Haemodynamic significance of ostial side branch nipping following percutaneous intervention at bifurcations: a pressure wire pilot study

N G Bellenger; R Swallow; D S Wald; I Court; A L Calver; K D Dawkins; N Curzen

doi:10.1136/hrt.2006.088690

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Haemodynamic significance of ostial side branch nipping following percutaneous intervention at bifurcations: a pressure wire pilot study

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Use of pressure wires to assess nipping of side branches after main vessel stenting
Clare Appleby
Published on: 6 March 2007

Published on: 6 March 2007
Use of pressure wires to assess nipping of side branches after main vessel stenting
- Clare Appleby, SpR cardiology
- Other Contributors:
  Dr A Wiper, Dr David H Roberts
Dear Editor,
We read with interest Bellenger et als description of the determination of fractional flow reserve (FFR) to guide treatment of side branch arteries following provisional stenting across a bifurcation. The use of pressure wires to guide treatment of main vessel narrowings (1) and ambigious stenoses in multi-vessel disease (2) and ACS (3) is established.
Based on their preliminary findings, tha...
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Dear Editor,
We read with interest Bellenger et als description of the determination of fractional flow reserve (FFR) to guide treatment of side branch arteries following provisional stenting across a bifurcation. The use of pressure wires to guide treatment of main vessel narrowings (1) and ambigious stenoses in multi-vessel disease (2) and ACS (3) is established.
Based on their preliminary findings, that there is a poor correlation between the angiographic degree of nipping by quantitative coronary angiography (QCA) and the FFR in the side branches after stenting the main vessel, the authors called for a randomised controlled trial to determine whether FFR-directed treatment of side branch nipping improves clinical and angiographic outcome following PCI at bifurcations.
Given that such side branches may be relatively small (2.3 +/-0.2mm in the current study) we question the assertion that a QCA stenosis >50% would trigger treatment by many interventionists. FFR determination encompasses the interaction between the degree of anatomic stenosis and the area of myocardium perfused by the vessel.
This goes some way in accounting for the occurrence of haemodynamically significant obstruction in only a minority of vessels (3/14) in the current study. Indeed others have shown that in larger side branches (> 2.5mm) where QCA-assessed stenosis is >75% following main vessel stenting, a greater proportion will demonstrate functional significance (38% vs 27% in vessels < 2.5mm), although the overall occurrence of functionally significant stenoses remains small (4). Further, were treatment of the side branch to be undertaken, it is as likely to involve POBA as a second stent procedure (5). The authors own findings would suggest that a strategy of treating only the main vessel is sufficient, achieving a "functionally adequate result" in the majority of cases (79%). Therefore the extra cost incurred by routine use of a pressure wire in this situation might prove difficult to justify if, as the authors concur, the likelihood of a functionally significant lesion is "infrequent". In their small pilot study, none of the lesions measuring less than 50% by QCA were associated with a FFR less than 0.75.
Undoubtedly deferring treatment of side branches will prevent unnecessary coronary interventions and their related complications - whether routine use of a pressure wire is required to achieve this is debateable.
References
1. Bech GJW, De Bruyne B, Pijls NHJ, et al.
Fractional Flow Reserve to Determine the Appropriateness of Angioplasty in Moderate Coronary Stenosis : A Randomized Trial.
Circulation. 2001; 103(24):2928-2934.
2. Berger A, Botman K-J, MacCarthy PA, et al.
Long-Term Clinical Outcome After Fractional Flow Reserve-Guided Percutaneous Coronary Intervention in Patients With Multivessel Disease.
JACC. 2005; 46(3):438-442.
3. Joshua J. Fischer X.
Outcome of patients with acute coronary syndromes and moderate coronary lesions undergoing deferral of revascularization based on fractional flow reserve assessment.
Catheterization and Cardiovascular Interventions. 2006; 68(4):544-548.
4. Koo B-K, Kang H-J, Youn T-J, et al.
Physiologic Assessment of Jailed Side Branch Lesions Using Fractional Flow Reserve.
JACC. 2005; 46(4):633-637.
5. Pan M, de Lezo JS, Medina A, et al.
Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: A randomized comparison of a simple versus complex strategy.
Am Heart J. 2004; 148(5):857-864.
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Conflict of Interest:
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