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Table 1.  

Complex Coronary Lesions Subsets: Technical Challenges and Approaches


Stenting of Complex Lesions: an Overview

  • Authors: Usman Baber, MD; Annapoorna S. Kini, MD; Samin K. Sharma, MD
  • CME Released: 8/24/2010
  • Valid for credit through: 8/24/2011, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for cardiologists, cardiovascular surgeons, interventional radiologists, and other health professionals caring for patients with complex CAD lesions requiring revascularization.

The goal of this activity is to describe percutaneous stenting techniques applicable to specific complex lesions in patients with CAD and to help clinicians decide on the optimal approach for each patient based on their angiographic characteristics, including the anatomy and location of these lesions.

Upon completion of this activity, participants will be able to:

  1. Describe prognosis and management in patients with bifurcation lesions on coronary angiography.
  2. Describe use of the SYNTAX score to risk-stratify and to identify the optimal revascularization approach for patients with complex CAD.


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  • Usman Baber, MD

    Cardiology Fellow, Mount Sinai Hospital, New York, NY


    Disclosure: Usman Baber, MD, has disclosed no relevant financial relationships.

  • Annapoorna S. Kini, MD

    Associate Professor of Medicine, Cardiology; Director, Interventional Cardiology Fellowship; Associate Director, Cath Lab, Mount Sinai Hospital, New York, NY


    Disclosure: Annapoorna S. Kini, MD, has disclosed no relevant financial relationships.

  • Samin K. Sharma, MD

    Professor of Medicine, Cardiology; Director, Cardiac Cath Lab and Intervention, Mount Sinai Hospital, New York, NY


    Disclosure: Samin K. Sharma, MD, has disclosed no relevant financial relationships.


  • Bryony Mearns, PhD

    Chief Editor, Nature Reviews Cardiology


    Disclosure: Bryony Mearns, PhD, has disclosed no relevant financial relationships.

CME Author(s)

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

  • Laurie E. Scudder, DNP, NP

    CME Accreditation Coordinator, Medscape, LLC


    Disclosure: Laurie E. Scudder, DNP, NP, has disclosed no relevant financial relationships.

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Stenting of Complex Lesions: an Overview

Authors: Usman Baber, MD; Annapoorna S. Kini, MD; Samin K. Sharma, MDFaculty and Disclosures

CME Released: 8/24/2010

Valid for credit through: 8/24/2011, 11:59 PM EST


Abstract and Introduction


Contemporary management of coronary artery disease relies increasingly on percutaneous techniques combined with medical therapy. Although percutaneous coronary intervention (PCI) can be performed successfully in most lesions, several difficult lesion subsets continue to present unique technical challenges. These complex lesions may be classified according to anatomic criteria, including extensive calcification, thrombus, and chronic occlusions, or by location, such as bifurcations, saphenous vein grafts and unprotected left main. PCI of these lesions often requires novel devices, such as drug-eluting stents, hydrophilic guidewires, distal protection balloons or filters, thrombectomy catheters, rotational atherectomy, and cutting balloons. An integrated approach that combines these devices with specialized techniques and adjunctive pharmacologic agents has greatly improved PCI success rates for these complex lesions.


The catheter-based treatment of coronary artery disease (CAD) has advanced substantially over the past 40 years and is currently a safe, reliable and effective therapeutic option for the millions of patients with Cad worldwide. Combined with medical therapy, percutaneous coronary intervention (PCI) reduces anginal symptoms and improves ischemia.[1,2] In select patients, particularly those with acute ST-segment elevation myocardial infarction (STEMI), primary PCI also prolongs survival.[3] The applicability of PCI to patients with CAD continues to expand, with recent data suggesting clinical equipoise between PCI and CABG surgery in complex coronary anatomy, including ostial or mid-shaft left main CAD.[4] These benefits notwithstanding, certain lesion subsets present unique challenges to the interventional cardiologist and are still associated with high rates of restenosis, technical difficulty, and procedural complications.[5] Successful PCI of these complex lesions requires advanced techniques, approaches, or adjunctive devices, and is usually performed by experienced operators at high-volume centers. In this Review, we outline the difficulties and contemporary interventional techniques utilized for six types of complex lesion ( Table 1 ).