True coronary bifurcation lesions: meta-analysis and review of literature

Predictors and 3-year outcomes of compromised left circumflex coronary artery after left main crossover stenting

BACKGROUND

There are few predictors of decreased fractional flow reserve (FFR) in the left circumflex coronary artery (LCx) after left main (LM) crossover stenting.

OBJECTIVES

We aimed to determine the predictors for low FFR at LCx and possible treatment strategies for compromised LCx, together with their long-term outcomes.

METHODS

Altogether, 563 patients who met the inclusion criteria were admitted to our hospital from February 2015 to November 2020 with significant distal LM bifurcation lesions. They underwent single-stent crossover percutaneous coronary intervention (PCI) under intravascular ultrasound (IVUS) guidance with further LCx intervention based on the measured FFR.

RESULTS

The patients showed significant angiographic LCx ostial affection post-LM stenting, but only 116 (20.6%) patients had FFR < 0.8. The three-year composite major adverse cardiac events (MACE) rates were comparable between the high and low FFR groups (16.8% vs. 15.5; p = 0.744). In a multivariate analysis, low FFR at the LCx was associated with post-stenting minimal luminal area (MLA) of LCx (odds ratio [OR]: 0.032, p < .001), post-stenting LCx plaque burden (OR: 1.166, p < .001), poststenting LM MLA (OR: 0.821, p = .038), and prestenting LCx MLA (OR: 0.371, p = .044). In the low FFR group, those with compromised LCx managed with drug-eluting balloon had the lowest three-year MACE rate (8.1%), as compared to either those undergoing kissing balloon inflation (KBI) (17.5%) or stenting (20.5%) (p = 0.299).

CONCLUSION

Unnecessary LCx interventions can be avoided with FFR-guided LCx intervention. Poststenting MLA and plaque burden of the LCx, and main vessel stent length are poststenting predictors of low FFR.

5-Year Outcomes According to FFR of Left Circumflex Coronary Artery After Left Main Crossover Stenting

OBJECTIVES

The aim of the current study was to evaluate the long-term clinical impact of fractional flow reserve (FFR) in jailed left circumflex coronary artery (LCx) after left main coronary artery (LM) simple crossover stenting.

BACKGROUND

Although the provisional side-branch intervention with FFR guidance has been validated for non-LM bifurcation lesions, the outcome of such a strategy in LM bifurcation disease is not well-known.

METHODS

Patients who underwent LM-to-left anterior descending coronary artery simple crossover stenting and who had FFR measurements in the LCx thereafter were enrolled. A low FFR was defined as ≤0.80. The clinical outcomes were assessed by the 5-year rate of target lesion failure (TLF) (a composite of cardiac death, target-vessel myocardial infarction, or target lesion revascularization).

RESULTS

In 83 patients, the mean FFR of the LCx after LM stenting was 0.87 ± 0.08, and 14 patients (16.9%) had a low FFR. There was no correlation between the FFR and angiographic % diameter stenosis in jailed LCx (R² = 0.039; p = 0.071) and there was no difference in the angiographic % diameter stenosis in the high and low FFR groups. At 5 years, the low FFR group had a significantly higher rate of TLF than the high FFR group (33.4% vs. 10.7%; hazard ratio: 4.09, 95% confidence interval: 1.15 to 14.52; p = 0.029). However, there was no difference in the clinical outcomes according to the angiographic % diameter stenosis. In a multivariate analysis, a low FFR was an independent predictor of the risk for a 5-year TLF (hazard ratio: 6.49; 95% confidence interval: 1.37 to 30.73; p = 0.018).

CONCLUSIONS

The patients with a high FFR in jailed LCx had better 5-year outcomes than those with a low FFR. The FFR measurement in jailed LCx can be helpful in selecting an adequate treatment strategy and may reduce unnecessary complex procedures.

Prognostic significance of the Medina classification in bifurcation lesion percutaneous coronary intervention with second-generation drug-eluting stents

The Medina classification is the most widespread method to describe bifurcation lesions. However, little is known regarding its prognostic impact. Therefore, the aim of this study is to assess the prognostic significance of the Medina classification following percutaneous coronary intervention (PCI). From a prospective registry of 738 consecutive patients undergoing PCI for bifurcation lesions, 505 were treated with second-generation drug-eluting stents (DES). Of these, 407 (80.6%) presented with "true bifurcation" (TB) lesions (Medina class 1.0.1, 1.1.1, 0.1.1) and 98 (19.4%) in all other categories ("non-true bifurcation" = NTB). We compared rates of death and major adverse cardiac events (MACE: cardiac death, myocardial infarction, or target vessel revascularization) at 12 months and 3 years. Patients with TB had lower rates of previous bypass surgery (7.4% vs. 11.2%, p = 0.043). TB lesions were more likely to be calcified (33.9% vs. 28.6%, p = 0.003) and ulcerated (8.8% vs. 4.1%, p < 0.01). At 12 months, mortality was numerically higher for TB PCI (4.1% vs. 2.1%, p = 0.052) and MACE rates were higher (19.2% vs. 10.2%, p < 0.001). At 3 years, both all-cause death (10.1% vs. 5.1%, p = 0.002) and rates of MACE (37.2% vs. 17.6%, p < 0.001) were higher for TB PCI. After performing regression analysis, TB remained an independent predictor for poor outcomes (OR-2.28 at 12 months, CI 1.45-9.50, p = 0.007, OR-3.75 at 3 years, CI 1.52-6.77, p = 0.001 for MACE). In conclusion, TB lesions, according to the Medina classification, portend worse prognosis for patients undergoing bifurcation PCI. This may guide prognostication and decision-making in treatment.

Building a cloud-based data sharing model for the Saudi national registry for implantable medical devices: Results of a readiness assessment

BACKGROUND

Implantable medical device registries are used as a medium to conduct post-marketing surveillance. Little information is available on the development and implementation of implantable biomedical device registries in general and specifically in Saudi Arabia and the Middle East.

OBJECTIVES

This study presents the experiences of building an implantable medical device registry in the Kingdom of Saudi Arabia. The work specifically addresses the early experiences of the Saudi Food and Drug Authority in the planning and development of a data sharing model for the implementation of a medical device registry at different hospital sites within the country.

METHODS

A two-year case study in which 60 health professionals from 5 hospitals in Saudi Arabia participated in a readiness assessment survey. The readiness assessment examined system-level capacity, hospital workflow and operations, clinical staff-level engagement, and technological assessment as they relate to the implementation of the Implantable Medical Device Registry (IMDR). Both subjective and objective data were collected as part of the readiness assessment survey at each hospital site. Data was collected from participants either individually or as part of a group at each hospital site. Using Microsoft Excel, Microsoft Word, flip charts, and back-and-forth discussion, the data was descriptively summarized and synthesized to provide an overview of hospital readiness for IMDR implementation.

RESULTS

Results show that there are large differences among Saudi hospitals in terms of their readiness for IMDR implementation due to a variety of factors relating to differences in hospital-wide organizational systems, clinical practice, technological infrastructure, and data sharing capabilities. Each of the hospitals surveyed in this study had differences in how clinical biomedical implantation policies and procedures were utilized. Manual entry into the cloud-based IMDR was recommended as the most optimal data sharing model that would mitigate the differences between hospital readiness for IMDR implementation.

CONCLUSION

Registries play a major role in monitoring the effectiveness of implantable biomedical devices. National standardized policies, enforced regulations, and information technology infrastructure are needed to achieve this goal. Furthermore, due to differences in hospital readiness, building a cloud-based registry system through manual data entry into the IMDR was found to be the most appropriate data sharing model that can be implemented at the national level.

Impact of Percutaneous Coronary Revascularization of Severe Coronary Lesions on Secondary Branches

INTRODUCTION AND OBJECTIVES

To analyze the percutaneous revascularization strategy for severe lesions in the secondary branches (SB) (diameter ≥ 2mm) of major epicardial arteries compared with conservative treatment.

METHODS

This study analyzed patients with severe SB lesions who underwent percutaneous revascularization treatment compared with patients who received pharmacological treatment. The study examined the percentage of branch-related events (cardiovascular death, myocardial infarction attributable to SB, or the need for revascularization of the SB).

RESULTS

We analyzed 679 SB lesions (662 patients). After a mean follow-up of 22.2±10.5 months, there were no significant differences between the 2 treatment groups regarding the percentage of death from cardiovascular causes (1.7% vs 0.4%; P=.14), nonfatal acute myocardial infarction (AMI) (1.7% vs 1.7%; P=.96), the need for SB revascularization (4.1% vs 5.4%; P=.45) or in the total percentage of events (5.1% vs 6.3%; P=.54). The variables showing an association with event occurrence on multivariate analysis were diabetes (SHR, 2.87; 95%CI, 1.37-5.47; P=.004), prior AMI (SHR, 3.54; 95%CI, 1.77-7.30; P<.0001), SB reference diameter (SHR, 0.16; 95%CI, 0.03-0.97; P=.047), and lesion length (SHR, 3.77; 95%CI, 1.03-1.13; P<.0001). These results remained the same after the propensity score analysis.

CONCLUSIONS

The percentage of SB-related events during follow-up is low, with no significant differences between the 2 treatment strategies. The variables associated with event occurrence in the multivariate analysis were the presence of diabetes mellitus, prior AMI, and greater lesion length.

Prewire channel stent: a novel stent for bifurcation lesions in a pig model

AIMS

Avoiding side branch occlusion is challenging when treating bifurcation lesions. A newly designed stent system called the prewire channel stent (PWCS) with a side channel positioned between the metallic mesh material and the balloon is introduced. We aimed to compare the time taken to position the PWCS against that for a conventional stent.

METHODS AND RESULTS

The PWCS and a conventional stent were used in a pig model. The time taken from the starting point with the stent outside the body to reaching the bifurcation of the vessel ready for further procedures such as balloon dilatation through the stent mesh opening and double kissing balloon technique, etc., was compared in the conventional stent and PWCS groups. The time taken in the PWCS stent group included the time from sending the stent from outside the body to the desired position of the bifurcation of the vessels of the heart, releasing the stent and pulling back the balloon (SB time). The time taken in the conventional stent included the time from sending the stent from outside the body to the desired position of the bifurcation of the vessels of the heart, releasing the stent, pulling back the balloon (SB time), and wire exchange (WE time). The SB times for the PWCS and the conventional stent groups were not different (28.5±3.8 vs. 25.25±0.75 seconds, n=4). The PWCS group did not have "wire exchange," and had no WE time, which was 28.5±5.7 seconds in the conventional stent group. The total time spent in the PWCS group was 28.5±3.8 seconds, which was shorter than the 53.75±6.2 seconds (n=4, p<0.05) in the conventional stent group.

CONCLUSIONS

The PWCS makes "wire exchange" in the side branch (SB) unnecessary and it can be as easily manipulated as a conventional stent.

Feasibility and usefulness of three-dimensional optical coherence tomography guidance for optimal side branch treatment in coronary bifurcation stenting

BACKGROUND

For the treatment of coronary bifurcation lesions, optimal guidewire (GW) recrossing after main vessel stenting is important for good stent apposition at the side branch (SB) orifice in kissing balloon inflation (KBI).

METHODS

We analyzed 150 bifurcation lesions treated with single stenting following KBI in the three-dimensional optical coherence tomography (3D-OCT) bifurcation registry study (2015-16) and a single center experience (2012-16). OCT examination was performed after GW recrossing to the SB and after KBI. Patients were divided into two-dimensional (2D, n=78) and 3D groups (n=72) according to 2D- or 3D-OCT guidance. GW recrossing position, jailing configuration of the stent over the SB (divided into Link-connecting type: stent link connecting to the carina and Link-free type: no stent link at the carina) and stent apposition were compared between the groups.

RESULTS

Distal GW recrossing was achieved in 75.6% and 91.7% in the 2D and 3D groups, respectively (P=0.004). Compared with the 2D group, the incidence of incomplete stent apposition (ISA) toward the SB in the 3D group tended to be lower in the whole cohort (14.5±13.6% vs 10.0±9.0%, P=0.077), and was significantly lower in left main trunk bifurcations (18.7±12.8% vs 10.3±8.9%, P=0.014). Independent contributors to ISA were the Link-connecting type (β 0.089, P<0.001), distal GW recrossing (β -0.078, P=0.001), and age (β -0.0020, P=0.012).

CONCLUSION

Optimal GW recrossing under 3D-OCT guidance is feasible and improves stent apposition, which may lead to a better clinical outcome in the treatment of bifurcation lesions.

A Novel Tram Stent Method in the Treatment of Coronary Bifurcation Lesions - Finite Element Study

A novel stent was designed for the treatment of coronary bifurcation lesion, and it was investigated for its performance by finite element analysis. This study was performed in search of a novel method of treatment of bifurcation lesion with provisional stenting. A bifurcation model was created with the proximal vessel of 3.2 mm diameter, and the distal vessel after the side branch (2.3 mm) was 2.7 mm. A novel stent was designed with connection links that had a profile of a tram. Laser cutting and shape setting of the stent was performed, and thereafter it was crimped and deployed over a balloon. The contact pressure, stresses on the arterial wall, stresses on the stent, the maximal principal log strain of the main artery and the side-branch were studied. The study was performed in Abaqus, Simulia. The stresses on the main branch and the distal branch were minimally increased after deployment of this novel stent. The side branch was preserved, and the stresses on the side branch were lesser; and at the confluence of bifurcation on either side of the side branch origin the von-Mises stress was marginally increased. The stresses and strain at the bifurcation were significantly lesser than the stresses and strain of the currently existing techniques used in the treatment of bifurcation lesions though the study was primarily focused only on the utility of the new technology. There is a potential for a novel Tram-stent method in the treatment of coronary bifurcation lesions.

Long-term outcomes of simple crossover stenting from the left main to the left anterior descending coronary artery

BACKGROUND/AIMS

Although complex bifurcation stenting in patients with non-left main (LM) bifurcation lesions has not yielded better clinical outcomes than simpler procedures, the utility of complex bifurcation stenting to treat LM bifurcation lesions has not yet been adequately explored.

METHODS

In the present study, patients who underwent LM-to-left anterior descending (LAD) coronary artery simple crossover stenting to treat significant de novo distal LM or ostial LAD disease, in the absence of angiographically significant ostial left circumflex (LCX) coronary artery disease, were consecutively enrolled. The frequencies of 3-year major adverse cardiovascular events (MACEs; cardiac death, myocardial infarction, and target lesion revascularization), were analyzed.

RESULTS

Of 105 eligible consecutive patients, only 12 (11.4%) required additional procedures to treat ostial LCX disease after main vessel stenting. The mean percentage diameter of ostial LCX stenosis increased from 22.5% ± 15.2% to 32.3% ± 16.3% (p < 0.001) after LM-to-LAD simple crossover stenting. The 3-year incidence of MACEs was 9.7% (cardiac death 2.2%; myocardial infarction 2.2%; target lesion revascularization 8.6%), and that of stent thrombosis 1.1%. Of seven cases (7.5%) requiring restenosis, pure ostial LCX-related repeat revascularization was required by only two.

CONCLUSIONS

Simple crossover LM-to-LAD stenting without opening of a strut on the LCX ostium was associated with acceptable long-term clinical outcomes.

Assessment of side branch predilation before a provisional T-stent strategy for bifurcation lesions. A randomized trial

BACKGROUND

A simple approach is the predominant strategy for the percutaneous coronary intervention of bifurcation lesions. Performing side branch (SB) predilation in this context is currently a matter of controversy. In this study, we assess the efficacy of SB predilatation before a provisional T-stent strategy for bifurcation lesions.

METHODS

Between February 2009 and November 2012, 372 patients with true bifurcation lesions were randomized to either predilation of the SB (n = 187) or no predilatation (n = 185) before main branch (MB) stent implantation and a subsequent SB provisional stent strategy.

RESULTS

There were no significant differences between the patient groups regarding the baseline characteristics. After MB stent implantation, the TIMI flow of the SB was higher in the patients with SB predilation: TIMI flow 0 to 1; 2 (1%) versus 18 (10%), P < .001; and TIMI flow III; 179 (96%) versus 152 (82%), P < .001. Side branch stenting rates were 4% versus 3%, P = not significant. In addition, 60 patients (32%) from the SB predilation group presented SB residual stenosis by visual inspection <50%, and TIMI flow ≥III did not require any additional treatment. The failure rate of SB rewiring, the time of rewiring, the number of wires used, and the incidence of major events were similar in both groups of patients.

CONCLUSIONS

Predilation of the SB resulted in improved TIMI flow after MB stenting and less indication to subsequently treat the SB. If rewiring of the SB is required, predilation did not hinder this maneuver.

Dedicated two-stent technique in complex bifurcation percutaneous coronary intervention with use of everolimus-eluting stents: the EES-bifurcation study

OBJECTIVES

To compare the outcomes of initial one-stent (1S) versus dedicated two-stent (2S) strategies in complex bifurcation percutaneous coronary intervention (PCI) using everolimus-eluting stents (EES).

BACKGROUND

PCI of true bifurcation lesions is technically challenging and historically associated with reduced procedural success and increased restenosis. Prior studies comparing initial one-stent (1S) versus dedicated two-stent (2S) strategies using first-generation drug-eluting stents have shown no reduction in ischemic events and more complications with a 2S strategy.

METHODS

We performed a retrospective study of 319 consecutive patients undergoing PCI at a single referral center with EES for true bifurcation lesions, defined by involvement of both the main vessel (MV) and side branch (SB). Baseline, procedural characteristics, quantitative coronary angiography and clinical outcomes in-hospital and at one year were compared for patients undergoing 1S (n=175) and 2S (n=144) strategies.

RESULTS

Baseline characteristics were well-matched. 2S strategy was associated with greater SB acute gain (0.65±0.41 mm vs. 1.11±0.47 mm, p<0.0001). In-hospital serious adverse events were similar (9% with 2S vs. 8% with 1S, p=0.58). At one year, patients treated by 2S strategy had non-significantly lower rates of target vessel revascularization (5.8% vs. 7.4%, p=0.31), myocardial infarction (7.8% vs. 12.2%, p=0.31) and major adverse cardiovascular events (16.6% vs. 21.8%, p=0.21).

CONCLUSION

In this study of patients undergoing PCI for true coronary bifurcation lesions using EES, 2S strategy was associated with superior SB angiographic outcomes without excess complications or ischemic events at one year.

Overview of Technical and Cost Considerations in Complex Percutaneous Coronary Intervention

Complex percutaneous coronary intervention (PCI), encompassing an ever-expanding range of challenging lesion sets and patient populations, accounts for a significant proportion of PCI procedures being performed currently. Specific lesion types associated with lower rates of procedural success and higher rates of recurrence or major adverse cardiac events (MACE) include multivessel disease, unprotected left main coronary artery disease, fibrocalcific or undilatable lesions, chronic total occlusions, degenerated saphenous vein graft lesions, thrombotic lesions, and bifurcation disease. Validated tools and technical strategies currently exist to address most procedural scenarios encountered and should be familiar to the complex PCI operator. Anticipated clinical outcomes, projected resource utilization, and cost considerations should all factor into the decisions of when, how, and in whom to intervene.

Rotablation in the treatment of high-risk patients with heavily calcified left-main coronary lesions

Objective

Heavily calcified left-main coronary diseases (LMCA) remain a formidable challenge for percutaneous interventions (PCI). This study was to investigate the safety and efficacy of using rotational atherectomy (RA) in treating such lesions in actual practice.

Methods

From February 2004 to March 2012, all consecutive patients who received RA for heavily-calcified LMCA lesions in our cath lab were enrolled. The relevant clinical and angiographic characteristics at the time of index PCI, as well as the clinical follow-up outcomes, were retrieved and analyzed.

Results

A total of 34 consecutive patients were recruited with a mean age 77.2 ± 10.2 years. There were 82.4% presented with acute coronary syndrome and 11.8% with cardiogenic shock. Chronic renal disease and diabetes were seen in 64.7% and 52.9%, respectively. Triple-vessel coronary disease was found in 76.5% of them. The mean SYNTAX score was 50 ± 15 and EuroSCORE II scale 5.6 ± 4.8. The angiographic success rate was 100% with a procedural success rate of 91.2%. The mean number of burrs per patient was 1.7 ± 0.5. Crossing-over stenting was used in 64.7%. Most stents were drug-eluting (67.6%). Intra-aortic ballon pump was used in 20.6% of the procedures. Three patients died during hospitalization, all due to presenting cardiogenic shock. No major complication occurred. Among 31 hospital survivors, the major adverse cardiac events (MACE) rate was 16.1%, all due to target lesion revascularization or target vessel revascularization.

Conclusions

In high-surgical-risk elderly patients, plaque modification with RA in PCI of heavily-calcified LMCA could be safely accomplished with a minimal complication rate and low out-of-hospital MACE.

Long-term outcomes following primary drug-eluting stenting of infrapopliteal bifurcations

PURPOSE

To investigate the outcomes following primary deployment of drug-eluting stents (DES) for the treatment of infrapopliteal bifurcation lesions in patients suffering from critical limb ischemia (CLI).

METHODS

This was a retrospective study of a registry enrolling all patients suffering from chronic infrapopliteal artery disease and undergoing treatment of tibial bifurcation lesions with DES using 3 techniques: balloon and stent (single stent), T-shape double-stent, and culotte double-stent. The analysis included 39 CLI patients (32 men; mean age 69 ± 10 years) who underwent primary stenting of 41 infrapopliteal bifurcations. Most patients (29, 70.7%) were classified as Rutherford category 4. The mean lesion length was 31.3 ± 13.1 mm. The primary endpoints were amputation-free survival, target lesion revascularization (TLR)-free survival, angiographic 2-vessel primary patency (2VPP), and 1-vessel primary patency (1VPP). Secondary endpoints included survival and angiographic binary restenosis. A Cox regression analysis was performed to identify independent predictors influencing outcomes

RESULTS

Technical success was achieved in all cases. The mean clinical and angiographic follow-up intervals were 47.5 ± 14.8 and 17.5 ± 12.5 months, respectively. According to the Kaplan-Meier analysis, overall survival, amputation-free survival, and TLR-free survival estimates were 79.5%, 84.3%, and 58.0%, respectively, at 5 years. At 12, 24, and 36 months, the 2VPP rates were 77.2%, 47.5%, and 33.9%, and the 1VPP rates were 84.0%, 65.5%, and 54.5%, respectively. Binary restenosis rates were 26.4%, 57.3%, and 82.2% at 12, 24, and 36 months; restenotic lesions were mainly detected at the origin of the bifurcations. The regression model did not identify any independent predictors influencing outcome.

CONCLUSION

DES application for below-the-knee bifurcation lesions was safe and resulted in satisfactory long-term angiographic and clinical outcomes comparable to those reported following infrapopliteal endovascular treatment.

Randomized study comparing everolimus- and sirolimus-eluting stents in patients with bifurcation lesions treated by provisional side-branch stenting

OBJECTIVES

To compare the efficacy of sirolimus- and everolimus-eluting stents in patients with bifurcation lesions treated with provisional side-branch stenting.

BACKGROUND

The efficacy of everolimus-eluting stents in bifurcation lesions has been poorly tested.

METHODS

Patients with all types of Medina bifurcation lesions were randomly assigned to treatment with either a sirolimus- (n = 145) or everolimus-eluting stent (n = 148). We included patients with main vessel diameter over 2.5 mm and side branches over 2.25 mm. Patients with diffuse side-branch stenosis were excluded.

RESULTS

There were no significant differences between patients from the sirolimus and everolimus groups in terms of age, risk factors, clinical status, location of the bifurcation lesions or angiographic variables. Immediate results and in-hospital outcome were also similar in both groups of patients. In-hospital death occurred in two patients, one from each group. Target lesion revascularization was required in nine patients: four patients (2.7%) from the sirolimus group and five patients (3.4%) from the everolimus group. Late cardiac mortality occurred in two patients from the sirolimus group and in one patient from the everolimus group. Major cardiac event rates at 1 year were similar in both groups: nine patients (6.2%) in the sirolimus group and nine patients (6.1%) from the everolimus group (p: ns).

CONCLUSIONS

In patients with bifurcation lesions, no significant differences in clinical outcome at 1-year follow-up were observed between sirolimus- and everolimus-eluting stent groups.

Simple or Complex Stenting for Bifurcation Coronary Lesions

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.

[Update in interventional cardiology]

This article contains a detailed review of the most important studies on interventional cardiology reported in either publications or presentations. With regard to coronary interventions, ST-elevation myocardial infarction is highlighted because of the ongoing substantial expansion in primary angioplasty programs. Drug-eluting stents, especially new-generation stents, continue to be the focus of numerous studies. Clinical outcomes in diabetic patients with left main coronary artery or multivessel disease are also dealt with by much research. In addition, intracoronary diagnostic techniques, particularly optical coherence tomography, is reviewed. Finally, there is increasing interest in the percutaneous treatment of structural heart disease, particularly percutaneous aortic valve implantation.