IJC Heart & Vasculature 49 (2023) 101311

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IJC Heart & Vasculature

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Impact of Medina classification on clinical outcomes of imaging-guided

coronary bifurcation stenting
Yoshinobu Murasato a, *, 1, Yoshihisa Kinoshita b, Masahiro Yamawaki c, Takayuki Okamura d,
Ryoji Nagoshi e, Yusuke Watanabe f, Nobuaki Suzuki g, Takahiro Mori a, Toshiro Shinke h,
Junya Shite e, Ken Kozuma f
a
Department of Cardiology & Clinical Research Centre, National Hospital Organization, Kyusyu Medical Centre, Fukuoka, Japan
b
Department of Cardiology, Toyohashi Heart Centre, Toyohashi, Japan
c
Department of Cardiology, Saiseikai Yokohama City Eastern Hospital, Yokohama, Japan
d
Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
e
Department of Cardiology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
f
Department of Medicine, Division of Cardiology, Teikyo University School of Medicine, Tokyo, Japan
g
Division of Cardiology, Teikyo University Mizonokuchi Hospital, Kawasaki, Japan
h
Department of Medicine, Division of Cardiology, Showa University School of Medicine, Tokyo, Japan

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Intracoronary imaging improves clinical outcomes after stenting of complex coronary bifurcation
Coronary bifurcation lesions (CBLs), but the impact of Medina classification-based CBL distribution on outcomes of imaging-guided
Drug-eluting stent bifurcation stenting is unclear.
Intracoronary imaging
Methods: In this integrated analysis of four previous studies, in which all CBLs were treated with drug-eluting
Medina classification
stents under intravascular ultrasound or optical coherence tomography guidance, the distribution of 763 CBLs
was assessed using angiographic Medina classification. Major adverse cardiac events (MACE), including target
lesion revascularization (TLR), myocardial infarction, stent thrombosis, and cardiac death, were investigated at
1-year follow-up.
Results: The most and least prevalent Medina subtypes were 0-1-0 (27.9 %) and 0-0-1 lesions (2.8 %). The most
and least frequent MACE/TLR rates were 18.2 %/18.2 % for 0-0-1 lesions and 4.1 %/2.8 % for 0-1-0 lesions.
Risks were higher for 0-0-1 lesions than for 0-1-0 lesions for both MACE (hazard ratio [HR]: 4.04, 95 % confi­
dence interval [CI]: 1.21–13.45, p = 0.02) and TLR (HR: 6.19, 95 % CI: 1.69–22.74, p = 0.006). MACE rates were
similar for true and non-true CBLs excluding 0-0-1 lesions (8.2 % and 5.9 %, HR 1.54, 95 % CI: 0.86–2.77, p =
0.15), while MACE (HR: 3.25, 95 % CI: 1.10–9.63, p = 0.03) and TLR (HR: 4.24, 95 % CI: 1.38–12.96, p = 0.01)
risks were higher for 0-0-1 lesions.
Conclusions: This integrated analysis of imaging-guided bifurcation stenting demonstrated similar clinical out­
comes in true and non-true CBLs, except for 0-0-1 lesions, which had a significantly higher risk of MACE/TLR.

1. Introduction
The Medina classification is widely used to characterise coronary
bifurcation lesions (CBLs) by indicating the presence or absence of sig­
nificant stenosis in the proximal main vessel (MV), distal MV, and side
branches (SB) during coronary angiography [1,2]. This classification
helps understand lesion distribution, stratify percutaneous coronary
intervention (PCI), and predict prognosis. True CBLs (those with
significant stenosis in both the MV and SB) require more SB treatment
and complex procedures, such as kissing balloon inflation (KBI) and two-
stent deployment, and are associated with an increased risk of target
lesion failure compared with non-true CBLs [3,4]. However, in complex
true CBLs, which have more diffuse or tighter SB stenosis and calcified
lesions, elective two-stenting had superior clinical outcomes compared
with provisional stenting [5,6]. Although the impact of lesion subgroups
in the Medina classification has not been systematically investigated, a

* Corresponding author at: Department of Cardiology, National Hospital Organization, Kyushu Medical Centre 1-8-1, Jigyohama, Chuo, Fukuoka 810-8563, Japan.
E-mail address: y.murasato@gmail.com (Y. Murasato).
1
These authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretations.

https://doi.org/10.1016/j.ijcha.2023.101311
Received 23 August 2023; Received in revised form 11 November 2023; Accepted 16 November 2023
2352-9067/© 2023 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
Y. Murasato et al.
recent analysis revealed that Medina 0-0-1 lesions (SB lesions only) and
Medina 1-1-1 lesions (the most complex) had a higher risk of target
lesion failure than Medina 1-0-0 lesions (hazard ratios [HRs] 4.0 and
2.6, respectively). The paradoxical finding of a higher risk associated
with both the simplest and most complex lesions is striking, but might be
influenced by the limited use of imaging guidance (12 %) [7]. Imaging
guidance enhances accurate lesion assessment, and PCI optimisation and
reduces unnecessary SB stenting [8,9]. However, the impact of imaging
guidance on CBL intervention by CBL distribution has not yet been
studied on a large scale. This study explored the influence of the CBL
distribution according to the angiographic Medina classification on the
clinical outcomes of CBL interventions using comprehensive imaging
guidance.
2. Methods
2.1. Study population
The study included 778 CBLs from 769 patients treated with drug-
eluting stent (DES) implantation under the guidance of intravascular
ultrasound (IVUS) or optical coherence tomography (OCT)/optical fre­
quency domain imaging (OFDI) in four previous studies (Fig. 1). The
studies included two multicentre prospective registry studies (J-
REVERSE; 300 CBLs with IVUS guidance [10]; and 3D OCT Bifurcation
Registry; 168 CBLs with OCT guidance [11]), one multicentre rando­
mised study (PROPOT; 119 CBLs with OCT/OFDI guidance) [12], and
one single-centre prospective registry study (Glider Balloon Registry;
201 CBLs with IVUS or OCT/OFDI guidance) [13]. Common inclusion
criteria were: ≥ 75 % stenosis in the MV, with or without ≥ 75 % stenosis
in the SB; MV reference diameter ≥ 2.5 mm; and SB reference diameter
≥ 2.0 mm. Mandatory imaging was performed during and after the
procedures. The exclusion criteria included contraindications to anti­
platelet or anticoagulant therapy, allergies to contrast agents, in-stent
restenosis, cardiogenic shock, chronic total occlusion, and bypass graft
lesions. Medina classifications were determined by on-site visual
assessment of baseline coronary angiography, and were expressed as the
presence (“1″) or absence (”0″) of significant stenosis in the proximal
MV, distal MV, and SB. Significant stenosis was regarded as ≥ 75 %
stenosis, or ≥ 50 % stenosis in the left main coronary artery. True CBL
(both MV and SB stenosis) was defined as Medina 1-1-1, 1-0-1, or 0-1-1
lesions. After excluding 15 cases without a reported classification, 763
CBL cases were analysed; 390 (51 %) using IVUS guidance and 373 (49
Fig. 1. Study flow and integrated analysis. The endpoint of the study is listed at the bottom right. IVUS: intravascular ultrasound; OCT: optical coherence to­
mography; CBL: coronary bifurcation lesion.
2
IJC Heart & Vasculature 49 (2023) 101311
%) using OCT/OFDI guidance. Clinical events, including target lesion
revascularisation (TLR), cardiac death, myocardial infarction, and def­
inite stent thrombosis, were recorded 9–12 months after CBL interven­
tion. Ethical approval was obtained for each study and the patients
provided written informed consent in accordance with the Declaration
of Helsinki.
2.2. PCI
After the administration of an appropriate dose of a combination of
dual antiplatelet agents, provisional CBL stenting using a DES is rec­
ommended. In cases of occlusion, serious dissection, or diffuse lesions in
the non-stenting branch, two-stenting was performed [10-13].
2.3. Outcome
The primary outcomes were major adverse cardiac events (MACE), a
composite of TLR due to PCI or surgery, cardiac death, myocardial
infarction, and definite stent thrombosis.
2.4. Statistical analysis
The data were expressed as mean ± standard deviation, or number
and percentage. Between-group comparisons of continuous variables
were performed using a one-way analysis of variance. Between-group
differences in counts and percentages were examined using chi-
squared tests and corrected using Fisher’s exact test when appropriate.
A Cox proportional hazards regression analysis was performed using
Medina 0-1-0 as a reference, with adjustments for the following factors:
acute coronary syndrome, lesion location, age, sex, hypertension, dia­
betes mellitus, dyslipidaemia, and current smoking. All p-values were
two-sided and considered statistically significant at p < 0.05. All ana­
lyses were performed using R (version 3.6.1; R Foundation for Statistical
Computing, Vienna, Austria).
3. Results
3.1. Lesion distribution according to the Medina classification
As shown in Fig. 2, the CBL subsets 1-1-1, 1-0-1, 0-1-1, 1-1-0, 1-0-0,
0-1-0, and 0-0-1 accounted for 17.4, 6.3, 12.6, 18.3, 12.9, 27.9, and 2.8
% of all CBLs, respectively. The most prevalent were 0-1-0 lesions; the
Y. Murasato et al. IJC Heart & Vasculature 49 (2023) 101311

Fig. 2. Distribution of Medina classification in coronary bifurcation lesions (CBLs).

least prevalent were 0-0-1 lesions.
3.2. Baseline patient characteristics
Patients’ baseline characteristics are summarised in Table 1. Mean
ages ranged from 66 to 71 years and males accounted for 69–89 %.
Hypertension was present in 73–82 %, diabetes mellitus in 33–43 %,
dyslipidaemia in 61–82 %, and current smokers accounted for 16–28 %.
No significant difference was observed in baseline characteristics among
the Medina classification groups. Acute coronary syndrome was
frequently observed in 1-1-1, 1-1-0, and 0-0-1 lesions (18–20 %) and less
frequently in 1-0-1, 1-0-0, and 0-1-0 lesions (6–9 %; p = 0.02).
3.3. Lesion characteristics
As shown in Table 2, the left anterior descending artery (LAD) was
the most frequently treated artery in all Medina classifications (48–68
%). The 0-0-1 lesions in the left circumflex artery (23 %) and the 1-0-
0 lesions in the right coronary artery (20 %, p = 0.002) were treated
more frequently than the other CBLs. The 0-1-1 lesion was less
frequently observed in the left main (LM) coronary artery (7 %, p =
0.03).
3.4. Procedure characteristics
As shown in Table 2, crossover stenting from the proximal to the
distal MV was performed in all CBLs except for 0-0-1 lesions (91 %). SB
stenting was frequently performed for 1-1-1 (19 %) and 0-0-1 (18 %, P <
0.001) lesions. More two-stent deployment was performed for 0-0-1
lesions (9 %) and true CBL (1-1-1 lesions, 19 %; 0-1-1 lesions, 10 %;
p < 0.001). Although the incidence of usage the proximal optimisation
technique (POT) was not significantly different among between lesions,
fewer POT procedures were performed for 0-0-1 lesions (32 %). SB
dilation (KBI or SB dilation alone) was performed most frequently in 1-1-
1 and 0-0-1 lesions (92 % and 86 %, respectively) and least frequently in
1-0-0 and 0-1-0 lesions (67 % and 76 %, respectively; p = 0.001).
3.5. Clinical events
As shown in Fig. 3, MACE rates were highest for 0-0-1 lesions (18.2
%) and lowest for 0-1-0 lesions (4.1 %). The HR after adjusting for
confounding factors using 0-1-0 lesions (lowest MACE rate) as a refer­
ence was significantly increased only in 0-0-1 lesions (HR 4.04, 95 %
confidence interval [CI]:1.31–13.45, p = 0.02), not in any other lesion
subset, even 1-1-1 lesions. The survival rate up to 1 year was also
significantly decreased only for 0-0-1 lesions (0.758, 95 % CI:
0.378–0.924, p = 0.02), as shown in the Supplementary Figure. The TLR
rates are indicated in Fig. 4, and the highest and lowest prevalence rates
of TLR were similar in 0-0-1 and 0-1-0 lesions (18.2 % and 2.8 %,
respectively). The adjusted HR was significantly elevated only for 0-0-1
lesions (HR 6.19, 95 % CI: 1.69–22.74, p = 0.006).
In the hazard regression analysis using non-true CBLs other than 0-0-
1 lesions as a reference, true CBLs did not present significantly higher
adjusted HRs for 1-year MACE (HR: 1.54, 95 % CI: 0.86–2.77, p = 0.15),
whereas 0-0-1 lesions presented an elevated risk (HR: 3.25, 95 % CI:
1.10–9.63, p = 0.03). Similarly, for 1-year TLR, true CBLs did not pre­
sent a significant risk elevation (HR: 1.06, 95 % CI: 0.51–2.22, p = 0.87),
whereas the TLR risk was higher for the 0-0-1 lesion (HR: 4.24, 95 % CI:
1.39–12.96, p = 0.01).
4. Discussion
4.1. Medina classification lesion distribution
The present study with complete imaging guidance demonstrated
fewer true CBLs (36.3 % vs. 47–52 %) [4,7,14,15] and LM bifurcations
(18 % vs. 23–30 %) [4,14,15] than those identified in previous studies
with less imaging guidance (14–39 %) (Table 3). Overestimation of

Table 1
Patient background in coronary bifurcation lesion subsets of Medina classification.
Medina classification number Age Male Hypertension Diabetes mellitus Dyslipidemia Current smoking Acute coronary syndrome
(year old)

1-1-1 135 69.1 ± 11.0 72 % 79 % 37 % 74 % 27 % 20 %

1-0-1 49 70.1 ± 9.9 69 % 73 % 33 % 61 % 16 % 6%
0-1-1 98 68.7 ± 10.1 76 % 82 % 50 % 71 % 28 % 10 %
1-1-0 142 69.7 ± 9.7 82 % 82 % 40 % 79 % 22 % 18 %
1-0-0 100 66.4 ± 10.1 89 % 80 % 38 % 79 % 19 % 8%
0-1-0 217 68.8 ± 9.6 77 % 75 % 43 % 71 % 24 % 9%
0-0-1 22 70.8 ± 8.9 77 % 77 % 41 % 82 % 27 % 18 %
P-value 0.10 0.81 0.99 0.71 0.89 0.70 0.02

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Y. Murasato et al. IJC Heart & Vasculature 49 (2023) 101311

Table 2
Lesion location and procedure of coronary bifurcation intervention in lesion subsets of Medina classification.
Medina Lesion location Main vessel stent Side branch stent 2-stent POT KBI SB Any SB
classification dilation dilation
LAD LCX RCA LM Incidence Size Length Incidence Size Length
alone
(mm) (mm) (mm) (mm)

1-1-1 67 10 4% 19 100 % 3.0 ± 22.6 ± 19 % 2.6 ± 22.0 ± 19 % 47 41 50 % 92 %

% % % 0.4 6.8 0.3 8.1 % %
1-0-1 59 8% 8% 24 100 % 3.0 ± 24.1 ± 4% 2.5 ± 11.5 ± 4% 43 47 31 % 78 %
% % 0.4 6.3 0.0 3.5 % %
0-1-1 68 19 5% 7% 100 % 3.1 ± 24.5 ± 9% 2.6 ± 23.8 ± 10 % 45 41 41 % 82 %
% % 0.4 6.5 0.3 8.9 % %
1-1-0 48 19 8% 25 100 % 3.0 ± 22.3 ± 2% 2.4 ± 18.5 ± 2% 58 40 44 % 85 %
% % % 0.4 7.3 0.1 5.5 % %
1-0-0 56 12 20 % 12 100 % 2.9 ± 24.2 ± 0% – – 0% 57 39 28 % 67 %
% % % 0.5 6.3 % %
0-1-0 57 17 7% 19 100 % 3.1 ± 21.5 ± 3% 2.6 ± 20.5 ± 3% 44 54 23 % 76 %
% % % 0.4 6.2 0.2 9.5 % %
0-0-1 55 23 9% 14 91 % 2.9 ± 22.7 ± 18 % 2.6 ± 16.5 ± 9% 32 59 27 % 86 %
% % % 0.4 7.0 0.1 3.8 % %
P-value 0.41 0.25 0.002 0.03 1.00 0.007 0.004 <0.001 0.89 0.39 <0.001 0.35 0.31 <0.001 0.001

LAD: left anterior descending artery, LCX: left circumflex artery, RCA: right coronary artery, LM: left main coronary artery, POT: proximal optimization technique, KBI:
kissing balloon inflation, SB: side branch.

Fig. 3. Major adverse cardiac events at 1-year follow-up for each lesion subset of the Medina classification. Lower table shows hazard analysis using the value in the
0-1-0 lesion as a reference. CBL: coronary bifurcation lesion.

Medina classification based on angiography was reported in comparison
with the classification based on coronary computed tomography angi­
ography (CCTA), with a discordance in 63 % and decrease in the inci­
dence of true CBL from 61.3 % to 44.8 % [16]. Considering the tendency
to overestimate lumen narrowing in CCTA compared to that revealed by
intracoronary imaging due to the blooming of calcification, some of the
true CBLs may have been overestimated. The on-site imaging observa­
tions used in the present study might have affected the assessment of the
angiography-based Medina classification, corrected the actual plaque
distribution, and recruited more angiographically nonsignificant lesions
with concrete atheromatous plaques. Considering these overestimations
of angiography-based assessments, the lesion distribution in the present
study was appropriate and unlikely to have been influenced by a se­
lection bias toward lower lesion complexity or underestimation.
4.2. True CBL vs. Non-true CBLs other than 0-0-1 lesions
Worse MACE was reported in cases with true CBLs compared with
non-true CBLs (HR 1.39) in 2,897 patients in the COBIS II study [4], and
worse target lesion failure occurred in cases with 1-1-1 lesions (HR 2.6)
compared to that observed in cases with 1–0-0 lesions in 4003 patients
in the e-Ultimaster registry [7]. This is because more complex anatomy
results in myocardial ischaemia or insufficient lumen dilation [3,4,7].
Pre-PCI intracoronary imaging facilitates the development of an effec­
tive PCI strategy and the selection of optimal device size and length by
referring to lesion severity, distribution, plaque morphology, and
reference diameter [8,9]. Post-PCI intracoronary imaging contributes to
the reduction of procedural failures, such as stent under-expansion, mal-
apposition, deformation, intra-stent protrusion, and edge dissection
[8,9]. In particular, imaging of the SB is useful for identifying actual
lumen dilation, the degree of dissection, and determining the necessity
of more aggressive treatment (i.e., additional SB stenting, elective two-
stenting, KBI, and more SB ostial dilation). In the present study, two-
stenting was less commonly used for true CBLs (total 13 %, minimum
4 % in 1–0-1 lesion, maximum 19 % in 1-1-1 lesion) compared with
previous studies (22–47 %) [4–7,17]. This was because SB dissection
after balloon dilation was assessed accurately in the imaging and was
relatively mild due to optimal balloon sizing based on the pre-PCI im­
aging observation, even when the angiographic image remained indis­
tinct. Angiographic assessment of the residual SB ostial lesion was
difficult because of SB foreshortening at a particular angle, overlapping
of the branches, uncertain visualisation of the bifurcation site, and

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Y. Murasato et al. IJC Heart & Vasculature 49 (2023) 101311

Fig. 4. Target lesion revascularization at the 1-year follow-up for each lesion subset of the Medina classification. Lower table shows hazard analysis using the value
in the 0-1-0 lesion as a reference. CBL: coronary bifurcation lesion.

Table 3
Coronary bifurcation lesion distribution according to Medina classification in previous and present studies.
COBIS II4 Vergara et al.14 BIFURCAT15 e-Ultimaster7 CT-PRECISION16 Present study

Case number 2897 1368 5537 4003 400 763

Imaging-guide PCI 39 % 39 % ND 14 % CCTA 100 % 100 %
LM bifurcation 29 % 23 % 30 % 12 % ND 18 %
Medina classification
1-1-1 32.4 % 32.6 % 32.1 % 35.5 % 32.8 % 17.4 %
0-1-1 12.2 % 2.3 % 7.7 % 7.2 % 8.0 % 12.6 %
1-0-1 7.3 % 1.7 % 7.9 % 8.7 % 4.0 % 6.3 %
1-1-0 14.7 % 51.6 % 24.7 % 26.8 % 27.2 % 18.3 %
1-0-0 11.9 % 10.5 % 9.8 % 8.3 % 13.8 % 12.9 %
0-1-0 17.5 % 0.4 % 13.6 % 10.0 % 14.2 % 27.9 %
0-0-1 3.9 % 1.0 % 4.2 % 3.5 % 0% 2.8 %

PCI: percutaneous coronary intervention, LM: left main coronary artery, ND: not described, CCTA: coronary computed tomography angiography.

ambiguous images reflected by the SB ostial stent struts. An increase in
imaging guidance avoided unnecessary two-stent deployment for true
CBLs, regardless of the uncertainty of the angiographic findings.
In the present study, with complete imaging guidance, no significant
increase in the HR for MACE or TLR was observed in the true CBL group
at 1-year follow-up. Although imaging guidance can overcome these
events, regardless of the complexity of the procedure, a longer follow-up
study is warranted to detect long-progressed in-stent neo-
atherosclerosis, asymptomatic organised thrombus accumulation, and
myocardial infarction due to late-phase stent thrombosis.
4.3. 0-0-1 lesions
The present study found worse clinical outcomes in 0-0-1 lesions,
despite complete imaging guidance. Previous IVUS studies demon­
strated that SB ostial lesions alone were rare (1 % of cases), and
consecutive atherosclerotic plaques were found in the proximal MV
[18]. Although angiography did not reveal significant MV stenosis,
imaging revealed mild-to-moderate plaques. The treatment approach for
0-0-1 lesions was similar to that for true CBLs, including higher rates of
MV crossover stenting (91 % vs. 100 % true CBLs), SB stenting (18 % vs.
13 %), two-stenting (9 % vs. 13 %), and SB dilation (86 % vs. 86 %).
These treatments aim to address the severity of myocardial ischaemia
induced by MV lesions and avoid adverse effects (MV compromise and
SB stent protrusion into the MV ostium). Compared with other non-true
CBLs, 0-0-1 lesions exhibited higher frequencies of SB stenting (18 % vs.
2 %) and two-stenting (9 % vs. 2 %). These are characterised by
fibrocalcific plaques and negative remodelling [19], leading to limited
lumen gain and an increased risk of recoil after dilation. Rheological
turbulence in the SB ostium contributes to low shear stress [20], pro­
moting neointimal hyperplasia and thrombotic events. Hinge motion of
the SB ostium further increases the risk of stent fracture and reactive
intimal hyperplasia [21].
The e-Ultimaster study showed an elevated risk of cardiac death with
0-0-1 lesions (HR = 4.6) [7], whereas the present study observed no
cardiac death. Complete imaging guidance facilitated optimal device
and procedure selection and reduced unnecessary treatments such as
two-stenting (9 % vs. 27 %) [7]. While elective two-stenting has limited
superiority in complex true CBLs [5,6,17,22], it should generally be
avoided in 0-0-1 lesions, except when accompanied by diffuse lesions or
severe dissection in the MV.
Preventing the overtreatment of 0-0-1 lesions is crucial. In a previous
study, computed tomography showed that SB with a perfusion territory
> 10 % of the left ventricle, indicating the superiority of PCI over
medical therapy, was 21 % for non-LM bifurcations and 96 % for LM
bifurcations.[23]. Discordance between angiographically significant
stenosis in stent-jailed SBs and physiological assessment is common
(27–29 %), highlighting the usefulness of physiological assessment for
avoiding unnecessary additional SB treatment [24].
Crossover stenting from the proximal MV to the SB, followed by use
of POT and KBI, is a reasonable treatment option [25]. However, there is
a higher TLR rate for LM-LCX crossover stenting compared with LM-LAD
stenting (18.2 % vs. 3.0 %) [26]. Wide bifurcation angles and dynamic
hinge motion in the LM bifurcation may have contributed to this

5
Y. Murasato et al.
outcome. Another treatment option involves stent deployment by nail­
ing the SB ostium, but this carries the risk of missing an SB ostial lesion
or protruding into the MV ostium. Precise identification of the SB ostium
during imaging and fluoroscopic recording enhances the accuracy of
stent positioning. However, this procedure remains challenging because
of cardiac motion, patient breathing, and stent migration caused by the
distal balloon contact with the vessel. Stent nailing for LAD ostial lesions
has been associated with higher rates of target vessel revascularization
than those associated with LM-LAD crossover stenting (21.0 % vs. 5.6 %,
respectively) [27].
Although not examined in this study, previous studies have sug­
gested the efficacy of drug-coated balloon (DCB) treatment in SB. The
DEBSIDE trial observed a lower late lumen loss in the SB (-0.04 ± 0.34
mm) at 6-month follow-up angiography when 50 patients received DES
in the MV and DCB treatment in the SB [28]. In a randomised trial
(PEPCAD-BIF) involving 64 patients with branch ostial lesions (0-1-0 or
0-0-1 lesions), DCB treatment demonstrated a significantly lower late
lumen loss (0.13 mm vs. 0.51 mm) and restenosis rate (6 % vs. 26 %)
compared with plain balloon angioplasty [29]. However, among the 49
patients with 0-0-1 lesions who were treated with DCB after cutting
balloon dilation, the target lesion failure rate at 1-year follow-up was 14
%[30], which was relatively higher than that observed in other studies
where DCB treatment was used for other CBL subsets. Whether DCB
treatment can effectively address the specific characteristics of 0-0-1
lesions remains unclear.
4.4. Medina classification in imaging-guided PCI
Angiography-based Medina classification is invaluable for the swift
evaluation of CBL distribution and stratification of PCI procedure. The
most complex true CBLs (1-1-1 lesions) more frequently necessitated
two-stent deployment and SB dilation. Nonetheless, the precise evalu­
ation of pre-PCI imaging mitigated potential overestimations and sub­
sequent overtreatment resulting from ambiguous angiographic findings
in CBLs. Procedural imaging guidance enabled more optimal PCI, which
ultimately led to a decreased risk of MACE and TLR in true CBLs, as well
as in non-true CBLs other than 0-0-1 lesions. This contrasts with previous
studies that used limited imaging. Even with imaging guidance, 0-0-1
lesions continued to exhibit a higher risk of MACE and TLR, warrant­
ing further investigation into management and outcomes for these
lesions.
4.5. Study limitations
The study included three nonrandomised trials, so the selection of
the lesion and interventional treatment included some bias. The SB
dilation methods varied among the trials. The identification of the
Medina classification on baseline angiography may have been influ­
enced by on-site imaging observations. SB stenosis after MV stenting was
assessed only by visual estimation on angiography and not by physio­
logical assessment. Patients undergoing SB or distal MV ostial stenting
were excluded from the study. Clinical outcomes at long-term follow-up
have not yet been investigated.
5. Conclusions
Imaging-guided bifurcation stenting yields the highest and lowest
MACE/TLR rates in 0-0-1 and 0-1-0 lesions, respectively. Imaging
guidance improves clinical outcomes for complex CBLs and leads to
comparable outcomes for true and non-true CBLs, except for 0-0-1 le­
sions. Even with the aid of imaging guidance, 0-0-1 lesions have a higher
risk of MACE and TLR similarly treated as in true CBLs.
CRediT authorship contribution statement
Yoshinobu Murasato: Conceptualization, Writing – original draft,
6
IJC Heart & Vasculature 49 (2023) 101311
Formal analysis, Data curation, Funding acquisition. Yoshihisa
Kinoshita: Investigation, Funding acquisition, Writing – review &
editing. Masahiro Yamawaki: . Takayuki Okamura: Investigation,
Formal analysis, Data curation, Writing – review & editing. Ryoji
Nagoshi: Investigation, Formal analysis, Data curation, Writing – re­
view & editing. Yusuke Watanabe: Investigation, Formal analysis, Data
curation, Writing – review & editing. Nobuaki Suzuki: Investigation,
Formal analysis, Data curation, Writing – review & editing. Takahiro
Mori: Investigation, Formal analysis, Writing – review & editing.
Toshiro Shinke: Investigation, Formal analysis, Writing – review &
editing. Junya Shite: Investigation, Formal analysis, Writing – review &
editing, Funding acquisition. Ken Kozuma: Investigation, Formal
analysis, Writing – review & editing, Funding acquisition.
Declaration of Competing Interest
The authors declare the following financial interests/personal re­
lationships which may be considered as potential competing interests: Y.
Murasato has received speaker fees from Abbott Medical, Medtronic,
Terumo, and Kaneka. N. Suzuki has received speaker fees from Abbott
Medical, Actelion Pharmaceuticals, Astellas, Astellas-Amgen, Bayer
Healthcare Pharmaceuticals, Boston Scientific, Bristol Myers Squibb,
Daiichi Sankyo, Nipro, Otsuka, Sanofi and Toa Eiyo. T. Okamura and J.
Shite have received honoraria for technical consulting from Abbott
Medical. K. Kozuma received lecture fees from Boston Scientific, Abbott
Medical, Medtronic, Otsuka, Takeda, Daiichi-Sankyo, Amgen, Novartis,
Behringer, Bayer, Life Science Institute, Mochida, and Zeon Medical, and
research grants from Boston Scientific and Abbott Medical. The other
authors have no conflicts of interest to declare.
Acknowledgments
None.
Funding
J-REVERSE was supported by unrestricted research grants from
Abbott Vascular, Cordis Corporation, Orbus Neich, and Kaneka Corpo­
ration. 3D-OCT Bifurcation Registry was supported by an unrestricted
research grant from Abbott Vascular. PROPOT was funded by Medtronic
Japan.
Appendix A. Supplementary material
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ijcha.2023.101311.
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