Impact of bifurcation technique on long-term clinical outcomes in 976 patients with distal unprotected left main coronary artery stenosis treated with drug-eluting stents; Milan and new-Tokyo registry

Abstract

Background: Unprotected distal left main (UDLM) bifurcation intervention still remains technically challenging despite improvement in device technology. Methods and results: Between April 2005 and August 2011, 976 consecutive patients with UDLM following PCI with DES implantation were evaluated: 633 were treated with 1 stent (1-S) and 343 with 2 stents (2-S). The end point of the study was the incidence of cardiac mortality, target lesion revascularization (TLR) and TLR for main-branch (TLR-MB) including ULM itself and proximal left anterior descending artery. More complex lesions were observed in the 2-S group (3 vessel disease, 53.3% vs. 43.9%, p=0.01, true-bifurcation, 85.5% vs. 49.8%, p<0.001, calcification; 61.0% vs. 49.1%, p<0.001) despite similar comorbidities. Peri-procedural MI occurred more frequently in the 2-S group as compared to the 1-S (12.0% vs. 6.1%, p=0.01). During follow-up period (median 36.9 months), survival free from cardiac mortality was similar between the 2 groups (cardiac mortality at 3-years; 5.1% in 1-S vs. 2.9% in 2-S, HR 0.56, CI 0.28-1.14, p=0.11) despite higher occurrence of TLR and TLR-MB at 3-years (TLR; 11.7% vs. 23.5%, HR 2.19 CI 1.60-3.00, p<0.001 and TLR-MB; 5.1% vs. 9.9%, HR1.60 CI 0.94-2.75, p=0.09). When we assess the impact of 2-S, mini-crush (109 patients), culotte technique (69) and TAP (41) were similar clinical result at long term while old crush technique (54) was worse as compared to these new techniques. (cardiac mortality at 3-years; 7.4% in crush, 0.9% in mini-crush, 2.4% in TAP vs. 2.9% in culotte, TLR at 3-years; 31.5%, 21.1%, 24.4% vs. 23.2% and TLR-MB; 14.8%, 4.6%, 7.3% vs. 11.6%, respectively). Conclusions: Compared with the 2-stent technique, the 1-stent technique is associated with a better TLR-free survival. However, our registry demonstrated that new 2-stent technique such as mini-crush, culotte and TAP technique seems to be feasible except higher incidence of revascularization.