Comparative study of simple versus complex stenting of coronary artery bifurcation lesions in daily practice in Chinese patients

Comparison of Angiographic Outcomes of Side Branch Ostium at Bifurcation Coronary Lesion between Two-stent and One-stent Techniques

Although the favored strategy for coronary bifurcation intervention is stenting main vessel with provisional side branch (SB) stenting, we occasionally use two-stent strategy. The objective of this study was to investigate the angiographic outcome of SB ostium in two-stent group, compared with one-stent group. We analyzed 199 patients with bifurcation lesion who underwent percutaneous coronary intervention (PCI) with drug-eluting stent and follow up angiography. The patients were divided into one-stent group (167 lesions, 158 patients) and two-stent group (41 lesions, 41 patients). Prior to intervention, SB ostium minimal luminal diameter (MLD) was smaller in two-stent group than in one-stent group (1.08±0.55 mm vs. 1.39±0.60 mm; P=0.01). But, immediately after PCI, SB MLD of two-stent group became greater than that of one-stent group (2.41±0.40 mm vs. 1.18±0.68 mm; P<0.01). Six to nine months after PCI, this angiographic superiority in SB MLD of two-stent group persisted (1.56±0.71 mm vs. 1.13±0.53 mm; P<0.01), although there was larger late loss in two-stent group (0.85±0.74 mm vs. 0.05±0.57 mm; P<0.01). In terms of target lesion revascularization and target vessel revascularization rates, one-stent group showed better results than two-stent group. We could attain wider long term SB ostium after two-stent strategy than after one-stent strategy.

A provisional strategy for treating true bifurcation lesions employing a scoring balloon for the side branch: final results of the AGILITY trial

BACKGROUND

The provisional approach for bifurcation stenting with side-branch balloon angioplasty is associated with dissections and suboptimal results requiring kissing balloon techniques or bailout stenting. We hypothesized that using a scoring balloon for the side branch and a drug-eluting stent for the main vessel might improve outcomes of true bifurcation lesions.

METHODS AND RESULTS

A total of 93 patients with complex bifurcations were enrolled in a multicenter, single-arm, prospective clinical trial. A drug-eluting stent was deployed in the main vessel following dilatation of the side-branch stenosis with a scoring balloon. The overall angiographic success rate was 93.5%, and procedural success rate was 91.4%. The final diameter stenosis was 13.9% ± 7.2% for the main vessel and 33.3% ± 22.9% for the side branch. Crossover to stent deployment in the side branch was required in 10.8%. The postscoring balloon dissection rate was 8.2% and 6% (all ≤ class C) for the main vessel and side branch respectively, which was reduced to 1.1 and 2.1% poststenting. At 9-month follow-up, the composite MACE rate [cardiac death, myocardial infarction, or target lesion revascularization (TLR)] was 5.4%, including a TLR rate of 3.3% (1.1% from hospital discharge to 9 months).

CONCLUSION

The 9-month results of the AGILITY trial support a simple provisional strategy for treating complex true bifurcation lesions with deployment of a drug-eluting stent in the main vessel after dilatation of the side-branch vessel with a scoring balloon. This strategy was associated with excellent and safe procedural results, a low rate of crossover to side-branch stenting, and favorable outcomes.

Comparing two-stent strategies for bifurcation coronary lesions: which vessel should be stented first, the main vessel or the side branch?

This study compared two-stent strategies for treatment of bifurcation lesions by stenting order, 'main across side first (A-family)' vs 'side branch first (S-family). The study population was patients from 16 centers in Korea who underwent drug eluting stent implantation with two-stent strategy (A-family:109, S-family:140 patients). The endpoints were cardiac death, myocardial infarction (MI), stent thrombosis (ST), and target lesion revascularization (TLR) during 3 years. During 440.8 person-years (median 20.2 months), there was 1 cardiac death, 4 MIs (including 2 STs), and 12 TLRs. Cumulative incidence of cardiac death, MI and ST was lower in A-family (0% in A-family vs 4.9% in S-family, P = 0.045). However, TLR rates were not different between the two groups (7.1% vs 6.2%, P = 0.682). Final kissing inflation (FKI) was a predictor of the hard-endpoint (hazard ratio 0.061; 95% CI 0.007-0.547, P = 0.013), but was not a predictor of TLR. The incidence of hard-endpoint of S-family with FKI was comparable to A-family, whereas S-family without FKI showed the poorest prognosis (1.1% vs 15.9%, retrospectively; P = 0.011). In conclusion, 'A-family' seems preferable to 'S-family' if both approaches are feasible. When two-stent strategy is used, every effort should be made to perform FKI, especially in 'S-family'.

Stent thrombosis following 2 drug-eluting stent implantations for coronary bifurcation lesion: a single-center analysis

BACKGROUND

The incidence of stent thrombosis (ST) following 2 drug-eluting stent (DES) implantations for coronary bifurcation lesions needs to be identified.

METHODS

From April 2004 to April 2009, 705 consecutive patients with true bifurcation lesions who underwent a double stenting procedure with DES at the Fu Wai Hospital were analyzed.

RESULTS

Six (0.85%) patients had a definite ST, all of them had an early (4 acute and 2 subacute) definite ST. Probable ST occurred in 4 patients; in all of these cases, the event occurred early and was adjudicated because of the occurrence of sudden death within 30 days of the procedure. Therefore, a total of 10/705 (1.42%) patients had a definite or probable ST. Possible stent thrombosis was adjudicated only in 1 patient 371 days after the initial PCI in whom the cause of death was unexplained. Compared to the patients without definite and probable ST, patients with definite and probable ST were older, had more unstable angina, lower LVEF, and more left main bifurcation lesions (63.2 +/- 8.9 vs. 56.8 +/- 10.9 yrs; P = 0.049, 100% vs. 64.7%; P = 0.018, 50.6 +/- 9.9 vs. 60.3 +/- 12.4%; P = 0.019 and 70.0% vs. 36.1%; P = 0.043). Logistic analysis results indicated that only LVEF (OR 0.92, 95% CI 0.87-0.93; P = 0.017) was associated with definite and probable ST.

CONCLUSIONS

The present study indicates that modern 2-DES technique for bifurcation lesions was comparatively safe with a low incidence of ST.