Stenting of coronary bifurcation lesions by using modified crush technique with double kissing balloon inflation (sleeve technique): Immediate procedure result and short-term clinical outcomes

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.

Angiographic and long-term clinical outcome of the sleeve technique in treating in-stent restenotic bifurcation lesions: a preliminary experience

BACKGROUND

No data has been published on the management of in-stent restenotic bifurcation lesions. The aim of this small case series was to examine the angiographic and long-term clinical outcomes of using sleeve technique to treat this lesion subset.

METHODS

Six consecutive and symptomatic patients with MEDINA classification 1,1,1 in-stent restenotic bifurcation lesion were treated with drug-eluting stents using sleeve technique. Dual antiplatelet therapy was prescribed for an average of 13.5 ± 2.3 months.

RESULTS

Most of the lesions (87%) were located at LAD/diagonal branch bifurcation. Kissing balloon inflation was performed successfully in all the patients. Follow-up angiography at nine months revealed a late loss of 0.35 ± 0.26 mm and 0.56 ± 0.56 mm in MV and SB, respectively. Angiographic restenosis was developed in 2 patients (33%), which were all located at the SB ostium. No in-hospital MACE was observed. One-year MACE was 17%, attributed by 1 patient with restenosis who needed revascularization. The mean follow up period was 50 ± 18 months, no stent thrombosis was detected.

CONCLUSIONS

The use of sleeve technique to treat in-stent restenotic bifurcation lesions is associated with good acute procedural result, a fairly low one-year MACE and long-term clinical safety.

Mini-crush versus T-provisional techniques in bifurcation lesions: clinical and angiographic long-term outcome after implantation of drug-eluting stents

OBJECTIVES

This retrospective study sought to assess the clinical and angiographic long-term outcome after implanting drug-eluting stents in bifurcation lesions with the T-provisional (T-prov) technique and mini-crush (MC) technique.

BACKGROUND

The best option on the treatment of coronary bifurcation lesions is a subject of considerable debate. However, recent evidence suggests that bifurcation lesions might be treated by drug-eluting stent on both branches using the MC technique with a low rate of major adverse cardiac event and restenosis.

METHODS

From April 2004 to July 2006, 457 patients were consecutively treated with either MC technique (n = 199) or T-prov technique (n = 258). Of these latter, 170 patients were treated with 1 stent and 88 patients with 2 stents. The 9-month angiographic follow-up was completed in 188 of 229 (82.1%) bifurcation lesions of MC patients and in 207 of 266 lesions (77.8%) of T-prov patients.

RESULTS

After a propensity score adjustment, 2-year cumulative major adverse cardiac events were similar between groups (p = 0.16). The MC group compared with the T-prov 1-stent group had significantly lower main and side branches restenosis (hazard ratio [HR]: 0.52, 95% confidence interval [CI]: 0.27 to 0.99; p = 0.047; and HR: 0.41, 95% CI: 0.20 to 0.85; p = 0.016, respectively). However, the MC group compared with the T-prov-only group had significantly lower side branch restenosis (HR: 0.55, 95% CI: 0.37 to 0.82; p = 0.004).

CONCLUSIONS

Both techniques of bifurcation treatment met high procedural success with low complication rates and similar major adverse cardiac event long-term outcome. However, the MC technique yields a lower restenosis rate at both main and side branches. These results may confirm the advantage of using prescheduled 2-stent technique to give a complete coverage of the side branches' ostium.

Long-term clinical and angiographic outcomes of the sleeve technique on non-left-main coronary bifurcation lesions

AIMS

The purpose of this study was to examine the long-term results of the sleeve technique, which is a modification of the crush technique and capable of increasing the success of final kissing balloon inflation (FKB) in the treatment of non-left-main coronary bifurcation lesions.

METHODS AND RESULTS

Forty-five patients with 45 non-left-main coronary bifurcation stenoses were treated with drug-eluting stents (DES) using the sleeve technique and prospectively evaluated. Follow-up angiography was performed on 41 patients (91%) at nine months. The mean age of patient was 65 years with predominance of male (73%); FKB was successfully performed in all patients. Post-procedure myocardial infarction was observed in four patients, leading to an in-hospital major adverse cardiac event (MACE) rate of 9%. At angiographic follow-up, the late loss in the main vessel and side-branch was 0.18+/-0.26 mm and 0.29+/-0.27 mm, respectively. Binary angiographic restenosis was seen in two patients (4.7%) at main vessel and one patient (2.4%) at side-branch. At 1-year follow-up, there were two non-cardiac deaths and three patients needed revascularisation.

CONCLUSIONS

The use of the sleeve technique and DES in the treatment of non-left-main coronary bifurcation lesions is associated with a low angiographic restenosis, particularly at side branch ostium, and long-term safety.

Importance of kissing balloon inflation in bifurcation stenting

Percutaneous bifurcation intervention is usually sufficient with a single-stent strategy. When the double-stent strategy is employed, higher restenosis and target lesion revascularization (TLR) rates are observed, especially at the side-branch ostium. The results may be improved, however, with refinement in techniques, for example, final kissing balloon inflation and double kissing balloon inflation.