Contemporary treatment of coronary artery disease is highly dependent on percutaneous coronary intervention (PCI) along with medical management. PCI techniques have advanced significantly over time and are used to stent even difficult lesions. There are, however, some lesions which present challenges via conventional PCI route. These lesions, termed complex coronary lesions are categorized as such based upon various anatomic, physiological, or functional difficulties.
Some of these complex lesions in coronary vessels include bifurcation lesion, calcified lesions, chronic total occlusions, unprotected left main coronary artery lesions, ostial lesions, or stenosis of the saphenous vein graft.[1] Each of these lesions presents unique challenges and approach to such lesions is individualized. Specialized techniques, as well as cardiologists with more advanced skill sets, have improved successful treatment of such lesions.[2]
Conventional PCI may not adequately resolve these lesions, and some may require advanced techniques. One such subset of advanced catheter oriented interventions is termed: complex high-risk and indicated PCI (CHIP). Such techniques are reserved for individuals who are very high risk for complications. Examples of these techniques include laser, rotational, and laser atherectomy, various bifurcation stenting techniques, and specialized approaches to chronic total occlusions.[3] These techniques are promising; however, studies are inconclusive if they have a positive impact on mortality. Some studies such as one from Habib et al. cite CABG as a more effective modality towards addressing these lesions.[4]
A brief explanation of some of the most common complex lesions follows.
Each complex coronary artery lesion has a unique set of etiologies. For example, bifurcation lesions are primarily anatomic-based.[11] Coronary artery calcifications can result from inherent inflammatory processes, as well as the activity of osteoblastic activity.[12] Presence of thrombus can often result from plaque disruption before or during PCI.[13] Saphenous vein graft occlusion is thought to be a process of intimal vessel smooth muscle proliferation.[14] There are disease processes which are common to each disorder. For example, Baris et al. identified diabetes mellitus and advanced age as independent predictors for all complex coronary lesions.[15] Each process has an individual process which contributes to its etiology. Other risk factors for coronary artery disease and atherosclerosis such as age, hypertension, obesity, male sex, smoking, and hypercholesterolemia can be inferred, but have not directly been identified in any significant studies as independent risk factors for all complex lesions.
Coronary bifurcation lesions are the most common of the complex coronary lesions. Some estimates have reported that these are found in up to 20% of all PCI’s.[16]
Most individuals with these lesions present similarly. The most common presentation is with angina pectoris given the occlusive nature of these coronary processes. Essential history elements include evaluating for risk factors of coronary artery disease. It is crucial to ask the patient questions regarding the history of any form of vascular disease, family history of heart disease, obesity, diabetes, hypertension, age, hyperlipidemia, and smoking history. Some of the most common symptoms of these lesions include:
Physical examination findings will vary based upon the status of the patient’s disease. Individuals can have chronic coronary artery disease or an acute unstable plaque, and their physical exam findings will manifest in completely different ways. Thus, it is important to evaluate each case distinctly when doing a physical exam. Some items to look for in the physical exam include:
Evaluation should include:
Treatment of primary coronary lesions varies with type:
Complex coronary lesions carry higher overall mortality in patients with stable angina than those with non-complex lesions. These complex lesions are often associated with diabetes, lower ventricular ejection fraction, lower HDL-C. The SYNTAX Score and SYNTAX Score II are frequently the means to decide on the best revascularization approach. Studies have shown SYNTAX Score II to be superior to the SYNTAX score as a tool of prognosis. The 4-year mortality showed an adequate correlation between score and mortality in patients with low and medium SYNTAX Score II, however, found that a high SYNTAX Score II underestimated mortality at four years.[52]
Patients should be active participants in their care. Given the morbidity and mortality involved with complex coronary lesions, providers should actively discuss the management of these lesions as well as all possible options and the potential complications associated with them. Medical, interventional, as well as surgical options, should be discussed with these individuals.
Management of complex coronary artery lesions requires an interprofessional team approach. Emergency medical personnel are often first responders and must be able to adequately screen for acute coronary syndromes. Nurses must be able to effectively recognize symptoms and decompensation of these patients at the bedside. Nurses and pharmacists are also needed to prepare, dispense, and efficiently administer various medications which may be necessary during these processes. Cath lab staff also play an essential role. Cath lab techs, as well as nurses, must be readily available to efficiently and effectively deliver care when acute coronary syndromes occur. And of course, interventional cardiologists play a vital role. Interventional cardiologists must be readily available to diagnose and treat those with complex coronary lesions. At times, interventional cardiologists may need to utilize advanced techniques in high-risk patients.
[1] | Wilensky RL,Selzer F,Johnston J,Laskey WK,Klugherz BD,Block P,Cohen H,Detre K,Williams DO, Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry). The American journal of cardiology. 2002 Aug 1; [PubMed PMID: 12127606] |
[2] | Baber U,Kini AS,Sharma SK, Stenting of complex lesions: an overview. Nature reviews. Cardiology. 2010 Sep; [PubMed PMID: 20725106] |
[3] | Tomey MI,Kini AS,Sharma SK, Current status of rotational atherectomy. JACC. Cardiovascular interventions. 2014 Apr; [PubMed PMID: 24630879] |
[4] | Habib RH,Dimitrova KR,Badour SA,Yammine MB,El-Hage-Sleiman AK,Hoffman DM,Geller CM,Schwann TA,Tranbaugh RF, CABG Versus PCI: Greater Benefit in Long-Term Outcomes With Multiple Arterial Bypass Grafting. Journal of the American College of Cardiology. 2015 Sep 29; [PubMed PMID: 26403338] |
[5] | Medina A,Suárez de Lezo J,Pan M, [A new classification of coronary bifurcation lesions]. Revista espanola de cardiologia. 2006 Feb; [PubMed PMID: 16540043] |
[6] | Demer LL,Tintut Y, Vascular calcification: pathobiology of a multifaceted disease. Circulation. 2008 Jun 3; [PubMed PMID: 18519861] |
[7] | Kalra SS,Shanahan CM, Vascular calcification and hypertension: cause and effect. Annals of medicine. 2012 Jun; [PubMed PMID: 22713153] |
[8] | Ramadan R,Boden WE,Kinlay S, Management of Left Main Coronary Artery Disease. Journal of the American Heart Association. 2018 Mar 31; [PubMed PMID: 29605817] |
[9] | Pritchard CL,Mudd JG,Barner HB, Coronary ostial stenosis. Circulation. 1975 Jul; [PubMed PMID: 1132121] |
[10] | Piana RN,Moscucci M,Cohen DJ,Kugelmass AD,Senerchia C,Kuntz RE,Baim DS,Carrozza JP Jr, Palmaz-Schatz stenting for treatment of focal vein graft stenosis: immediate results and long-term outcome. Journal of the American College of Cardiology. 1994 May; [PubMed PMID: 8176086] |
[11] | Benezet J,Agarrado A,Oneto J, Treatment of a Coronary Bifurcation Lesion Using One Dedicated Sirolimus Eluting Bifurcation Stent in Combination with a Bioresorbable Vascular Scaffold: A Novel Option for Coronary Bifurcation Approach. Case reports in cardiology. 2016; [PubMed PMID: 27066276] |
[12] | Karwowski W,Naumnik B,Szczepański M,Myśliwiec M, The mechanism of vascular calcification - a systematic review. Medical science monitor : international medical journal of experimental and clinical research. 2012 Jan; [PubMed PMID: 22207127] |
[13] | Srikanth S,Ambrose JA, Pathophysiology of coronary thrombus formation and adverse consequences of thrombus during PCI. Current cardiology reviews. 2012 Aug; [PubMed PMID: 22920487] |
[14] | Bryan AJ,Angelini GD, The biology of saphenous vein graft occlusion: etiology and strategies for prevention. Current opinion in cardiology. 1994 Nov; [PubMed PMID: 7819622] |
[15] | Baris N,Akdeniz B,Uyar S,Ozel E,Kirimli O,Badak O,Aslan O,Guneri S, Are complex coronary lesions more frequent in patients with diabetes mellitus? The Canadian journal of cardiology. 2006 Sep; [PubMed PMID: 16971978] |
[16] | Collins N,Seidelin PH,Daly P,Ivanov J,Barolet A,Mackie K,Bui S,Schwartz L,Dzavík V, Long-term outcomes after percutaneous coronary intervention of bifurcation narrowings. The American journal of cardiology. 2008 Aug 15; [PubMed PMID: 18678296] |
[17] | Eggen DA,Strong JP,McGill HC Jr, Coronary calcification. Relationship to clinically significant coronary lesions and race, sex, and topographic distribution. Circulation. 1965 Dec; [PubMed PMID: 5845254] |
[18] | Tejada C,Strong JP,Montenegro MR,Restrepo C,Solberg LA, Distribution of coronary and aortic atherosclerosis by geographic location, race, and sex. Laboratory investigation; a journal of technical methods and pathology. 1968 May; [PubMed PMID: 5681195] |
[19] | Goel M,Wong ND,Eisenberg H,Hagar J,Kelly K,Tobis JM, Risk factor correlates of coronary calcium as evaluated by ultrafast computed tomography. The American journal of cardiology. 1992 Oct 15; [PubMed PMID: 1414915] |
[20] | Fefer P,Knudtson ML,Cheema AN,Galbraith PD,Osherov AB,Yalonetsky S,Gannot S,Samuel M,Weisbrod M,Bierstone D,Sparkes JD,Wright GA,Strauss BH, Current perspectives on coronary chronic total occlusions: the Canadian Multicenter Chronic Total Occlusions Registry. Journal of the American College of Cardiology. 2012 Mar 13; [PubMed PMID: 22402070] |
[21] | Jeroudi OM,Alomar ME,Michael TT,El Sabbagh A,Patel VG,Mogabgab O,Fuh E,Sherbet D,Lo N,Roesle M,Rangan BV,Abdullah SM,Hastings JL,Grodin J,Banerjee S,Brilakis ES, Prevalence and management of coronary chronic total occlusions in a tertiary Veterans Affairs hospital. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography [PubMed PMID: 24142769] |
[22] | Chaitman BR,Bourassa MG,Davis K,Rogers WJ,Tyras DH,Berger R,Kennedy JW,Fisher L,Judkins MP,Mock MB,Killip T, Angiographic prevalence of high-risk coronary artery disease in patient subsets (CASS). Circulation. 1981 Aug; [PubMed PMID: 7249303] |
[23] | Ragosta M,Dee S,Sarembock IJ,Lipson LC,Gimple LW,Powers ER, Prevalence of unfavorable angiographic characteristics for percutaneous intervention in patients with unprotected left main coronary artery disease. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography [PubMed PMID: 16892431] |
[24] | Valdes PJ,Diaz MA, Vein Graft Stenosis 2019 Jan; [PubMed PMID: 29763122] |
[25] | Maynard SJ,Menown IB,Adgey AA, Troponin T or troponin I as cardiac markers in ischaemic heart disease. Heart (British Cardiac Society). 2000 Apr; [PubMed PMID: 10722528] |
[26] | Hwang C,Levis JT, ECG diagnosis: ST-elevation myocardial infarction. The Permanente journal. 2014 Spring; [PubMed PMID: 24867559] |
[27] | Kenigsberg DN,Khanal S,Kowalski M,Krishnan SC, Prolongation of the QTc interval is seen uniformly during early transmural ischemia. Journal of the American College of Cardiology. 2007 Mar 27; [PubMed PMID: 17394962] |
[28] | Lim YC,Teo SG,Poh KK, ST-segment changes with exercise stress. Singapore medical journal. 2016 Jul; [PubMed PMID: 27440279] |
[29] | Kotler JA,Stewart JM,Kurzon JD, Pharmacologic myocardial perfusion stress tests. Adenosine thallium stress test. The Journal of the Florida Medical Association. 1992 Jan; [PubMed PMID: 1548455] |
[30] | Topol EJ,Nissen SE, Our preoccupation with coronary luminology. The dissociation between clinical and angiographic findings in ischemic heart disease. Circulation. 1995 Oct 15; [PubMed PMID: 7554219] |
[31] | Van Mieghem CA,Thury A,Meijboom WB,Cademartiri F,Mollet NR,Weustink AC,Sianos G,de Jaegere PP,Serruys PW,de Feyter P, Detection and characterization of coronary bifurcation lesions with 64-slice computed tomography coronary angiography. European heart journal. 2007 Aug; [PubMed PMID: 17623681] |
[32] | Kulik A,Abreu AM,Boronat V,Ruel M, Intensive versus moderate statin therapy and early graft occlusion after coronary bypass surgery: The Aggressive Cholesterol Therapy to Inhibit Vein Graft Events randomized clinical trial. The Journal of thoracic and cardiovascular surgery. 2019 Jan; [PubMed PMID: 30122341] |
[33] | Dash D, An update on coronary bypass graft intervention. Heart Asia. 2014; [PubMed PMID: 27326165] |
[34] | Vermeersch P,Agostoni P,Verheye S,Van den Heuvel P,Convens C,Bruining N,Van den Branden F,Van Langenhove G, Randomized double-blind comparison of sirolimus-eluting stent versus bare-metal stent implantation in diseased saphenous vein grafts: six-month angiographic, intravascular ultrasound, and clinical follow-up of the RRISC Trial. Journal of the American College of Cardiology. 2006 Dec 19; [PubMed PMID: 17174178] |
[35] | Vermeersch P,Agostoni P,Verheye S,Van den Heuvel P,Convens C,Van den Branden F,Van Langenhove G, Increased late mortality after sirolimus-eluting stents versus bare-metal stents in diseased saphenous vein grafts: results from the randomized DELAYED RRISC Trial. Journal of the American College of Cardiology. 2007 Jul 17; [PubMed PMID: 17631219] |
[36] | Byrne RA,Joner M,Kastrati A, Stent thrombosis and restenosis: what have we learned and where are we going? The Andreas Grüntzig Lecture ESC 2014. European heart journal. 2015 Dec 14; [PubMed PMID: 26417060] |
[37] | Pan M,de Lezo JS,Medina A,Romero M,Segura J,Pavlovic D,Delgado A,Ojeda S,Melián F,Herrador J,Ureña I,Burgos L, Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy. American heart journal. 2004 Nov; [PubMed PMID: 15523318] |
[38] | Steigen TK,Maeng M,Wiseth R,Erglis A,Kumsars I,Narbute I,Gunnes P,Mannsverk J,Meyerdierks O,Rotevatn S,Niemelä M,Kervinen K,Jensen JS,Galløe A,Nikus K,Vikman S,Ravkilde J,James S,Aarøe J,Ylitalo A,Helqvist S,Sjögren I,Thayssen P,Virtanen K,Puhakka M,Airaksinen J,Lassen JF,Thuesen L, Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation. 2006 Oct 31; [PubMed PMID: 17060387] |
[39] | Ormiston JA,Webster MW,Webber B,Stewart JT,Ruygrok PN,Hatrick RI, The [PubMed PMID: 19463329] |
[40] | Porto I,van Gaal W,Banning A, [PubMed PMID: 16844850] |
[41] | Chen SL,Santoso T,Zhang JJ,Ye F,Xu YW,Fu Q,Kan J,Paiboon C,Zhou Y,Ding SQ,Kwan TW, A randomized clinical study comparing double kissing crush with provisional stenting for treatment of coronary bifurcation lesions: results from the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial. Journal of the American College of Cardiology. 2011 Feb 22; [PubMed PMID: 21329837] |
[42] | Chen SL,Zhang JJ,Han Y,Kan J,Chen L,Qiu C,Jiang T,Tao L,Zeng H,Li L,Xia Y,Gao C,Santoso T,Paiboon C,Wang Y,Kwan TW,Ye F,Tian N,Liu Z,Lin S,Lu C,Wen S,Hong L,Zhang Q,Sheiban I,Xu Y,Wang L,Rab TS,Li Z,Cheng G,Cui L,Leon MB,Stone GW, Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial. Journal of the American College of Cardiology. 2017 Nov 28; [PubMed PMID: 29096915] |
[43] | Iakovou I,Foin N,Andreou A,Viceconte N,Di Mario C, New strategies in the treatment of coronary bifurcations. Herz. 2011 May; [PubMed PMID: 21541738] |
[44] | Lee SW,Lee PH,Ahn JM,Park DW,Yun SC,Han S,Kang H,Kang SJ,Kim YH,Lee CW,Park SW,Hur SH,Rha SW,Her SH,Choi SW,Lee BK,Lee NH,Lee JY,Cheong SS,Kim MH,Ahn YK,Lim SW,Lee SG,Hiremath S,Santoso T,Udayachalerm W,Cheng JJ,Cohen DJ,Muramatsu T,Tsuchikane E,Asakura Y,Park SJ, Randomized Trial Evaluating Percutaneous Coronary Intervention for the Treatment of Chronic Total Occlusion: The DECISION-CTO Trial. Circulation. 2019 Feb 28; [PubMed PMID: 30813758] |
[45] | Olivari Z,Rubartelli P,Piscione F,Ettori F,Fontanelli A,Salemme L,Giachero C,Di Mario C,Gabrielli G,Spedicato L,Bedogni F, Immediate results and one-year clinical outcome after percutaneous coronary interventions in chronic total occlusions: data from a multicenter, prospective, observational study (TOAST-GISE). Journal of the American College of Cardiology. 2003 May 21; [PubMed PMID: 12767645] |
[46] | Carlino M,Azzalini L,Mitomo S,Colombo A, Antegrade fenestration and re-entry: A new controlled subintimal technique for chronic total occlusion recanalization. Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography [PubMed PMID: 29314567] |
[47] | Tanayama S,Tsuchida E,Suzuoki Z, Metabolism of 6-chloro-5-cyclohexylindane-1-carboxylic acid (TAI-284), a new non-steroidal anti-inflammatory agent. I. Absorption, distribution and excretion in rats. Xenobiotica; the fate of foreign compounds in biological systems. 1973 Oct; [PubMed PMID: 4774631] |
[48] | Fernandez JP,Hobson AR,McKenzie D,Shah N,Sinha MK,Wells TA,Levy TM,Swallow RA,Talwar S,O'Kane PD, Beyond the balloon: excimer coronary laser atherectomy used alone or in combination with rotational atherectomy in the treatment of chronic total occlusions, non-crossable and non-expansible coronary lesions. EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2013 Jun 22; [PubMed PMID: 23454891] |
[49] | Weintraub WS,Garratt KN, Should Chronic Total Occlusion Be Treated With Coronary Artery Bypass Grafting? Chronic Total Occlusion Should Not Routinely Be Treated With Coronary Artery Bypass Grafting. Circulation. 2016 May 3; [PubMed PMID: 27143549] |
[50] | Montalescot G,Sechtem U,Achenbach S,Andreotti F,Arden C,Budaj A,Bugiardini R,Crea F,Cuisset T,Di Mario C,Ferreira JR,Gersh BJ,Gitt AK,Hulot JS,Marx N,Opie LH,Pfisterer M,Prescott E,Ruschitzka F,Sabaté M,Senior R,Taggart DP,van der Wall EE,Vrints CJ,Zamorano JL,Achenbach S,Baumgartner H,Bax JJ,Bueno H,Dean V,Deaton C,Erol C,Fagard R,Ferrari R,Hasdai D,Hoes AW,Kirchhof P,Knuuti J,Kolh P,Lancellotti P,Linhart A,Nihoyannopoulos P,Piepoli MF,Ponikowski P,Sirnes PA,Tamargo JL,Tendera M,Torbicki A,Wijns W,Windecker S,Knuuti J,Valgimigli M,Bueno H,Claeys MJ,Donner-Banzhoff N,Erol C,Frank H,Funck-Brentano C,Gaemperli O,Gonzalez-Juanatey JR,Hamilos M,Hasdai D,Husted S,James SK,Kervinen K,Kolh P,Kristensen SD,Lancellotti P,Maggioni AP,Piepoli MF,Pries AR,Romeo F,Rydén L,Simoons ML,Sirnes PA,Steg PG,Timmis A,Wijns W,Windecker S,Yildirir A,Zamorano JL, 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. European heart journal. 2013 Oct; [PubMed PMID: 23996286] |
[51] | Karabulut A,Cakmak M, Treatment strategies in the left main coronary artery disease associated with acute coronary syndromes. Journal of the Saudi Heart Association. 2015 Oct; [PubMed PMID: 26557745] |
[52] | Misumida N,Ahmed AE,Barlow M,Goodwin R,Goodwin E,Musa A,Mathbout M,Ogunbayo G,Kim SM,Abdel-Latif A,Ziada KM, Prognostic Value of Anatomical SYNTAX Score and SYNTAX Score II in Veterans With Left Main and/or Three-Vessel Coronary Artery Disease. The American journal of cardiology. 2018 Jul 15; [PubMed PMID: 29866582] |
[53] | Antonsen L,Thayssen P,Jensen LO, Large coronary intramural hematomas: a case series and focused literature review. Cardiovascular revascularization medicine : including molecular interventions. 2015 Mar; [PubMed PMID: 25497372] |
[54] | McCormick LM,Ko BS,Zaman S,Ahmar W,Meredith IT, Persistent type III cavity-spilling coronary perforation due to covered stent malapposition. Cardiovascular intervention and therapeutics. 2016 Oct; [PubMed PMID: 26197781] |