Abstract
Objectives The aim of this study was to assess the clinical impact of 3 bifurcation angles in left main (LM) bifurcation treated with the 2-stent technique. Background Data are limited regarding the impact of bifurcation angles after LM percutaneous coronary intervention (PCI). Methods Using patient-level 4 multicenter registries in Korea, 462 patients undergoing LM bifurcation PCI with the 2-stent technique were identified (181 crush, 167 T-stenting; 63% 1st generation drug-eluting stent (DES), 37% 2nd generation DES). Three bifurcation angles, between the LM and left anterior descending (LAD), the LM and left circumflex (LCX), and the LAD and LCX, were measured. The primary outcome was target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization (TLR). Results In patients treated with the crush technique, the best cutoff value (BCV) to predict TLF was 152° of the LM-LAD angle. In the crush group, a significantly higher TLF rate, mostly driven by TLR, was observed in the LM-LAD angle ≥152° group compared with the <152° group (35.7% vs. 14.6%; adjusted hazard ratio 3.476; 95% confidence interval 1.612–7.492). An LM-LAD angle ≥152° was an independent predictor of TLF. In the T-stenting, no bifurcation angle affected the clinical outcomes. Conclusions In LM bifurcation PCI using the 2-stent technique, wide LM-LAD angle (≥152°) was associated with a greater risk of TLF in the crush, whereas none of the bifurcation angles affected T-stenting outcomes.
Highlights
Bifurcation disease remains a challenging lesion subset posing a higher risk of adverse events in the drug-eluting stent (DES) era [1, 2]
Consecutive patients from 19 major coronary intervention centers in Korea were enrolled in this study between 2003 and 2010. e inclusion criteria were (1) age ≥18 years; (2) coronary bifurcation lesions treated with DES; and (3) a side branch or left circumflex (LCX) reference diameter ≥2.3 mm and at least stentable with a 2.5 mm stent. e exclusion criteria were (1) protected left main (LM) disease; (2) cardiogenic shock; and (3) history of cardiopulmonary resuscitation in the same hospitalization. e Seoul National University Hospital (SNUH) LM registry is a retrospective registry of patients undergoing percutaneous coronary intervention (PCI) of bifurcation lesions at SNUH
receiver operating characteristic (ROC) curve analysis revealed that an LM-left anterior descending (LAD) bifurcation angle of 152° is the best cutoff value to predict target lesion failure (TLF) in the crush group (Figure 3)
Summary
Bifurcation disease remains a challenging lesion subset posing a higher risk of adverse events in the drug-eluting stent (DES) era [1, 2]. Journal of Interventional Cardiology factors in the stent strategy selection process is bifurcation angle: for example, T-stenting is considered appropriate for bifurcation with a near 90° angle between the main branch (MB) and side branch (SB) [3]. This practice is based on theoretical assumption without thorough validation using real-world data. We sought to comprehensively assess the clinical impact of 3 different bifurcation angles (angles between the LM and the left anterior descending (LAD) artery, between the LM and the LCX, and between the LAD and the LCX) in patients undergoing LM bifurcation PCI using the 2-stent technique. Because visual estimation is widely adopted to assess bifurcation angles and determine a type of 2-stent technique in real-world practice, we used 2-dimensional quantitative coronary angiography (QCA) to measure bifurcation angles, results of which should be applied to daily practice
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