Jailed high-pressure balloon technique is superior to jailed wire technique in protecting side branch of coronary bifurcation lesions

Figures & data

Figure 1. Our study consecutively enrolled 254 patients with bifurcation lesions at the Second Hospital of Tianjin Medical University, Tianjin, China (between March 2019 and December 2022). Exclusion criteria included left main stem lesion, chronic total occlusion and the bifurcation lesions were considered unsuitable for quantitative coronary angiographic analysis according to CAG. Finally, 216 cases with non-left main bifurcation lesions were defined as the study subjects.

Figure 2. The procedure of the modified active jailed balloon technique. (a) Two guidewires were introduced into both the MV and the SB. (b) The MV was pre-dilated with a balloon first. The MV stent was placed to the distal of the bifurcation lesion before the jailed balloon was placed in SB. (c) The MV stent was withdrawn to an appropriate position that could cover the MV lesion, and the mid-segment of the jailed balloon was adjusted to be located at the ridge of the lesion. (d) The SB balloon was inflated, and the position of the stent was verified by angiography. (e) The MV stent was then inflated. (f) The MV stent balloon was deflated. (g) The jailed balloon was deflated. (h) The MV stent balloon was re-inflated to make the stent appose the vessel wall.

Table 1. Demographic and clinical characteristics of the study patients.

Patient characteristics	A-JBT N = 105	JWT N = 111	p Value
Male	80 (76.2%)	86 (77.5%)	.823
Age, years	64.47 ± 9.33	66.59 ± 10.30	.117
Diabetes mellitus	35 (33.3%)	35 (31.5%)	.777
Hypertension	76 (72.4%)	71 (64.0%)	.185
Dyslipidemia	17 (16.2%)	15 (13.5%)	.580
Chronic kidney disease	24 (22.9%)	20 (18.0%)	.377
Hyperuricemia	6 (5.7%)	5 (4.5%)	.686
Atrial fibrillation	8 (7.6%)	6 (5.4%)	.509
Cerebrovascular disease	21 (20.0%)	23 (20.7%)	.895
Peripheral artery disease	3 (2.9%)	5 (4.5%)	.522
History of smoking	52 (49.5)	54 (48.6%)	.898
Previous PCI	31 (29.5%)	29 (26.1%)	.577
Previous coronary bypass	1 (1.0%)	0 (0%)	.978
Previous myocardial infarction	20 (19.0%)	24 (21.6%)	.639
Cardiogenic shock on admission	0 (0)	0 (0)
Cardiopulmonary arrest on admission	0 (0)	0 (0)
LVEF, (%)	69 (49, 64)	60 (52, 63)	.679
Clinical diagnosis			.199
UA	63 (60.0%)	79 (71.2%)
STEMI	12 (11.4%)	13 (11.7%)
NSTEMI	27 (25.7%)	18 (16.2%)
SCAD	1 (1.0%)	1 (0.9%)
LCHD	2 (1.9%)	0 (0)
Target vessel			.681
LAD/diagonal	82 (78.1%)	81 (73.0%)
LCX/OM	19 (18.1%)	25 (22.5%)
RCA bifurcation	4 (3.8%)	5 (4.5%)
Medina classification			.906
True bifurcation
1.1.1	69 (65.7%)	69 (62.2%)
1.0.1	16 (15.2%)	18 (16.2)
0.1.1	14 (13.3%)	19 (17.1%)
Nontrue bifurcation
1.1.0	4 (3.8%)	4 (3.6%)
0.0.1	2 (1.9%)	1 (0.9%)
1.0.0	0 (0)	0 (0)
0.1.0	0 (0)	0 (0)
Bifurcation angle			.379
<30°	12 (11.4%)	8 (7.2%)
30°–60°	72 (68.6%)	74 (66.7%)
>60°	21 (20.0%)	29 (26.1%)

A-JBT: active jailed balloon technique; JWT: jailed wire technique; LAD: left anterior descending artery; LCX: left circumflex artery; RCA: right coronary artery; TIMI: thrombolysis in myocardial infarction; LVEF: left ventricular ejection fraction; MI: myocardial infarction; NSTEMI: non-ST-elevation myocardial infarction; PCI: percutaneous coronary intervention; SA: stable angina; STEMI: ST-elevation myocardial infarction; UA: unstable angina; LCHD: latent coronary heart disease.

Data presented as mean ± standard deviation or n (%).

Table 2. QCA analysis of targeted lesions in the initial and final angiography.

	JBT N = 105	JWT N = 111	p Value
Preoperative
MB LL (mm)	23.96 ± 10.52	23.13 ± 9.12	.538
The proximal of main-branch
MV RVD (mm)	3.68 ± 0.86	3.70 ± 0.78	.808
MV SVD (mm)	1.74 ± 1.12	1.80 ± 1.00	.694
MV DS (%)	53.56 ± 26.55	51.61 ± 23.46	.566
Pre-dilation SD (mm)	2.28 ± 1.04	2.26 ± 0.82	.914
Pre-dilation MV DS (%)	38.54 ± 23.05	38.24 ± 19.39	.916
The distal of main-branch
MV RVD (mm)	3.25 ± 0.70	3.11 ± 0.63	.126
MV SVD (mm)	1.37 ± 0.92	1.40 ± 0.66	.798
MV DS (%)	58.61 ± 24.45	54.57 ± 19.84	.185
Pre-dilation SD (mm)	1.81 ± 0.82	1.79 ± 0.59	.865
Pre-dilation MV DS (%)	43.83 ± 21.24	41.50 ± 17.83	.383
SB LL (mm)	7.26 ± 1.93	6.73 ± 3.11	.134
SB RVD (mm)	2.83 ± 0.64	2.65 ± 0.73	.057
SB SVD (mm)	1.15 ± 0.74	1.18 ± 0.59	.695
SB DS (%)	60.40 ± 21.32	55.57 ± 18.50	.076
Postoperative
The proximal of main-branch
MV RVD (mm)	4.03 ± 0.78	3.94 ± 0.64	.375
MV SVD (mm)	3.65 ± 0.78	3.42 ± 0.64	.022*
MV DS (%)	9.49 ± 9.04	12.86 ± 10.32	.011*
The change in DS (%)	−29.42 ± 23.72	−25.38 ± 18.66	.167
The distal of main-branch
MV RVD (mm)	3.59 ± 0.66	3.46 ± 0.51	.102
MV SVD (mm)	3.27 ± 0.69	3.07 ± 0.59	.025*
MV DS (%)	9.11 ± 7.85	11.43 ± 8.00	.032*
The change in DS (%)	−34.28 ± 21.99	−30.07 ± 18.99	.137
SB RVD (mm)	2.72 ± 0.63	2.58 ± 0.56	.108
SB SVD (mm)	1.53 ± 0.69	0.95 ± 0.52	<.001*
SB DS (%)	44.34 ± 18.30	63.69 ± 17.34	<.001*
The change in DS (%)	−16.06 ± 22.48	8.12 ± 17.15	<.001*

A-JBT: active jailed balloon technique; JWT: jailed wire technique; DS: diameter stenosis; LL: lesion length; MLD: minimal lumen diameter; QCA: quantitative coronary angiography; RVD: reference vessel diameter; DS: diameter stenosis; LL: lesion length; MV: main vessel; RVD: reference vessel diameter; SB: side branch.

Change in DS (%): postoperative diameter stenosis (%) − preoperative diameter stenosis (%).

* p < 0.05 vs. control.

Table 3. The characteristics of stent and balloon.

	A-JBT N = 105	JWT N = 111	p Value
MV predilation balloon diameter (mm)	2.00 (2.00, 2.50)	2.00 (2.00, 2.50)	.028*
MV predilation balloon length (mm)	20.00 (16.00, 20.00)	16.00 (15.00, 20.00)	<.001*
MV predilation balloon inflation pressure (atm)	12.59 ± 3.06	10.86 ± 2.89	<.001*
MV stent diameter (mm)	3.00 (2.75, 3.50)	3.00 (2.75, 3.00)	.002*
MV stent length (mm)	24.00 (21.00, 33.00)	24.00 (21.00, 29.00)	.844
MV stent inflation pressure (atm)	10.04 ± 2.12	10.27 ± 2.39	.461
SB jailed balloon diameter (mm)	2.00 (1.50, 2.00)
SB jailed balloon length (mm)	16.00 (16.00, 20.00)
SB jailed balloon inflation pressure (atm)	12.87 ± 1.67
Operation time (min)	29.26 ± 13.32	31.76 ± 15.06	.199

A-JBT: active jailed balloon technique; JWT: jailed wire technique; SB: side branch; MV: main vessel; atm: standard atmospheric pressure.

* p < .05 vs. control.

Table 4. Medications and laboratory test results during hospitalization.

	A-JBT N = 105	JWT N = 111	p Value
Antiplatelet drugs			.524
Aspirin + clopidogrel	86 (81.9%)	86 (77.5%)
Aspirin + tigecycline	15 (14.3%)	17 (15.3%)
Indobufen + clopidogrel	4 (3.8%)	8 (7.2%)
Stain	103 (98.1%)	107 (96.4%)	.730
Etizolam	21 (20.0%)	23 (20.7%)	.895
Acipimox	15 (14.3%)	12 (10.8%)	.440
β-blocker	41 (39.0%)	56 (50.0%)	.092
ACEI/ARB	45 (42.9%)	58 (52.3%)	.167
Preoperative heparin	20 (19.0%)	31 (27.9%)	.125
Postoperative heparin	97 (92.4%)	99 (89.2%)	.419
LDL-C (mmol/L)	2.45 ± 1.06	2.70 ± 1.02	.136
cTNT (0–0.15 ng/ml)	29 (27.6%)	30 (27.0%)	.922
D-dimer (0–500 μg/L)	31 (29.5%)	34 (30.6%)	.859
NT-proBNP (0–300 ng/ml)	49 (46.7%)	40 (30.6%)	.113
CK (0–178 U/L)	14 (13.3%)	10 (9.0%)	.312
CK-MB (0–16 U/L)	25 (23.8%)	18 (16.2%)	.162

A-JBT: active jailed balloon technique; JWT: jailed wire technique; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; LDL-C: low-density lipoprotein cholesterol; cTNT: cardiac troponin T; NT-proBNP: N-terminal pro-brain natriuretic peptide; CK: creatine kinase; CK-MB: creatine kinase-M.

Table 5. Procedural outcomes of A-JBT and JWT.

	A-JBT N = 105	JWT N = 111	p Value
Guide catheter			.719
6F	91 (86.7%)	98 (88.3%)
7F	14 (13.3%)	13 (11.7%)
Arterial puncture
Radial artery	105 (100%)	111 (100%)
Femoral artery	0	0
IVUS	9 (8.6%)	5 (4.5%)	.225
Dominant coronary artery			.720
Right dominance	87 (82.9%)	89 (80.2%)
Left dominance	10 (9.5%)	10 (9.0%)
Balanced type	8 (7.6%)	12 (10.8%)
Procedural success	105 (100%)	111 (100%)
SB dissection	0 (0)	4 (3.6%)	.145
SB pre-dilatation	8 (7.6%)	9 (8.1%)	.894
SB occlusion	2 (1.9%)	20 (18.0%)	<.001*
SB dropout	0 (0)	5 (4.5%)	.081
GW entrapment	0	0
GW recross	26 (24.8%)	22 (19.8%)	.383
SB post-dilatation	0 (0)	24 (21.6%)	<.001*
SB provisional stenting	0	0
BKST	25 (23.8%)	13 (11.7%)	.02*
MV stent post-dilatation	84 (80.0%)	77 (69.4%)	.073
Periprocedural MI	0	0
In hospital MACE	1 (1.0%)	0 (0)	.978
Stent			.318
Excrossal	15 (14.3%)	18 (16.2%)
Lepu	11 (10.5%)	9 (8.1%)
Firebird	37 (35.2)	50 (45.0%)
GuReater	26 (24.8%)	16 (14.4%)
Resolute	16 (15.2%)	18 (16.2%)

BSKT: balloon-stent kissing technique; A-JBT: active jailed balloon technique; JWT: jailed wire technique; MACE: major adverse cardiac event; MI: myocardial infarction; GW: guidewire; MV: main vessel; SB: side branch; IVUS: intravascular ultrasound.

* p < .05 vs. control.

Table 6. Univariable and multivariable analyses for SB occlusion.

	Univariable		Multivariable
	OR [95%CI]	p Value	OR [95%CI]	p Value
The proximal of main-branch MV DS (%) ≥55.88	3.40 [1.33–8.73]	.011*	3.25 [1.11–9.53]	.032*
The distal of main-branch MV DS (%) ≥83.63	2.42 [0.81–7.24]	.113
SB LL ≥8.62 mm	2.36 [0.89–6.26]	.084	4.55 [1.37–15.14]	.013*
SB RVD ≤2.51 mm	2.54 [1.02–6.34]	.045*
SB MLD ≤0.64 mm	4.77 [1.92–11.85]	.001*	4.85 [1.68–14.02]	.004*
Bifurcation angle ≥45.3°	3.79 [1.23–11.68]	.02*	5.62 [1.59–19.84]	.007*

A-JBT: active jailed balloon technique; JWT: jailed wire technique; DS: diameter stenosis; LL: lesion length; MLD: minimal lumen diameter; RVD: reference vessel diameter; CI: confidence interval; OR: odds rat.

* p < .05 vs. control.

Figure 3. A PCI procedure was performed on a 67-year-old male patient with a bifurcation lesion in the mid-segment of the left circumflex artery. (a) The CAG displayed that was a true bifurcation of the LCX/OM. (b) The stent (3.5 mm × 20 mm) was withdrawn to an appropriate position that cover the MV lesion, and the mid-segment of the jailed balloon (1.5 mm × 16 mm) was adjusted to be located at the ridge of the lesion. (c) The MV stent was inflated at 8 atm and the jailed balloon was inflated at 11 atm. (d) The MV stent balloon was deflated. (e) The MV stent balloon was re-inflated to make the stent appose the vessel wall. (f) The diameter stenosis of the side branch had a significant improvement.

Figure 4. Diagram of bifurcation lesion.