Technique For Coronary Bifurcation Lesions Research Articles

Letter: Cardiovascular outcomes after 2-stent or stepwise provisional techniques for coronary bifurcation lesions.

Letter: Cardiovascular outcomes after 2-stent or stepwise provisional techniques for coronary bifurcation lesions.

Reply: Cardiovascular outcomes after 2-stent or stepwise provisional techniques for coronary bifurcation lesions.

Reply: Cardiovascular outcomes after 2-stent or stepwise provisional techniques for coronary bifurcation lesions.

Intervenção coronária percutânea com técnica mini culotte estadiada para reestenose ostial de grande ramo lateral

Understanding the anatomy and physiology of a bifurcation is crucial in today’s interventional field. The bifurcation lesion is one of the most challenging coronary conditions to treat percutaneously. Numerous interventional strategies have been investigated because of the high level of interest in these lesions, but the relatively poor procedural and long-term results. Improvements in stenting and other interventional procedures have reduced the likelihood of adverse clinical outcomes, by creating the most favorable environment for stents to do their work. Provisional stenting has been widely accepted as the initial interventional technique for coronary bifurcation lesions by the medical community for over 15 years. Restenosis of a major branch is possible after angioplasty of the main vessel using a provisional one-stent approach. Although side branch restenosis following bifurcation angioplasty is less common with modern bifurcation procedures, it still occurs in 5% of cases during angiographic follow-up for symptoms. In our case series of five patients, severe side-branch restenosis presented with recuring anginal symptoms, which required target vessel revascularization. By applying bifurcation principles, we improved the “staged mini culotte” part of the culotte bifurcation stent technique, making it more user-friendly, and reducing exposure to radiation and operating time.

Double kissing inflation outside the stent versus jailed balloon technique for coronary bifurcation lesions

Abstract Background Side branch (SB) occlusion remains challenging in percutaneous coronary intervention (PCI) for bifurcation lesions even in the era of jailed balloon technique (JBT). Our previous single-arm study introduced a novel method to protect SB named double kissing inflation outside the stent (DKo), which features twice inflation of the protective balloon kissing with the stent balloon and post-dilation balloon. Objective To confirm whether DKo can protect SB better than JBT in a large sample of bifurcation lesions. Methods This retrospective, single-center cohort study enrolled 875 consecutive patients underwent bifurcation PCI either in DKo (n=209) or JBT group (n=666). The primary endpoint was transient SB loss after removal of the protective balloon. The secondary endpoints included rates of SB rewiring, final kissing balloon inflation (FKBI), SB stenting, final SB loss, and peri-procedural myocardial infarction (PMI). Results Transient SB loss occurred in only 1 patient (0.5%) in DKo but 32 patients (4.8%) in JBT (p<0.005). Transient loss in JBT group was triggered by rewiring (n=21), post-dilation (n=8) and severe dissection (n=3). DKo caused lower rates of rewiring (0.5% vs. 13.8%, p<0.001), FKBI (0.5% vs. 7.7%, p<0.001) and PMI (0.5% vs. 2.9%, p=0.045). SB stenting and final SB loss showed a lower tendency in DKo [0% vs. 0.8%, p=0.21; 0% vs. 1.2%, p=0.11]. DKo was the only protector against transient SB loss [odds ratio=0.08, 95% confidence interval (0.01-0.59), p=0.013]. Conclusion DKo protects SB better than JBT in PCI for bifurcation lesions. Randomized controlled studies are required to confirm the long-term benefit.

Double Kissing Inflation Outside the Stent Versus Jailed Balloon Technique for Coronary Bifurcation Lesions

Side branch (SB) occlusion remains challenging in bifurcation percutaneous coronary intervention. We have introduced a novel method to protect SB named double kissing inflation outside the stent (DKo), which features twice inflation of protective balloon kissing with stent and postdilation balloon. This study compared protective effects of DKo vs jailed balloon technique (JBT) for bifurcation. This retrospective, single-center study enrolled 875 consecutive bifurcation lesions receiving either DKo (n = 209) or JBT (n = 666). At the 12-month follow-up, major adverse cardiac event occurred less in DKo (6.7% vs 12.0%; P = 0.042), even in 1:2 propensity score matching analysis (6.4% vs 12.3%; P = 0.034). Rewiring and transient SB loss occurred also less in DKo (0.5% vs 13.8% [P < 0.001]; 0.5% vs 4.8% [P = 0.003]). Similar results were observed in matching analysis. This study demonstrated DKo protected SB better than JBT in bifurcation percutaneous coronary intervention.

Jailed pressure wire technique for coronary bifurcation lesions: structural damage and clinical outcomes

Introduction and objectivesThe use of a pressure wire as a jailed wire to evaluate side branch results during provisional stenting seems feasible. However, safety concerns exist due to the mechanical damage of the wire and the lack of prospective data evaluating the prognosis of patients treated using this technique. This study sought to evaluate the structural damage of the pressure wire in patients treated using the jailed pressure wire technique and to assess mid-term clinical outcomes. MethodsWe enrolled 99 patients with single bifurcation lesions and provisional stenting as the strategy of choice. A jailed pressure wire was used to guide side branch intervention according to the instantaneous wave-free ratio (iFR). A total of 114 patients and the respective nonpolymer-coated jailed wires were used as historical controls. Guidewire damage was evaluated by stereomicroscopy. The primary endpoint was significant microscopic damage. Major adverse cardiac events were evaluated at 2-year follow-up. ResultsSignificant microscopic damage was more frequent in pressure wires than in nonpolymer-coated wires (53.5% vs 22.8%, P<.001). There were no fractures in either group. There were fewer side branch interventions in the pressure wire group (postdilation/kissing balloon, 32.3% vs 56.1%, P=.001; stenting, 0.0% vs 2.6%, P=.104). The 2-year rate of major adverse cardiac events was similar between the 2 groups (HRadj, 0.42; 95%CI, 0.10-1.73; P=.229). ConclusionsPressure wires were less resistant to jailing than conventional nonpolymer-coated wires. Patients treated with iFR-guided provisional stenting required fewer side branch interventions but had similar 2-year clinical outcomes than patients treated with the angiography-guided technique.

Single stenting versus double stenting technique in true bifurcation coronary lesions

Abstract Introduction The ideal treatment technique for coronary bifurcation lesions remains unknown. Although single-stenting strategy has been recommended by default, little evidence exists regarding clinical outcomes between single versus double-stenting in current practice. Purpose To compare procedural details and clinical outcomes between single vs double-stenting techniques in true bifurcation coronary lesions. Methods Retrospective study of all patients (pts) referred for percutaneous coronary intervention (PCI) of true bifurcation lesions between June 2018 and June 2020. Only Medina X,X,1 lesions were included. Pts were split in 2 groups: group 1 (single-stenting) and group 2 (double-stenting). Procedural details and clinical outcomes were assessed. Acute and long-term adverse events included procedural complications (a composite outcome of side branch occlusion, coronary iatrogenic dissection and type 4 acute myocardial infarction (AMI)) and a composite of cardiovascular death, AMI, stroke, re-restenosis and reintervention, respectively. Results A total of 118 pts were included, 74,6% male, mean age of 66,4±11 years. Ninety-five pts (80,5%) were treated with single-stenting (G1) and 23 pts (19,5%) with double-stenting technique (G2). Both groups were well matched regarding baseline characteristics and clinical presentation. T and protrusion (TAP) and minicrush were the most frequent double-stenting techniques (43,5% and 21,7%). G2 lesions mainly involved the left main (LM) and proximal left anterior descendent artery (LAD) (52,2%) and in G1 mid LAD (34,7%). LM lesions were more common in G2 (26,1% vs 8,4%; p=0,030). G1 had more lesions Medina 1,1,1 (75,8% vs 52,2%; p=0,025) and less Medina 0,1,1 (9,5% vs 30,4%; p=0,015). Proximal optimization technique and kissing balloon occurred more in G2 (p&amp;lt;0,05). G2 had more intravascular ultrasound guided PCI (p=0,046). Femoral access, heparin, contrast and radiation dose, and fluoroscopy time were higher in G2 (p&amp;lt;0,05). Acute adverse composite outcome was similar in both groups (G1 13% vs G2 14,3%; p=0,855). Median follow-up was similar (G1 16,8±7,9 and G2 19,7±8,8 months; p=0,127). G1 had less occurrence of long-term adverse composite outcome (7,4% vs 26,3%; p=0,032). Excluding interventions in LM, G2 had more significant incidence of acute events (20% vs 2,6%; p=0,028), and higher rate of long-term adverse events (20% vs 4,2%; p=0,056). In interventions of the LM only, no differences were noticed in acute and long-term composite events between groups. Conclusions Double-stenting techniques in true coronary bifurcation lesions included more often LM lesions and were complex procedures requiring frequently intracoronary imaging. Although acute adverse events were similar to those of single-stenting, long-term adverse outcomes were more frequent in double-stent group, except for LM lesions. Funding Acknowledgement Type of funding sources: None.

A Novel guide extension assisted stenting technique for coronary bifurcation lesions.

A challenging technical scenario frequently encountered in a percutaneous coronary intervention of a coronary bifurcation lesion (CBL) is stent implantation of only the stenosed segment without compromising the other two normal segments in non-true bifurcation lesions. Another is precise stent implantation covering the side branch ostium without leaving excessive stent metal at the other two segments of a bifurcation lesion in complex true bifurcation lesions. The aim of this study was to describe a novel stenting technique for both non-true and true CBLs by using a guide extension catheter (GuideLiner). With the assistance of a guide extension catheter mounted on both the main and the side-branch guidewires and with its intubation down to the bifurcation carina, a stent can be implanted in the side branch segment or distal main segment of the bifurcation lesion appropriately without compromising the other two segments of the coronary bifurcation. Stent implantation is described in three bifurcation lesions in three cases and shown in detail with illustrative figures. The technique facilitates side-branch only stenting in side-branch mono-ostial (medina 0, 0, 1) CBL or only the distal main segment in distal mono-ostial (medina 0, 1, 0) CBL without compromising the other two remaining segments when using the one-stent technique in non-true CBLs without leaving unnecessary excessive stent metal at the bifurcation site and when using a two-stent technique in complex true bifurcation lesions (tri-ostial or medina 1, 1, 1). Consequently, through optimizing stent deployment, the technique may have the potential to reduce the risk of subacute stent thrombosis and future in-stent restenosis. The most appropriate lesions suitable for the technique, and some other practical tips are also described.

Side branch long lesion with main vessel vulnerable plaques by optical coherence tomography predict target-vessel myocardial infarction after provisional stenting in patients with coronary bifurcation

Abstract Background Provisional side branch (SB) stenting is correlated with target-vessel myocardial infarction (TVMI) in patients with coronary bifurcation lesions. However, the underlying mechanisms remain unknown. Objectives We aimed to determine the correlation of SB lesion length with vulnerable plaques using optical coherence tomography (OCT) and TVMI in patients with coronary bifurcation lesions treated by a provisional approach. Methods A total of 405 patients with 405 bifurcation lesions who underwent pre-PCI OCT imaging of both main vessel (MV) and SB was prospectively enrolled. Patients were defined as Long-SB lesion (SB lesion length ≥10 mm) and Short-SB lesion (SB lesion length &amp;lt;10 mm) groups according to quantitative coronary analysis and were also stratified by the presence of vulnerable plaques based on OCT findings. The primary endpoint was the occurrence of TVMI after provisional stenting at one-year follow-up. Results 178 (43.9%) patients had long SB lesions. Vulnerable plaques predominantly localized in the main vessel (MV) and more frequently in the Long-SB lesion group (42.7%) compared to 24.2% in the Short-SB lesion group (p&amp;lt;0.001). At one-year follow-up after provisional stenting, there were 31 (8.1%) TVMIs, with 11.8% in the Long-SB lesion group and 4.4% in the Short-SB lesion group (p=0.009), leading to significant difference in target lesion failure between two groups (15.2% vs. 6.6%, p=0.007). The rate of cardiac death, revascularization, and stent thrombosis was comparable between study groups. By multivariate regression analysis, long SB lesion length (p=0.011), presence of vulnerable plaques in the polygon of confluence (p=0.001), and true coronary bifurcation lesions (p=0.004) were three independent factors of TVMI. Conclusions Long-SB lesion length with MV vulnerable plaques predict increased TVMI after provisional stenting in patients with true coronary bifurcation lesions. Further study is warranted to identify the better stenting techniques for coronary bifurcation lesions with long lesion in the SB Kaplan-Meier survival curve Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): NSFC

Stenting techniques for coronary bifurcation lesions: Evidence from a network meta-analysis of randomized clinical trials.

We conducted a systematic review and network meta-analysis of available randomized clinical trials (RCTs) to compare cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions. Although provisional stenting of the main branch and balloon angioplasty of the side branch is considered the standard approach, the use of two stents is often pursued with a wide variety of bifurcation stenting techniques available. We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov from inception to December 2018. We performed a frequentist network meta-analysis to estimate relative risks (RR) of death, major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST) among different two stent bifurcation techniques. We identified 14 studies, yielding data on 4,285 patients. Double Kissing (DK) Crush and Mini-crush were associated with significant reductions in MACE, TVR, and TLR when compared with the Provisional stenting (RR 0.31-0.55 [all p < .01] and RR 0.42-0.45 [all p < .02], respectively) and with the remaining bifurcation techniques (RR 0.44-0.55 [all p < .05] for DK Crush and RR 0.37-0.45 [all p < .05] for Mini-crush). In addition, Culotte and Crush were associated with an increased risk for ST compared to Provisional stenting (RR 3.25-4.27 [both p < .05]) and to DK crush (RR 3.02-3.99 [both p < .05]). DK crush and mini-crush were found to be associated with fewer events and complications compared to the other techniques reviewed, including the Provisional approach. Further, Culotte and Crush were associated with an increased risk of stent thrombosis when compared to the Provisional approach.

Optical coherence tomography predictors of target vessel myocardial infarction after provisional stenting in patients with coronary bifurcation disease.

Provisional side branch (SB) stenting is correlated with target vessel myocardial infarction (TVMI) in patients with coronary bifurcation lesions. However, the mechanisms underlying this association remain unknown. To determine the correlation between SB lesion length with vulnerable plaques and TVMI using optical coherence tomography (OCT). The correlation between SB lesion length with vulnerable plaques and TVMI is unknown. A total of 405 patients with 405 bifurcation lesions who underwent preprocedure OCT imaging of both the main vessel (MV) and the SB were enrolled. Patients were divided into long SB lesion (SB lesion length ≥10 mm) and short SB lesion (SB lesion length <10 mm) groups according to quantitative coronary analysis; they were also stratified by the presence of vulnerable plaques identified by OCT. The primary endpoint was the occurrence of TVMI after provisional stenting at 1-year follow-up. In total, 178 (43.9%) patients had long SB lesions. Vulnerable plaques were predominantly localized in the MV and were more frequently in the long SB lesion group (42.7%) than in the short SB lesion group (24.2%, p < .001). At 1-year follow-up after provisional stenting, there were 31 (7.7%) TVMIs, with 21 (11.8%) in the long SB lesion group and 10 (4.4%) in the short SB lesion group (p=.009). Multivariate regression analysis showed that long SB lesion length (p=.011), absence of vulnerable plaques in the polygon of confluence (p=.001), and true coronary bifurcation lesions (p=.004) were the three independent factors of TVMI. The presence of long SB lesion with MV vulnerable plaques predicts the increased risk of TVMI after provisional stenting in patients with true coronary bifurcation lesions. Further studies are warranted to identify the best stenting techniques for coronary bifurcation lesions with long SB lesions.

Szabo 2-stent technique for coronary bifurcation lesions: procedural and short-term outcomes

BackgroundProvisional 1-stent technique is currently regarded as the default approach for the majority of bifurcation lesions. Nonetheless, 2-stent techniques may be required for complex bifurcations with high compromise risk or fatal consequences of side branch (SB) occlusion. Limitations exist in current approaches, as stents gap, multiple metal layers and stent malapposition caused by imprecise placement with fluoroscopic guide and intrinsic technical defects. This study was designed to investigate the effectiveness of the novel Szabo 2-stent technique for coronary bifurcation lesions.MethodsIn the Szabo 2-stent technique, one stent is precisely implanted at the SB ostium with Szabo technique resulting in a single strut protruding into the main vessel (MV). After MV rewiring and SB guidewire withdrawal, another stent is implanted in MV followed by proximal optimization technique, SB rewiring, and final kissing inflation (FKI).ResultsThe technique tested successfully in silicone tubes (n = 9) with: procedure duration, 31.2 ± 6.8 min; MV and SB rewiring time, 26.8 ± 11.2 s and 33.3 ± 15 s; easy FKI; and 2.3 ± 0.5 balloons/procedure. Bifurcation lesions (n = 22) were treated with angiographic success in MV and SB, respectively: increased minimal lumen diameter (0.63 ± 0.32 mm to 3.20 ± 0.35 mm; 0.49 ± 0.37 mm to 2.67 ± 0.25 mm); low residual stenosis (12.4 ± 2.4%; 12.4 ± 2.3%); and intravascular ultrasound confirmed (n = 19) full coverage; minimal overlap and malapposition; minimal lumen area (2.4 ± 1.2 mm2; 2.1 ± 1.0 mm2); plaque burden (78.1 ± 11.3%; 71.6 ± 15.5%); and minimal stent area (9.1 ± 1.6 mm2; 6.1 ± 1.3 mm2). Periprocedural cardiac troponin increased in 1 asymptomatic patient without electrocardiographic change. There was no target lesion failure (cardiac death, myocardial infarction, target lesion revascularization) at 6-month follow-up.ConclusionsThe Szabo 2-stent technique for bifurcation lesions provided acceptable safety and efficacy at short-term follow-up.

Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients

ObjectivesThe aim of this study was to compare clinical outcomes of different bifurcation percutaneous coronary intervention (PCI) techniques. BackgroundDespite several randomized trials, the optimal PCI technique for bifurcation lesions remains a matter of debate. Provisional stenting has been recommended as the default technique for most bifurcation lesions. Emerging data support double-kissing crush (DK-crush) as a 2-stent technique. MethodsPubMed and Scopus were searched for randomized controlled trials comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE). Secondary outcomes of interest were cardiac death, myocardial infarction, target vessel or lesion revascularization, and stent thrombosis. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis. ResultsTwenty-one randomized controlled trials including 5,711 patients treated using 5 bifurcation PCI techniques were included. Investigated techniques were provisional stenting, T stenting/T and protrusion, crush, culotte, and DK-crush. Median follow-up duration was 12 months (interquartile range: 9 to 36 months). When all techniques were considered, patients treated using the DK-crush technique had less occurrence of MACE (OR: 0.39; 95% credible interval: 0.26 to 0.55) compared with those treated using provisional stenting, driven by a reduction in target lesion revascularization (OR: 0.36; 95% credible interval: 0.22 to 0.57). No differences were found in cardiac death, myocardial infarction, or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed among provisional stenting, culotte, T stenting/T and protrusion, and crush. In non–left main bifurcations, DK-crush reduced MACE (OR: 0.42; 95% credible interval: 0.24 to 0.66). ConclusionsIn this network meta-analysis, DK-crush was associated with fewer MACE, driven by lower rates of repeat revascularization, whereas no significant differences among techniques were observed for cardiac death, myocardial infarction, and stent thrombosis. A clinical benefit of 2-stent techniques was observed over provisional stenting in bifurcation with side branch lesion length ≥10 mm.

279Clinical outcome after coronary bifurcation stenting: a systematic review and network meta-Analysis of PCI bifurcation techniques comprising 5572 patients

Abstract Background The optimal PCI technique for bifurcation lesions remains a matter of debate. Several RCT have compared different bifurcation PCI techniques. Provisional stenting has been recommended as the default technique for most bifurcation lesions. However, emerging data suggests that double-kissing crush technique can be considered in true left main bifurcation lesions and has been endorsed by the European Society of Cardiology Guidelines. Purpose To compare the clinical outcome between different bifurcation PCI techniques. Methods We searched MEDLINE for randomized clinical trials (RCT) comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE) defined as the composite of cardiac death, myocardial infarction (MI) and target vessel or lesion revascularization (TVR/TLR), and the individual components of MACE. Stent thrombosis was assessed as defined by the ARC. Stratification based on left-main or distal bifurcations was performed. We evaluated the studies' risk of bias in accordance to the Cochrane Handbook for Systematic Reviews of Interventions, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis. Results We identified 263 studies and of these included 19 RCT including 5572 patients treated with 5 bifurcation PCI techniques namely provisional stenting, systematic T-stenting, crush, culotte and double-kissing crush. Median follow-up was 12 months (IQR 8 to 36). When all bifurcation lesions were combined, double-kissing crush technique reduced the occurrence of MACE (OR 0.42; CrI 0.28 to 0.61) compared to provisional stenting. This difference was driven by a reduction in TVR/TLR (OR 0.39; CrI 0.25 to 0.65). No differences were found in cardiac death, MI or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed between provisional stenting, systematic T-stenting, crush. In distal bifurcations (n=17 studies, 4634 patients), double-kissing crush also showed to reduce MACE (OR 0.48; CrI 0.29 to 0.67 vs. Provisional). In left-main bifurcations (n=3 studies, 938 patients) no differences in MACE were found between PCI techniques. Conclusions In this network meta-analysis, PCI bifurcation techniques were similar with respect to the occurrence of cardiac death, myocardial infarction and stent thrombosis. When all coronary bifurcations were combined, an advantage of double-kissing crush was observed in terms of MACE driven by lower rate of repeated revascularization. Further studies are required to define the best PCI bifurcation technique for left main coronary artery disease.

P5752Which is the best stenting technique for coronary bifurcation lesions? Evidence from a network meta-analysis of randomized clinical trials

Abstract Background Bifurcation lesions represent 20% of all coronary lesions treated by percutaneous coronary interventions (PCI). Although provisional technique with 1 stent in the main branch and balloon angioplasty of the side branch is considered the standard approach, the implantation of 2 stents is often being pursued with a wide variety of bifurcation stenting techniques. We thus conducted a systematic review and network meta-analysis of randomized clinical trials (RCTs) to compare clinical cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions. Methods We searched on Pubmed, Google Scholar, Embase and Cochrane Library, up to October 2018 for published and unpublished RCTs that compared clinical cardiovascular outcomes in patients with bifurcation lesions treated with 7different techniques (crush [Cr]; culotte [Cu]; double kissing crush [DKCr], mini-crush [mCr], routine T-stenting [RTS], T-stenting and small protrusion [TAP], and provisional (1 stent technique)). We performed a frequentist fixed-effect network meta-analysis to estimate relative risks (RR) of major adverse cardiovascular events (“MACE”, typically defined as death, myocardial infarction and target vessel revascularization), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST). Results We identified 14 studies, yielding data on 4285 patients. DKCr and mCr yielded significant reductions in MACE, TVR, and TLR when compared with the 1-stent technique (RR 0.31–0.55 [all P&lt;0.01] and RR 0.42–0.45 [all P&lt;0.02], respectively) and with the rest of the bifurcation techniques (RR 0.44–0.55 [all P&lt;0.05] for DKCr and RR 0.37–0.45 [all P&lt;0.05] for mCr). On the other hand, Cu and Cr were associated with an increased risk for ST compared to 1-stent technique (RR 3.25–4.27 [both P&lt;0.05]) and to DKCr (RR 3.02–3.99 [both P&lt;0.05]). We found no heterogeneity nor inconsistency between studies. Conclusions The various PCI bifurcation stenting techniques are associated with different cardiovascular outcomes, with double kissing crush and mini crush being more effective than others, including the 1-stent approach, whereas culotte and crush are associated with increased risk of stent thrombosis. Acknowledgement/Funding None

Cardiovascular outcomes associated with crush versus provisional stenting techniques for bifurcation lesions: a systematic review and meta-analysis

BackgroundPercutaneous coronary intervention (PCI) for bifurcation lesions has often been challenging for Interventionists. Application of the correct intra-procedural technique is vital to generate beneficial outcomes after PCI. We aimed to systematically compare the post interventional cardiovascular outcomes which were reported using crush versus provisional stenting techniques for bifurcation lesions.MethodsA computerized search was carried out through Medical Literature Analysis and Retrieval System Online, EMBASE, the Cochrane Central and through www.ClinicalTrials.gov for English publications comparing crush versus the provisional stenting techniques for coronary bifurcation lesions during PCI. Major adverse cardiac events, all-cause mortality, cardiac death, myocardial infarction, stent thrombosis, target vessel and target lesion revascularizations were the endpoints in this analysis. Odds ratios (OR) and 95% confidence intervals (CI) were generated during statistical analysis to represent the data.ResultsSix studies consisting of a total number of 2220 participants (1085 participants were assigned to the crush stenting technique and 1135 participants were assigned to the provisional stenting technique) enrolled between years 2004 and 2016 were included in this analysis.During a follow-up time period from six to sixty months, major adverse cardiac events (OR: 0.73, 95% CI: 0.59–0.91; P = 0.005), target vessel revascularization (OR: 0.62, 95% CI: 0.43–0.89; P = 0.01) and target lesion revascularization (OR: 0.62, 95% CI: 0.45–0.85; P = 0.003) were significantly lower in patients who were assigned to the crush stenting technique. However, all-cause mortality (OR: 0.90, 95% CI: 0.48–1.68; P = 0.74), cardiac death (OR: 0.56, 95% CI: 0.29–1.08; P = 0.08), myocardial infarction (OR: 0.89, 95% CI: 0.62–1.27; P = 0.53) and stent thrombosis (OR: 0.72, 95% CI: 0.36–1.42; P = 0.34) were not significantly different.ConclusionIn patients with coronary bifurcation lesions undergoing PCI, crush stenting technique was associated with significantly lower major adverse cardiac events and repeated revascularization without any change in mortality, myocardial infarction and stent thrombosis when compared to the provisional technique showing a benefit of crush over the provisional stenting technique during PCI.

Two-stent techniques for coronary bifurcation lesions (main vessel first versus side branch first): results from the COBIS (COronary BIfurcation Stenting) II registry.

It has not been known which two-stent technique is best for treating bifurcation lesions. We aimed to compare the outcomes from main vessel (MV) first and side branch (SB) first techniques for patients with bifurcation lesions requiring a two-stent approach. A total of 673 patients with bifurcation lesions were treated with two-stent techniques: MV first (n=250) or SB first (n=423). The rate of a composite of cardiac death, myocardial infarction, or target lesion revascularisation (TLR) was similar in the two groups (SB first versus MV first, 15.1% versus 15.6% in the total population [p=0.90]; 14.3% versus 17.4% in a propensity score-matched population [p=0.80]). There were significant interactions associated with TLR risk between MV and SB first techniques according to angiographic factors. Patients in the MV first group had a lower risk of TLR when they had a lesion with MV diameter stenosis ≥70% (p for interaction=0.04), more severe stenosis of the MV than of the SB (p for interaction=0.008), or MV lesion length ≥18 mm (p for interaction=0.01). Clinical outcomes were similar for patients treated with MV or SB first two-stent techniques. Using "more severe lesion first" two-stent techniques might offer a favourable prognosis.

Highlights from the Circulation Family of Journals.

Highlights from the Circulation Family of Journals.

Challenging the “Provisional” Technique for Coronary Bifurcation Lesions

Despite considerable progress in the field of interventional cardiology, percutaneous treatment of coronary bifurcations continues to be associated with a lower procedural success rate and a higher incidence of complications, target lesion revascularization, and stent thrombosis [(1)][1]. Excluding

Complex bifurcation lesions: Randomized comparison of a fully bioresorbable modified t stenting strategy versus bifurcation reconstruction with a dedicated self-expanding stent in combination with bioresorbable scaffolds, an OCT study: Rationale and design of the COBRA II trial.

There is an ongoing controversy regarding the efficacy and safety of different percutaneous stenting techniques for coronary bifurcation lesions needing >1 stent. The promise of safe vessel restoration with bioresorbable scaffolds (BRS) may not be transferable to complex double BRS bifurcation techniques, and permanent metallic scaffolding of the bifurcation core may be needed. We identified modified-T stenting as the most promising fully bioresorbable 2-stent strategy in a preclinical setting. The objective of this study is to assess acute performance and compare long-term vessel healing with this strategy, versus an approach combining BRS with a dedicated metallic drug-eluting bifurcation stent. In a single center, 60 consecutive patients with true and complex coronary bifurcation lesions will be randomly assigned to treatment with the dedicated self-expanding Axxess™ biolimus-eluting bifurcation stent in the proximal main vessel and additional Absorb™ everolimus-eluting BRS in the branches versus a modified T technique using Absorb™ only. Angiography and optical coherence tomography (OCT) will be performed immediately after implantation and at 30 months, and clinical follow-up is foreseen up to 5 years after implantation. The primary endpoint is the change in minimal luminal area assessed with OCT from baseline to 30 months in pre-specified bifurcation segments. To date the use of Absorb™ BRS in complex coronary bifurcations has not been evaluated in a randomized clinical trial setting. The COBRA II study will examine the role and safety of a double BRS strategy in coronary bifurcations, alone or in combination with a metallic dedicated bifurcation device. © 2016 Wiley Periodicals, Inc.