).
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Fractional flow reserve vs. percent stenosis at follow-up angiography
Both follow-up angiogram and FFR were available in 65 lesions. Mean percent stenosis, reference diameter, and lesion length of side-branch lesions were 70 ± 14%, 2.3 ± 0.3 mm, and 7.3 ± 3.0 mm, respectively. When 75% binary restenosis criteria were applied, restenosis rate was 48%. However, functional restenosis rate was only 8% (5/65). Among the five lesions with functional restenosis, three (14%) were from the lesions with kissing balloon inflation and two (5%) were from those without kissing balloon inflation (Figure 2).
Comparison of clinical outcomes with conventional group
There were no differences in baseline clinical and angiographic characteristics between the two groups except for the length of the main and side-branch lesions (Table 1). There were five cases of target lesion revascularization in the FFR group (three main branch, one side branch, and one both branches). Although side-branch intervention was performed more frequently (45 vs. 30%, P = 0.02) and there was less residual stenosis at side branch (60 ± 20 vs. 74 ± 12%, P < 0.001) in the conventional group, no difference was found in 9-month clinical outcomes between the two groups. In both groups, there was no myocardial infarction or cardiac death during 9-month follow-up (Table 3).
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Discussion |
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The important findings of our study are as follows: (1) functional severity of jailed side-branch lesions after drug-eluting stent implantation does not change significantly during 6-month follow-up; (2) angiographic evaluation overestimates the functional severity of jailed side-branch lesions in every step of the provisional strategy for bifurcation lesions; and (3) side-branch intervention using a relatively small balloon results in significant improvement of functional status of side-branch lesions.
Provisional side-branch intervention strategy is still preferred for most bifurcation lesions because no study has shown a benefit of the systematic two stenting strategy over this strategy.1–4,7–9 Various goals for side-branch balloon angioplasty are currently being used, however, none of these has been validated yet. Aggressive dilatation accompanies a higher risk of vessel dissection requiring side-branch stent implantation, which may increase the risk of stent thrombosis17,18 and may have a bad influence on the flow dynamics of the main branch.19 In previous studies using angiographic stenosis of 50% as a treatment goal of side-branch balloon angioplasty, the side-branch balloon artery ratio was 1.1–1.3.1,3,8 As no jailed side-branch lesion with <75% stenosis was functionally significant in our previous study,12 we hypothesized that a balloon angioplasty using a small balloon would be functionally sufficient as long as the initial benefit could be maintained during follow-up. In this study, the balloon artery ratio of jailed side-branch lesions was 0.84 ± 0.14. Although the side-branch residual stenosis after kissing balloon inflation was 69 ± 10%, the functional goal (FFR 0.75) was achieved in 92% of the lesions. Because there was no significant functional late loss during follow-up, this strategy was successful in maintaining the functional patency of most side-branch lesions. These results suggest that in a side-branch lesion with tight stenosis after main branch stent implantation, angioplasty using a relatively small balloon (balloon/artery ratio <1) may result in good functional outcome in most lesions. However, it is not known whether more aggressive side-branch dilatation would be followed by the better functional outcomes. Considering the small number of the lesions with side-branch intervention and a trend towards more FFR decrement during follow-up in lesions with side-branch intervention, further studies are needed to validate this strategy.
In lesions without side-branch intervention, FFR was slightly increased during follow-up (0.87 ± 0.06 to 0.89 ± 0.07, P = 0.1) and functional restenosis rate was only 5%. van't Veer et al.20 showed that the drug-eluting stents have a better physiological and haemodynamic performance than bare metal stents in non-bifurcation lesion. Although we did not measure the detailed haemodynamic parameters, both the main and side-branch lesions showed no deterioration of FFR during follow-up. This result suggests that the beneficial effect of the drug-eluting stents may be applied to both main and side branches in a bifurcation lesion.
In addition to our previous study,12 this study revealed that the current angiographic criteria overestimates the functional severity of the jailed side-branch lesions at every step of provisional side-branch intervention strategy. As shown in Figure 4, the application of the angiographic criterion of 75% stenosis would have resulted in 68, 32, and 48% of the lesions requiring additional side-branch intervention after main branch stent implantation, after kissing balloon dilatation and at follow-up, respectively. However, these were reduced to 31, 8, and 8% with the application of the functional criterion of FFR <0.75. Considering these results and the fact that complex intervention for bifurcation lesion is a predictor of stent thrombosis,17,18 a stricter angiographic evaluation criterion needs to be applied in every step of the provisional side-branch intervention strategy.
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In the recently published Nordic bifurcation study, Steigen et al.4 used an extremely conservative criteria for side-branch intervention in the provisional group. Side-branch intervention was allowed only in lesions with TIMI flow <3 after main branch stent implantation and TIMI flow = 0 after side-branch balloon angioplasty and final kissing balloon inflation was performed in 32% of lesions and side-branch stent implantation in 4.3%. Although it was not shown how many of these interventions were performed by the study protocol, the clinical outcome of this group was excellent. Interestingly, these percentages are very similar to our FFR data that showed that additional intervention was required in 31% after main branch stent implantation and 8% after side branch balloon angioplasty. When we compared the clinical outcomes of FFR-guided intervention and conventional intervention strategies, the FFR-guided protocol was not inferior to the conventional strategy with regard to adverse cardiac events during follow-up. Side-branch intervention was performed more in conventional group (45 vs. 30%, P = 0.03). Although our study was not a randomized study to compare the outcome of these two strategies nor was it powered to do so, our results also support the current concept that an aggressive side-branch intervention strategy with better angiographic results does not guarantee better clinical outcomes in bifurcation lesions.
The pressure wire is not the best one for the access of jailed side branches and complex side-branch interventions. In our study, side-branch access using the pressure wire was successful in 91/95 lesions (96%) and all kissing balloon inflations were done over the pressure wire. As FFR-guided strategy showed no clinical benefit over conventional intervention strategy and this strategy requires more time and invasive procedures, we have no intention to say that the FFR-guided strategy should be used in all bifurcation lesions. However, our study results showed that FFR-guided side-branch intervention strategy was feasible in most cases and might be helpful in decision making for jailed side-branch treatment.
Limitations
This study has some limitations. First, our study only included relatively short side-branch lesions, and therefore, our results cannot be extended to diffuse lesions. However, since the side-branch lesion length of our study was comparable with that of previous studies, our study results seem to be applicable to most of the bifurcation lesions in real world practice. Second, the number of patients was relatively small and the rates of angiographic and FFR follow-up were relatively low. Third, post-stenting and post-angioplasty side-branch FFRs may not reflect the true lesion severity due to thrombus or oedema related to intervention.21 There may be some increase in FFR during the very early period of intervention, which may decrease thereafter due to luminal late loss. However, as no significant functional late loss was shown during follow-up in our study, immediate post-procedural side-branch FFR seems to be a useful parameter that can predict the functional patency of these lesions during follow-up. Fourth, quantitative coronary angiography system used in our study does not have a dedicated bifurcation analysis system. Like most conventional quantitative coronary angiography systems,22 manual correction needed for the analysis of side-branch ostial lesions is subject to a possible error. Finally, as this study was not a randomized study to evaluate the outcome of functional criteria-guided side-branch intervention strategy and the length of main and side-branch lesions was different between the two groups, it is uncertain whether this strategy could result in better clinical outcomes. This should be evaluated in a large-scale randomized trial comparing the clinical outcomes of different intervention criteria for side-branch lesions.
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Conclusions |
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In conclusion, FFR-guided side-branch intervention strategy resulted in good functional outcomes. Measurement of FFR seems to be helpful in determining the functional significance of lesions at each step of the provisional side-branch intervention strategy.
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Funding |
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This study was supported by the grants from the Korea Health 21 R&D Project, Ministry of Health and Welfare, Republic of Korea (0412-CR02-0704-0001), from the Innovative Research Institute for Cell Therapy (IRICT: A062260), and from the Korean Society of Circulation, Industrial-educational cooperation 2004 (2004–5).
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Acknowledgement |
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The authors appreciate comments and feedback from the Medical Research Collaborating Center on the manuscript of this paper.
Conflict of interest: none declared.
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References |
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- Colombo A, Moses JW, Morice MC, Ludwig J, Holmes DR Jr, Spanos V, Louvard Y, Desmedt B, Di Mario C, Leon MB. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation (2004) 109:1244–1249.
[Abstract/Free Full Text] - 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. Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: A randomized comparison of a simple versus complex strategy. Am Heart J (2004) 148:857–864.[CrossRef][Web of Science][Medline]
- Ge L, Tsagalou E, Iakovou I, Sangiorgi GM, Corvaja N, Airoldi F, Chieffo A, Montorfano M, Michev I, Colombo A. In-hospital and nine-month outcome of treatment of coronary bifurcational lesions with sirolimus-eluting stent. Am J Cardiol (2005) 95:757–760.[CrossRef][Web of Science][Medline]
- Steigen TK, Maeng M, Wiseth R, Erglis A, Kumsars I, Narbute I, Gunnes P, Mannsverk J, Meyerdierks O, Rotevatn S, Niemela M, Kervinen K, Jensen JS, Galloe A, Nikus K, Vikman S, Ravkilde J, James S, Aaroe J, Ylitalo A, Helqvist S, Sjogren I, Thayssen P, Virtanen K, Puhakka M, Airaksinen J, Lassen JF, Thuesen L;, Nordic PCI Study Group. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions. The Nordic bifurcation study. Circulation (2006) 114:1955–1961.
[Abstract/Free Full Text] - Tanabe K, Hoye A, Lemos PA, Aoki J, Arampatzis CA, Saia F, Lee C, Degertekin M, Hofma SH, Sianos G, McFadden E, Smits PC, van der Giessen WJ, de Feyter P, van Domburg DT, Serruys PW. Restenosis rates following bifurcation stenting with sirolimus-eluting stents for de novo narrowings. Am J Cardiol (2004) 91:115–118.
- Ge L, Iakovou I, Cosgrave J, Agostoni P, Airoldi F, Sangiorgi GM, Michev I, Chieffo A, Montorfano M, Carlino M, Corvaja N, Colombo A. Treatment of bifurcation lesions with two stents: one year angiographic and clinical follow up of crush versus T stenting. Heart (2006) 92:371–376.
[Abstract/Free Full Text] - Lefevre T, Louvard Y, Morice MC, Dumas P, Loubeyre C, Benslimane A, Premchand RK, Guillard N, Piechaud JF. Stenting of bifurcation lesions: classification, treatments, and results. Catheter Cardiovasc Interv (2000) 49:274–283.[CrossRef][Web of Science][Medline]
- Yamashita T, Nishida T, Adamian MG, Briguori C, Vaghetti M, Corvaja N, Albiero R, Finci L, Di Mario C, Tobis JM, Colombo A. Bifurcation lesions: two stents versus one stent-immediate and follow-up results. J Am Coll Cardiol (2000) 35:1145–1151.
[Abstract/Free Full Text] - Al Suwaidi J, Berger PB, Rihal CS, Garratt KN, Bell MR, Ting HH, Bresnahan JF, Grill DE, Holmes DR Jr. Immediate and long-term outcomes of intracoronary stent implantation for true bifurcation lesions. J Am Coll Cardiol (2000) 35:1145–1151.
[Abstract/Free Full Text] - Ziaee A, Parham WA, Hermann SC, Stewart RE, Lim MJ, Kern MJ. Lack of relation between imaging and physiology in ostial coronary artery narrowings. Am J Cardiol (2004) 93:1404–1407.[CrossRef][Web of Science][Medline]
- Bech GJ, Droste H, Pijls NH, De Bruyne B, Bonnier HJ, Michels HR, Peels KH, Koolen JJ. Value of fractional flow reserve in making decisions about bypass surgery for equivocal left main coronary artery disease. Heart (2001) 86:547–552.
[Abstract/Free Full Text] - Koo BK, Kang HJ, Youn TJ, Chae IH, Choi DJ, Kim HS, Sohn DW, Oh BH, Lee MM, Park YB, Choi YS, Tahk SJ. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol (2005) 46:633–637.
[Abstract/Free Full Text] - Pijls NH, van Son JA, Kirkeeide RL, De Bruyne B, Gould KL. Experimental basis of determining maximum coronary myocardial, and collateral blood flow by pressure measurements for assessing functional stenosis severity before and after PTCA. Circulation (1993) 87:1354–1367.
[Abstract/Free Full Text] - De Bruyne B, Bartunek J, Sys SU, Heyndrickx GR. Relation between myocardial fractional flow reserve calculated from coronary pressure measurement and exercise-induced myocardial ischemia. Circulation (1995) 92:39–46.
[Abstract/Free Full Text] - Pijls NH, De Bruyne B, Peels K, van der Voort PH, Bonnier HJ, Bartunek J, Koolen JJ. Measurement of fractional flow reserve to assess the functional severity of coronary artery stenoses. N Engl J Med (1996) 334:1703–1708.
[Abstract/Free Full Text] - Koo BK, Kim CH, Na SH, Youn TJ, Chae IH, Choi DJ, Kim HS, Lee MM, Oh BH, Park YB, Choi YS, Tahk SJ. Intracoronary continuous adenosine infusion. Circ J (2005) 69:908–912.[CrossRef][Medline]
- 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. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA (2005) 293:2126–2130.
[Abstract/Free Full Text] - Joner M, Finn AV, Farb A, Mont EK, Kolodgie FD, Ladich E, Kutys R, Skorija K, Gold HK, Virmani R. Pathology of drug-eluting stents in humans: delayed healing and late thrombotic risk. J Am Coll Cardiol (2006) 48:193–202.
[Abstract/Free Full Text] - Richter Y, Groothuis A, Seifert P, Edelman ER. Dynamic flow alterations dictate leukocyte adhesion and response to endovascular interventions. J Clin Invest (2004) 113:1607–1614.[CrossRef][Medline]
- van't Veer M, Pijls NH, Aarnoudse W, Koolen JJ, van de Vosse FN. Evaluation of the haemodynamic characteristics of drug-eluting stents at implantation and at follow up. Eur Heart J (2006) 27:1811–1817.
[Abstract/Free Full Text] - Thomas M, Hildick-Smith D, Louvard Y, Albiero R, Darremont O, Stankovic G, Pan M, Legrand V, De Bruyne B, Lefevre T. Percutaneous coronary intervention for bifurcation disease. A consensus view from the first meeting of the European bifurcation club. EuroInterv (2006) 2:149–153.
- Goktekin O, Kaplan S, Dimopoulos K, Barlis P, Tanigawa J, Vatankulu MA, Koning G, Tuinenburg JC, Di Mario C. A new quantitative analysis system for the evaluation of coronary bifurcation lesions: comparison with current conventional methods. Catheter Cardiovasc Interv (2007) 69:172–180.[CrossRef][Medline]
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