Treatment of Coronary Bifurcation Lesions

Interventional cardiology has been witnessing technological advances and improved success over the last decade. Increasing success and safety levels of interventional cardiac procedures has improved the outcomes for patients with coronary artery disease (CAD). An underlying pathologic process called atherosclerosis can make the coronary arteries lose their flexibility and elasticity over time. Plaque build-up causes the artery to narrow thereby impairing the blood flow to the heart tissues. One of the common coronary heart disease symptoms is chest pain or discomfort accompanied by shortness of breath. In most cases, the pain may occur during physical or emotional stress. Early diagnosis and treatment is the best way to tackle heart disease and live a quality life. That is why it is often advised to seek immediate medical attention when faced with common coronary heart disease symptoms.

Advanced diagnostic techniques and therapeutic approaches are available for detecting and treating CAD conditions. Percutaneous coronary intervention (PCI) with its minimally invasive procedure and reduced complication rate has superseded Coronary Artery bypass Grafting (CABG) in the treatment of single vessel CAD. Despite the advancements in stent technology and catheterization tools, interventional cardiologists find it a challenge to treat some complex coronary lesions that are often associated with higher restenosis, worse outcomes and greater complication rates. Complex bifurcation lesions are a case in point. When defined in medical terms, coronary bifurcation lesions can be defined as – “a lesion ≥50% diameter stenosis involving a main branch and/or contiguous side branch with a diameter of ≥2.5 mm”. Around 15% to 20% of the CAD lesions are bifurcation lesions, which present a challenge to interventional cardiologists.  Even though coronary angiography is considered as the gold standard for diagnosing heart ailments, angiographic evaluation alone can’t provide substantial information about the stenosis.

Innatelimitations of coronary angiography were a major concern in devising a right risk stratification approach for the complex lesions. Moreover, plain balloon angioplasty and bare metal stenting results were suboptimal because of the high rates of restenosis. But with the introduction of fractional flow measurement, advanced medical imaging methods and bioabsorbable drug eluting stent technology, percutaneous treatment of complex bifurcation lesions seems possible. Several studies and clinical trials are going on with the objective to address concerns related to stenting, and will hopefully hold the key to the successful treatment of bifurcations.

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Left Main Coronary Artery Stenting – Is it a Safe Approach?

Common coronary heart disease (CHD) also to referred as ischemic heart disease is the leading cause of heart attacks and angina. Atherosclerotic plaque build-up in the inner walls of coronary arteries hardens the blood vessels and restricts the blood supply to heart. Lack of oxygen leads to the damage or death of heart tissues which results in ischemia. Clots in the arteries can be life-threatening, as it eventually restricts or completely cuts off the oxygen-rich blood supply resulting in angina or myocardial infarctions (heart attacks). Some of the common coronary heart disease symptoms include sharp pain or pressure in the chest that travels to the arms and jaw, shortness of breath, light-headedness and fatigue. Even if the symptoms are mild, seeking immediate medical attention is necessary.

The left main coronary artery (LMCA) is responsible for supplying blood to a large segment of the myocardium and stenosis of LMCA will lead to acute cardiac events. Coronary Artery Bypass Graft (CABG) has been considered the standard therapeutic option for treating left main coronary artery disease (LMD), because it provides better survival rates when compared to drug therapy. Percutaneous coronary intervention (PCI) with bare metal stents tended to result in in-stent restenosis and a need for revascularization, making it a risky choice. But with the advent of state-of-the-art catheterization technologies, drug-eluting stents and antithrombotic agents, newer left main coronary artery stenting has made it a viable option for patients with high surgical risks or co-morbidities.

Ongoing clinical trials and research studies have been evaluating the effectiveness of using drug-eluting stents (DES) for Unprotected LMCA compared with CABG. Targeted lesion revascularization advantages of minimally invasive newer left main coronary artery stenting can be considered as a safe and effective alternative to CABG, especially for patients in a high-risk group. Even though DES is considered as a great step in interventional cardiology, concerns over the polymer-associated complications and risk of thrombosis have raised questions about its safety. Drug-eluting stent thrombosis is closely associated with acute myocardial infarction resulting in mortality and morbidity. Biocompatible and bioabsorbable stents that are developed in order to overcome issues such as drug-eluting stent thrombosis is a recent development in the interventional community that offers a promising approach for PCI in treating left main coronary artery disease. But in the meantime, cardiologists have to choose either PCI or CABG to manage the left main disease based on the SYNTAX score and medical-surgical consultation. 

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Treatment of Coronary Artery Stenosis

We have been hearing a lot about the rapid advancements and changes in the field of medical technology ranging from patient registration to data assessment and diagnostic methods to surgical procedures. Yet, some diseases continue to remain as a dreadful term for us; heart disease is a case in point. Coronary Heart Disease (CAD) also known as Coronary Artery Disease (CAD) is the most common type of heart disease that kills more people than any other disease across the world. The main cause of CAD is atherosclerosis (hardening of arteries). Build-up of calcium and cholesterol on the walls of coronary arteries cut down the blood supply to the heart muscles, thereby leading into cardiac ischemia or myocardial infarction (heart attack) among CAD patients.

Severe chest pain or discomfort, also termed as angina pectoris is one of the major coronary heart disease symptoms. The pain can be localised to shoulders, arms, neck, jaw or back. Though, in some cases people also experience nausea, shortness of breath and dizziness. The sensation of discomfort experienced during myocardial ischemia or myocardial infarction develops as a result of coronary artery stenosis. As the degree of coronary artery stenosis increases, myocardial blood flow is reduced resulting in severe chest pain.

Treatment plans differ according to the types of angina, which includes stable angina, unstable angina (UA), variant angina and microvascular angina. When stable angina follows a regular pattern, UA typically occurs when a person is at rest which demonstrates its highest unpredictability and risky nature. On the other hand, variant angina is a rare kind induced due to spasm in the coronary artery and can be treated with medical therapy. Severe pain persists for a long time when it comes to microvascular angina. Patients admitted with coronary heart disease symptoms are advised to undergo different laboratory tests and imaging studies to devise a treatment plan.  

Surgical intervention or medical therapy is the preferred treatment approach to tackle coronary artery stenosis. However, interventional cardiologists find it challenging to deal with coronary bifurcation lesions (a lesion in the parent coronary artery very close or involving a significant side branch) that increases the procedural complexity. An optimal surgical or medical approach for managing coronary artery bifurcation lesions is still on debate as it involves restoring lumen of both the vessels. Time is the main factor in managing angina; hence it is essential to make a quick and safe decision based on the results.

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