Bifurcations – What Have we Learned from Randomised Trials?

Abstract

In percutaneous coronary intervention, bifurcations are a challenging lesion subset and treatment results are dependent on lesion assessment and operator experience. In recent years, a number of well designed and performed randomised clinical trials have dealt with different aspects of the bifurcation lesion procedure. Results from these trials may be helpful in planning a successful bifurcation treatment. Balloon angioplasty and use of bare metal stents are associated with high rates of restenosis in bifurcation lesions. Drug-eluting stents reduce restenosis in these procedures to levels close to non-bifurcation lesion treatment and should be used, if possible. It may be recommended to use the simple strategy of optional stenting of the side branch. The fundamental safety and efficacy of this strategy has been extensively documented in a number of randomised clinical trials. Typically, this strategy may be implemented as the so called ‘step-by-step approach’. However, using drug-eluting stents, also two-stent bifurcation treatment using the culotte or different T-stenting techniques or crush techniques, are associated with excellent short- and long-term results. When two-stent techniques are used, the procedure should always be finalised with a kissing balloon dilatation. However, in the one-stent bifurcation treatment, kissing balloon dilation does not seem to be mandatory, but may be recommended in genuine bifurcations. It must be borne in mind that the general applicability of randomised clinical trials may be limited by inclusion of selected patients. Using drug-eluting stents and a variety of stenting techniques, the randomised bifurcation trails have documented excellent clinical results in the treatment of this complex lesion subset. Therefore, the results from these trials leave room for operator judgement in the selection of the specific bifurcation treatment based on patient and lesion characteristics and personal experience.