Clinical Outcome of Double Kissing Crush Versus Provisional Stenting of Coronary Artery Bifurcation Lesions: The 5-Year Follow-Up Results From a Randomized and Multicenter DKCRUSH-II Study (Randomized Study on Double Kissing Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions)

A drug-eluting Balloon for the trEatment of coronarY bifurcatiON lesions in the side branch: a prospective multicenter ranDomized (BEYOND) clinical trial in China

Supplemental Digital Content is available in the text

Background

Treatment of coronary bifurcation lesions remains challenging; a simple strategy has been preferred as of late, but the disadvantage is ostium stenosis or even occlusion of the side branch (SB). Only a few single-center studies investigating the combination of a drug-eluting stent in the main branch followed by a drug-eluting balloon in the SB have been reported. This prospective, multicenter, randomized study aimed to investigate the safety and efficacy of a paclitaxel-eluting balloon (PEB) compared with regular balloon angioplasty (BA) in the treatment of non-left main coronary artery bifurcation lesions.

Methods

Between December 2014 and November 2015, a total of 222 consecutive patients with bifurcation lesions were enrolled in this study at ten Chinese centers. Patients were randomly allocated at a 1:1 ratio to a PEB group (n = 113) and a BA group (n = 109). The primary efficacy endpoint was angiographic target lesion stenosis at 9 months. Secondary efficacy and safety endpoints included target lesion revascularization, target vessel revascularization, target lesion failure, major adverse cardiac and cerebral events (MACCEs), all-cause death, cardiac death, non-fatal myocardial infarction, and thrombosis in target lesions. The main analyses performed in this clinical trial included case shedding analysis, base-value equilibrium analysis, effectiveness analysis, and safety analysis. SAS version 9.4 was used for the statistical analyses.

Results

At the 9-month angiographic follow-up, the difference in the primary efficacy endpoint of target lesion stenosis between the PEB (28.7% ± 18.7%) and BA groups (40.0% ± 19.0%) was –11.3% (95% confidence interval: –16.3% to –6.3%, P_superiority <0.0001) in the intention-to-treat analysis, and similar results were recorded in the per-protocol analysis, demonstrating the superiority of PEB to BA. Late lumen loss was significantly lower in the PEB group than in the BA group (–0.06 ± 0.32 vs. 0.18 ± 0.34 mm, P < 0.0001). For intention-to-treat, there were no significant differences between PEB and BA in the 9-month percentages of MACCEs (0.9% vs. 3.7%, P = 0.16) or non-fatal myocardial infarctions (0 vs. 0.9%, P = 0.49). There were no clinical events of target lesion revascularization, target vessel revascularization, target lesion failure, all-cause death, cardiac death or target lesion thrombosis in either group.

Conclusions

In de novo non-left main coronary artery bifurcations treated with provisional T stenting, SB dilation with the PEB group demonstrated better angiographic results than treatment with regular BA at the 9-month follow-up in terms of reduced target lesion stenosis.

Trial registration

ClinicalTrials.gov, NCT02325817; https://clinicaltrials.gov

One- and 3-year outcomes of percutaneous bifurcation left main revascularization with modern drug-eluting stents: a systematic review and meta-analysis

AIMS

Optimal percutaneous coronary intervention (PCI) strategy for coronary left main (LM) bifurcation lesions remains controversial. We performed systematic review and meta-analysis comparing one and 3-year clinical outcomes of 1- and 2- stent strategies using modern drug eluting stents (DESs) for revascularization of LM bifurcation disease.

METHODS

We systematically identified all investigations published between January 2015 and February 2020 comparing the use of single versus double-stent strategies for the revascularization of LM bifurcation lesions. The primary endpoint was 1- and 3-years all-cause mortality. Secondary outcomes included target lesion revascularization (TLR), target lesion failure (TLF), major adverse cardiovascular vents (MACEs) and cardiovascular (CV) mortality while the tertiary outcome was overall occurrence of stent thrombosis (ST) at 1- and 3-years.

RESULTS

No significant differences were observed between the two groups in terms of all-cause mortality rate both at 1 and 3-year follow-up. Single stent strategy was associated with a significantly lower risk of TLR (OR 0.78, 95% CI 0.62- 0.97, p = 0.03, I2 = 61%) as well as of MACEs (OR 0.78, 95% CI 0.63-0.97, I2 = 24%) compared to 2-stent strategy. Conversely no significant differences between the two groups were observed in terms of TLF, CV mortality and ST during the same follow-up period.

CONCLUSIONS

In patients with LM bifurcation disease, single stent strategy demonstrated lower rate of MACEs and TLR but was not superior to 2-stent strategy in terms of CV mortality, TLF and ST at 1 and 3-year follow-up.

Coronary artery double stenting techniques and their results in complex left main bifurcation disease

Aim: Complex left main (LM) bifurcation disease seems to be better approached by a planned double stent technique. Materials & methods: Medline search for articles including randomized trials, prospective series, large registries and retrospective studies >50 patients has been performed. Results: Double kissing crush demonstrated its superiority over culotte stenting and cross over, while other techniques such as the T-stenting and T-stent and Protrusion have not been extensively reported in LM setting. The nano inverted-T-stenting has provided evidences that the use of ultrathin strut stents and very minimal crush is beneficial for both the physiological and rheological properties. Conclusion: The double stenting techniques used in LM should be evaluated in terms of procedural differences and technical simplicity.

Randomised, non-inferiority, controlled procedural outcomes TrIal comParing reverse T And Protrusion versus double-kissing and crush stenting: protocol of the TIP TAP I randomised trial

INTRODUCTION

To assess the impact of 'reverse T and Protrusion' (TAP) technique on the outcome after stenting of true bifurcation lesions of the left main (LM) or proximal epicardial vessels as compared with double kissing (DK)-crush technique.

METHODS AND ANALYSIS

50 consecutive patients with true coronary bifurcation lesion (Medina 1,1,1 or 0,1,1) of the LM or the proximal main vessels, requiring a two-stent technique as first-line strategy at University Medical Center Mainz, are randomised in a 1:1 ratio to reverse TAP or DK-crush stenting. As recommended by best clinical practice, final angiographic result is evaluated and optical coherence tomographic (OCT) intracoronary imaging is performed to assess and optimise the final result. The primary end point is defined as the percentage of stent expansion in the side branch. Secondary end points consist of angiographic and procedural success (assessed until patient's discharge), procedural parameters (procedural time, fluoroscopy time, use of devices, X-ray dose) and OCT parameters expressing expansion of the stents. Safety parameters include all adverse events up to 6 months after discharge. A clinical, angiographic and intracoronary imaging control at 6 months is planned.

ETHICS AND DISSEMINATION

The protocol complies with good clinical practice and the ethical principles described in the Declaration of Helsinki and is approved by the local ethics committee. The results of the trial will be published as original article(s) in medical journals and/or as presentation at congresses.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03714750).

An Upfront Two-Stent Strategy for True Coronary Bifurcation Lesions with A Large Side Branch in Acute Coronary Syndrome: A Two-Year Follow-Up Study

Background and Objectives: Little is known about the upfront two-stent strategy (U2SS) for true coronary bifurcation lesions (CBLs) in acute coronary syndrome (ACS). We aimed to present our two-year follow-up results on the U2SS by using different two-stent techniques for the true CBL with a large side branch (SB) in ACS patients, including unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI), and to identify independent predictors of the presence of major adverse cardiac events (MACEs) after intervention. Materials and Methods: The study included 201 consecutive ACS patients with true CBLs who underwent percutaneous coronary intervention (PCI) using U2SS from October 2015 to March 2018. Clinical outcomes at follow-up were assessed. MACE was defined as a composite of cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR). Results: 31.3% of the patients had an UA, 46.3% had an NSTEMI, and 22.4% had an STEMI. CBL was most frequently located in the left anterior descending (LAD)/diagonal artery (59.2%). In total, 71.1% of the patients had a Medina classification (1,1,1). Overall, 62.2% of cases were treated with mini-crush stenting. Clopidogrel was given in 23.9% of the patients; 71.1% of the patients received everolimus eluting stent (EES); and 11.9% received a sirolimus eluting stent (SES). Final kissing balloon inflation was carried out in all patients, with an unsatisfactory rate of 5%. A proximal optimization technique sequence was successfully carried out in all patients. The MACE incidence was 16.9% with a median follow-up period of 2.1 years. There were seven cardiac deaths (3.5%). The TLR rate was 13.4% (n = 27), with PCI treatment in 16 patients, and coronary artery bypass grafting treatment in 11 patients. After multivariate penalized logistic regression analysis (Firth logistic regression), clopidogrel use (odds ratio (OR): 2.19; 95% confidence interval (CI): 0.41–2.51; p = 0.007) and SES use (OR: 1.86; 95% CI: 0.31–2.64; p = 0.014) were independent predictors of the presence of MACE. Conclusion: U2SS is feasible and safe for the true CBLs with large and diseased SB in ACS patients, and is related to a relatively low incidence of MACE. Clopidogrel use and SES use may predict the MACE development in ACS patients treated using U2SS.

Randomised comparison of provisional side branch stenting versus a two-stent strategy for treatment of true coronary bifurcation lesions involving a large side branch: the Nordic-Baltic Bifurcation Study IV

Background

It is still uncertain whether coronary bifurcations with lesions involving a large side branch (SB) should be treated by stenting the main vessel and provisional stenting of the SB (simple) or by routine two-stent techniques (complex). We aimed to compare clinical outcome after treatment of lesions in large bifurcations by simple or complex stent implantation.

Methods

The study was a randomised, superiority trial. Enrolment required a SB≥2.75 mm, ≥50% diameter stenosis in both vessels, and allowed SB lesion length up to 15 mm. The primary endpoint was a composite of cardiac death, non-procedural myocardial infarction and target lesion revascularisation at 6 months. Two-year clinical follow-up was included in this primary reporting due to lower than expected event rates.

Results

A total of 450 patients were assigned to simple stenting (n=221) or complex stenting (n=229) in 14 Nordic and Baltic centres. Two-year follow-up was available in 218 (98.6%) and 228 (99.5%) patients, respectively. The primary endpoint of major adverse cardiac events (MACE) at 6 months was 5.5% vs 2.2% (risk differences 3.2%, 95% CI -0.2 to 6.8, p=0.07) and at 2 years 12.9% vs 8.4% (HR 0.63, 95% CI 0.35 to 1.13, p=0.12) after simple versus complex treatment. In the subgroup treated by newer generation drug-eluting stents, MACE was 12.0% vs 5.6% (HR 0.45, 95% CI 0.17 to 1.17, p=0.10) after simple versus complex treatment.

Conclusion

In the treatment of bifurcation lesions involving a large SB with ostial stenosis, routine two-stent techniques did not improve outcome significantly compared with treatment by the simpler main vessel stenting technique after 2 years.

Trial registration number

NCT01496638.

Summary of Practice Considerations for Percutaneous Coronary Intervention of Left Main Bifurcation Disease

Left main bifurcation percutaneous coronary intervention is a challenging subset that requires expertise in techniques that are in constant modification. Imaging is important in lesion preparation and optimising outcomes. The interventionalist needs to be highly skilled in the different techniques, as missteps may lead to stent thrombosis and critical in-stent restenosis. Lesion classification between simple and complex identifies those who would best benefit from a two-stent technique. Current technical approaches and practice considerations are summarised in this manuscript.

Double kissing mini-culotte versus mini-culotte stenting: insights from micro-computed tomographic imaging of bench testing

AIMS

This study aimed to evaluate the morphologic characteristics of double kissing (DK) mini-culotte and mini-culotte stenting through imaging of bench testing.

METHODS AND RESULTS

DK mini-culotte and mini-culotte stenting were performed in two silicone bifurcated phantoms with branch vessel diameter differences of 0.5 mm (Model 1) and 1.25 mm (Model 2), and their morphologic characteristics were evaluated by micro-computed tomography. In Model 1, metal carina length (0.25±0.13 mm vs 0.55±0.15 mm), area stenosis of the side branch ostium (SBO) (4.65±3.24% vs 12.5±3.93%), and maximum distance of malapposed struts for the wall facing the SBO (0.27±0.08 mm vs 0.49±0.15 mm) were lower in the DK mini-culotte group than in the mini-culotte group. In Model 2, metal carina length (0.21±0.47 mm vs 0.47±0.12 mm), SBO area stenosis (5.13±3.37% vs 15.00±6.18%), and maximum distance of malapposed struts (0.32±0.13 mm vs 0.68±0.10 mm) were also lower in the DK mini-culotte group. The results of factorial analysis showed that maximum distance of malapposed struts tended to be shorter in Model 1 (F=4.226, p=0.062).

CONCLUSIONS

Compared with mini-culotte stenting, DK mini-culotte stenting was associated with shorter metal carina length, shorter maximum distance of malapposed struts, and smaller SBO area stenosis. Thus, DK mini-culotte stenting may obtain better morphologic characteristics.

A Systematic Literature Review of Three Stenting Strategies for Bifurcation Lesions in Coronary Artery Disease

BACKGROUND

Bifurcation lesions represent 15-20% of all patients undergoing a percutaneous coronary intervention (PCI) for coronary artery disease. The provisional 1-stent stenting strategy is the preferred strategy to treat bifurcation lesions. Other strategies used to treat bifurcation lesions include 2-stent complex stenting strategies and the Tryton Side Branch Stent^® (TSB)-a dedicated side-branch stent for bifurcation lesions, which gained FDA approval in March 2017.

OBJECTIVES

To conduct a systematic literature review of the safety and effectiveness of three stenting strategies (provisional, complex, and Tryton Side Branch Stent^®) for bifurcation lesions with a side-branch diameter ≥2.25 mm, undergoing PCI.

METHODS

Literature searches in Medline, Cochrane Library, Web of Science and Embase were conducted to identify prospective clinical trials from January 2007-July 2017.

RESULTS

602 articles were identified. Nine articles (6275 patients) met all inclusion criteria. Seven studies (5282 patients) compared provisional to complex stenting strategies. Two studies (993 patients) compared provisional to the TSB. Outcomes of interest reported were target vessel failure in 2 studies, major adverse cardiac event (MACE) (cardiac death, all myocardial infarction, ischemic driven target legion revascularization TLR) in 5 studies. For target vessel failure, the provisional strategy ranged from 5.6% to 15.6 %; complex at 7.2% (one study); and TSB from 11.3% to 17.4%. For MACE, provisional strategy ranged from 8%-13.2%; complex from 11.9%-15.2%; and TSB from 8.2%-18.6%.

CONCLUSIONS

To our knowledge, this is the first review comparing three bifurcation lesion stenting strategies. Significant heterogeneity in the study design of the nine studies reviewed prevented a meta-analysis. A clinical trial comparing the TSB to both the provisional and complex strategies would provide better inference on the safety and effectiveness when comparing strategies.

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

Background

Percutaneous 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.

Methods

A 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.

Results

Six 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.

Conclusion

In 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.

Technical Approaches to Left Main Coronary Intervention: Contemporary Best Practices

Left main percutaneous coronary intervention is an acceptable alternative to coronary artery bypass grafting, and in experienced hands, excellent procedural results can be obtained. A systematic approach to stenting and meticulous attention to detail are required. For most lesions, a single-stent provisional approach is sufficient, but for the more complex lesion, a 2-stent technique is required. Herein, the optimal approach to left main lesion assessment and percutaneous intervention is described.

Thin and crush: The new mantra in left main stenting?

Complex bifurcations have been suggested to be better approached by a planned double stent technique; however, recent randomized trials have shown better outcomes of provisional compared to planned two-stent strategy, in terms of both short-term efficacy and safety. In left main (LM) bifurcations, double kissing (DK)-Crush has demonstrated its superiority over Culotte and provisional-T in terms of restenosis and stent thrombosis, gaining respect as one of the most performant techniques for bifurcations stenting. On the other hand, the Nano-Crush technique has recently become part of the repertoire of double stenting techniques, providing evidence that the use of ultrathin strut stents and very minimal crush would be beneficial for both the physiological and rheological properties of the complex bifurcations, even in LM scenario, leading to a lower rate of thrombosis and restenosis at both side branch and true carina. Finally, the newest generation of ultrathin strut stents are gaining a reputation for its safe and effective use in LM treatment thanks to improved design with increased expansion rate capable of LM treatment up to 5-6 mm diameter. The modern crush techniques, such as DK-Crush and Nano-Crush, are providing excellent results on mid and long-term follow up, suggesting that minimal crushing obtained using ultra-thin stents is a good way to obtain surgical-like outcomes in the treatment of complex LM bifurcation disease.

Modified double-stent strategy may be an optimal choice for coronary bifurcation lesions: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The modified double-stent and provisional stenting strategies have been widely used in patients with coronary bifurcation lesions, but what is the optimization has not been clearly defined. This meta-analysis is to elucidate the benefits from modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions.

METHODS

Electronic databases were searched to identify studies comparing the modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions. The clinical outcomes were divided into early (≤6 months) and late (>6 months) events according to the follow-up duration. The early endpoints included cardiac death, myocardial infarction, target lesion revascularization or target vessel revascularization, and major adverse cardiac events (MACE), and the late endpoints also include stent thrombosis in addition to the early endpoints index. The angiographic endpoint was in-stent restenosis. Data were analyzed by the statistical software RevMan (version 5.3).

RESULTS

A total of 6 studies involving 1683 patients with coronary bifurcation lesions were included in this meta-analysis, which found that the modified double-stent strategy was associated with a lower risk of cardiac death (odds ratio [OR] = 0.29, 95% confidence intervals [CI] 0.11-0.78, P = .01), myocardial infarction (OR = 0.41, 95% CI 0.21-0.82, P = .01), target lesion revascularization or target vessel revascularization (OR = 0.31, 95% CI 0.15-0.63, P = .001), and MACE (OR = 0.41, 95% CI 0.22-0.74, P = .003) compared with provisional stenting in the early follow-up endpoint events, while the risk of cardiac death and stent thrombosis were similar between both strategies (OR = 0.59, 95% CI 0.31-1.10, P = .09; and OR = 0.62, 95% CI 0.34-1.15, P = .13; respectively) in the late follow-up endpoint events. There were significant differences between both strategies in myocardial infarction (OR = 0.42, 95% CI 0.24-0.75, P = .003), MACE (OR = 0.44, 95% CI 0.31-0.62, P < .00001), and target lesion revascularization or target vessel revascularization (OR 0.35, 95% CI 0.25-0.49, P < .00001) between both strategies in the late follow-up endpoint events. The risk of in-stent restenosis favored the modified double-stent strategy (OR 0.29, 95% CI 0.20-0.43, P < .00001).

CONCLUSION

The modified double-stent strategy is associated with excellent clinical and angiographic outcomes except for the occurrence of cardiac death and stent thrombosis late-term outcome compared with provisional stenting strategy in patients with coronary bifurcation lesions. These findings suggest that the modified double-stent strategy can be recommended as an optimization in patients with coronary bifurcation lesions.

Contemporary techniques in percutaneous coronary intervention for bifurcation lesions

INTRODUCTION

Treatment of coronary bifurcation lesions with contemporary state-of-the-art percutaneous coronary intervention (PCI) is still associated with higher rate of adverse cardiovascular events compared to non-bifurcation lesions. Bench testing and virtual computer modeling have increased our understanding of bifurcation PCI guiding refinement in bifurcation techniques. New insights on bifurcation PCI have the potential to further improve clinical outcomes in patients presenting with bifurcation lesions. Areas covered: The present manuscript aims to review the methods for bifurcation lesion assessment and treatment strategy step by step supported on bench and clinical evidence. Expert commentary: Invasive pressure-wire evaluation is essential to determine the appropriateness of bifurcation PCI, particularly in intermediate coronary stenosis. Treatment strategy relies on four parameters: diameters of the three segments of the bifurcation; lesion length and plaque distribution; and bifurcation angle. The optimal technique for bifurcation PCI is still debated, an individualized approach with an initial provisional side branch stenting strategy seems to be suitable in the 75 to 95% of patients. For more complex bifurcations, two-stent techniques may be required with increasing evidence supporting the usefulness of the double kissing balloon crush (DK-crush) technique.

Treatment of Bifurcation Lesions: Has DK Crush"ed" the Competition?

PURPOSE

This paper reviews the double-kiss crush (DK crush) technique in coronary artery bifurcation lesions. The technical aspects of the procedure and the clinical data supporting its use are summarized.

RECENT FINDINGS

Randomized studies support the adoption of DK technique in complex bifurcation lesions for both left main and non-left-main lesions. For true bifurcation lesions, DK crush may become the default technique for lesions in which the side-branch disease is complex and long. Optimal technique is essential for obtaining the clinical outcomes noted in the DKCRUSH randomized studies.

Intravascular ultrasound-guided drug-eluting stent implantation is associated with improved clinical outcomes in patients with unstable angina and complex coronary artery true bifurcation lesions

Stenting coronary artery bifurcation lesion is associated with suboptimal clinical results. Clinical improvement by intravascular ultrasound (IVUS) guided bifurcation stenting is controversial because small-side-branch (SB), low-risk patients and false bifurcations were included in previous studies that had no exact IVUS criteria for optimal stent expansion. We sought determine whether IVUS guidance is superior to angiography guidance for patients with true and complex bifurcation lesions. Between July 2006 and July 2012, 1465 patients with unstable angina and Medina 1,1,1 or 0,1,1 coronary bifurcation lesions were prospectively studied. 310 patients in the IVUS guidance (defined as stent symmetry index > 0.7, stent expansion index > 0.9, well apposition, and no Type B/C dissection) group were paired with 620 patients in the angiography group by propensity score-matching. The primary endpoint was the rate of composite major adverse cardiac events (MACE) (cardiac death, myocardial infarction (MI), or clinically-driven target vessel revascularization) at 1-year and at the end of study after indexed procedure. Use of IVUS guidance was mainly driven by stenting technique selection and identification of lesions' specificities. IVUS criteria for optimal stent expansion were achieved in 82.9% of patients which contribute to IVUS group data assessment and the rest did not meet optimal criteria. MACE occurred in 10.0% of patients at 1-year follow-up and 15.2% at the 7-year follow-up in the IVUS group, significantly different from 15.0% (p = 0.036) and 22.4% (p = 0.01) in the angiography group, respectively. Compared to angiography guidance, IVUS guidance also resulted in a lower 7-year cardiac death rate (6.5 versus 1.3%, p = 0.002) and MI (8.4 versus 2.3%, P < 0.001). Any revascularization was also statistically lower in the IVUS group through whole study period, compared to the angiography group. Lower MACE rates were observed in IVUS guidance group in a 7-year follow-up compared with angiography guidance alone.

Single- Versus 2-Stent Strategies for Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis of Randomized Trials With Long-Term Follow-up

Background

The majority of coronary bifurcation lesions are treated with a provisional single‐stent strategy rather than an up‐front 2‐stent strategy. This approach is supported by multiple randomized controlled clinical trials with short‐ to medium‐term follow‐up; however, long‐term follow‐up data is evolving from many data sets.

Methods and Results

Meta‐analysis of randomized controlled trials evaluating long‐term outcomes (≥1 year) according to treatment strategy for coronary bifurcation lesions. Nine randomized controlled trials with 3265 patients reported long‐term clinical outcomes at mean weighted follow‐up of 3.1±1.8 years. Provisional single stenting was associated with lower all‐cause mortality (2.94% versus 4.23%; risk ratio: 0.69; 95% confidence interval, 0.48–1.00; P=0.049; I²=0). There was no difference in major adverse cardiac events (15.8% versus 15.4%; P=0.79), myocardial infarction (4.8% versus 5.5%; P=0.51), target lesion revascularization (9.3% versus 7.6%; P=0.19), or stent thrombosis (1.8% versus 1.6%; P=0.28) between the groups. Prespecified sensitivity analysis of long‐term mortality at a mean of 4.7 years of follow‐up showed that the provisional single‐stent strategy was associated with reduced all‐cause mortality (3.9% versus 6.2%; risk ratio: 0.63; 95% confidence interval, 0.42–0.97; P=0.036; I²=0).

Conclusions

Coronary bifurcation percutaneous coronary intervention using a provisional single‐stent strategy is associated with a reduction in all‐cause mortality at long‐term follow‐up.

Current Interventions for the Left Main Bifurcation

Contemporary clinical trials, registries, and meta-analyses, supported by recent results from the EXCEL (Everolimus-Eluting Stents or Bypass Surgery for Left Main Coronary Artery Disease) and NOBLE (Percutaneous Coronary Angioplasty Versus Coronary Artery Bypass Grafting in Treatment of Unprotected Left Main Stenosis) trials, have established percutaneous coronary intervention of left main coronary stenosis as a safe alternative to coronary artery bypass grafting in patients with low and intermediate SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) scores. As left main percutaneous coronary intervention gains acceptance, it is imperative to increase awareness for patient selection, risk scoring, intracoronary imaging, vessel preparation, and choice of stenting techniques that will optimize procedural and patient outcomes.

Final kissing balloon inflation for coronary bifurcation lesions treated with single-stent technique : A meta-analysis

BACKGROUND

The efficacy of final kissing balloon (FKB) inflation in one-stent techniques for bifurcation lesions is controversial. The goal of the present study was to investigate the impact of FKB on long-term clinical outcomes in one-stent strategies.

METHODS

A literature search of the PubMed, Embase, and Cochrane Library databases was undertaken through August 2017. The primary outcome was major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction, and target lesion revascularization. Overall hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using the random-effects model.

RESULTS

Ten studies comprising 7364 patients treated with a one-stent technique were included in the analysis. Overall, FKB did not demonstrate a significant reduction in MACE compared with non-FKB in both randomized trials (HR: 1.13; 95% CI: 0.65-1.98) and observational studies (HR: 0.86; 95% CI: 0.61-1.20). The risk of cardiac death (HR: 0.89; 95% CI: 0.53-1.49), myocardial infarction (HR: 0.76; 95% CI: 0.53-1.09), and target lesion revascularization (HR: 0.96; 95% CI: 0.74-1.23) was also similar in both groups.

CONCLUSION

FKB may not be mandatory and a selective FKB strategy might be more justified in one-stent techniques for bifurcation lesions.

The Proximal Optimisation Technique for Intervention of Coronary Bifurcations

The proximal optimisation technique (POT) has been proposed as a strategy to improve the results of stent scaffolding of bifurcation lesions. It is a straightforward technique whereby a short, appropriately-sized balloon is inflated in the main vessel just proximal to the carina. The technique has several advantages: it reduces the risk of side branch compromise related to shifting of the carina, it improves stent apposition in the proximal main vessel, and it facilitates side branch access after main vessel stent implantation. When treating bifurcations, final kissing balloon dilation (KBD) has traditionally been used routinely to optimise angiographic results. However, recent clinical data have questioned this philosophy and bench models have demonstrated several shortcomings of KBD. Instead, the optimal strategy may centre on performing POT, followed by side branch dilation, and completed with a final (re)-POT. The following review article describes how to perform POT and presents the evidence to support its' routine use.