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Hildick-Smith D, Behan MW, Lassen JF, Chieffo A, Lefèvre T, Stankovic G, Burzotta F, Pan M, Ferenc M, Bennett L, Hovasse T, Spence MJ, Oldroyd K, Brunel P, Carrie D, Baumbach A, Maeng M, Skipper N, Louvard Y. The EBC TWO Study (European Bifurcation Coronary TWO): A Randomized Comparison of Provisional T-Stenting Versus a Systematic 2 Stent Culotte Strategy in Large Caliber True Bifurcations. Circ Cardiovasc Interv 2017; 9:CIRCINTERVENTIONS.115.003643. [PMID: 27578839 DOI: 10.1161/circinterventions.115.003643] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 07/15/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND For the treatment of coronary bifurcation lesions, a provisional strategy is superior to systematic 2-stent techniques for the most bifurcation lesions. However, complex anatomies with large side branches (SBs) with significant ostial disease length are considered by expert consensus to warrant a 2-stent technique upfront. This consensus view has not been scientifically assessed. METHODS AND RESULTS Symptomatic patients with large caliber true bifurcation lesions (SB diameter ≥2.5 mm) and significant ostial disease length (≥5 mm) were randomized to either a provisional T-stent strategy or a dual stent culotte technique. Two hundred patients aged 64±10 years, 82% male, were randomized in 20 European centers. The clinical presentations were stable coronary disease (69%) and acute coronary syndromes (31%). SB stent diameter (2.67±0.27 mm) and length (20.30±5.89 mm) confirmed the extent of SB disease. Procedural success (provisional 97%, culotte 94%) and kissing balloon inflation (provisional 95%, culotte 98%) were high. Sixteen percent of patients in the provisional group underwent T-stenting. The primary end point (a composite of death, myocardial infarction, and target vessel revascularization at 12 months) occurred in 7.7% of the provisional T-stent group versus 10.3% of the culotte group (hazard ratio, 1.02; 95% confidence interval, 0.78-1.34; P=0.53). Procedure time, x-ray dose, and cost all favored the simpler procedure. CONCLUSIONS When treating complex coronary bifurcation lesions with large stenosed SBs, there is no difference between a provisional T-stent strategy and a systematic 2-stent culotte strategy in a composite end point of death, myocardial infarction, and target vessel revascularization at 12 months. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT 01560455.
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Affiliation(s)
- David Hildick-Smith
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Miles W Behan
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.).
| | - Jens F Lassen
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Alaide Chieffo
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Thierry Lefèvre
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Goran Stankovic
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Francesco Burzotta
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Manuel Pan
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Miroslaw Ferenc
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Lorraine Bennett
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Thomas Hovasse
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Mark J Spence
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Keith Oldroyd
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Philippe Brunel
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Didier Carrie
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Andreas Baumbach
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Michael Maeng
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Nicola Skipper
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
| | - Yves Louvard
- From the Sussex Cardiac Centre, Brighton and Sussex University Hospitals, United Kingdom (D.H.-S., L.B., N.S.); Edinburgh Heart Centre, United Kingdom (M.W.B.); Department of Cardiology, Aarhus University Hospital, Skejby, Denmark (J.F.L., M.M.); Department of Cardiology, San Raffaele Scientific Institute, Milan, Italy (A.C.); Institute Cardiovasculaire Paris Sud, Hospital Privé Jacques Cartier, Massy, France (T.L., T.H., Y.L.); Department of Cardiology, Clinical Centre of Serbia, Belgrade (G.S.); Medical Faculty, University of Belgrade, Serbia (G.S.); Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy (F.B.); Department of Cardiology, Reina Sofia Hospital, University of Cordoba, Spain (M.P.); University Heart Center Freiburg, Bad Krozingen, Germany (M.F.); Department of Cardiology, Royal Victoria Hospital, Belfast, United Kingdom (M.J.S.); Department of Cardiology, Golden Jubilee National Hospital, Glasgow, United Kingdom (K.O.); Department of Cardiology, Clinique de Fontaine-les-Djon, France (P.B.); Department of Cardiology, Rangueil Hospital, Toulouse, France (D.C.); and Bristol Heart Institute, United Kingdom (A.B.)
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Behan MW, Holm NR, Curzen NP, Erglis A, Stables RH, de Belder AJ, Niemelä M, Cooter N, Chew DP, Steigen TK, Oldroyd KG, Jensen JS, Lassen JF, Thuesen L, Hildick-Smith D. Simple or Complex Stenting for Bifurcation Coronary Lesions. Circ Cardiovasc Interv 2011; 4:57-64. [DOI: 10.1161/circinterventions.110.958512] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Controversy persists regarding the correct strategy for bifurcation lesions. Therefore, we combined the patient-level data from 2 large trials with similar methodology: the NORDIC Bifurcation Study (NORDIC I) and the British Bifurcation Coronary Study (BBC ONE).
Methods and Results—
Both randomized trials compared simple (provisional T-stenting) versus complex techniques, using drug-eluting stents. In the simple group (n=457), 129 patients had final kissing balloon dilatation in addition to main vessel stenting, and 16 had T-stenting. In the complex group (n=456), 272 underwent crush, 118 culotte, and 59 T-stenting techniques. A composite end point at 9 months of all-cause death, myocardial infarction, and target vessel revascularization occurred in 10.1% of the simple versus 17.3% of the complex group (hazard ratio 1.84 [95% confidence interval 1.28 to 2.66],
P
=0.001). Procedure duration, contrast, and x-ray dose favored the simple approach. Subgroup analysis revealed similar composite end point results for true bifurcations (n=657, simple 9.2% versus complex 17.3%; hazard ratio 1.90 [95% confidence interval 1.22 to 2.94],
P
=0.004), wide-angled bifurcations >60 to 70° (n=217, simple 9.6% versus complex 15.7%; hazard ratio 1.67 [ 95% confidence interval 0.78 to 3.62],
P
=0.186), large (≥2.75 mm) diameter side branches (n=281, simple 10.4% versus complex 20.7%; hazard ratio 2.42 [ 95% confidence interval 1.22 to 4.80],
P
=0.011), longer length (>5 mm) ostial side branch lesions (n=464, simple 12.1% versus complex 19.1%; hazard ratio 1.71 [95% confidence interval 1.05 to 2.77],
P
=0.029), or equivalent sized vessels (side branch <0.25 mm smaller than main vessel) (n=108, simple 12.0% versus complex 15.5%; hazard ratio 1.35 [95% confidence interval 0.48 to 3.70],
P
=0.57).
Conclusions—
For bifurcation lesions, a provisional single-stent approach is superior to systematic dual stenting techniques in terms of safety and efficacy. A complex approach does not appear to be beneficial in more anatomically complicated lesions.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT 00376571 and NCT 00351260.
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Affiliation(s)
- Miles W. Behan
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Niels R. Holm
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Nicholas P. Curzen
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Andrejs Erglis
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Rodney H. Stables
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Adam J. de Belder
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Matti Niemelä
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Nina Cooter
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Derek P. Chew
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Terje K. Steigen
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Keith G. Oldroyd
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Jan S. Jensen
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Jens Flensted Lassen
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - Leif Thuesen
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
| | - David Hildick-Smith
- From the Golden Jubilee National Hospital (M.W.B., K.G.O.), Glasgow, United Kingdom; Department of Cardiology (N.R.H., J.F.L., L.T.), Aarhus University Hospital, Skejby, Aarhus, Denmark; Southampton University Hospitals (N.P.C.), Southampton, United Kingdom; Latvian Centre of Cardiology (A.E.), Paul Stradins Clinical Hospital, Riga, Latvia; Liverpool Heart and Chest Hospital (R.H.S.), Liverpool, United Kingdom; Sussex Cardiac Centre (A.J.d.B., N.C., D.H.-S.), Brighton and Sussex University Hospitals
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