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

Abstract

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.

Two-Stent Strategy for Bifurcation Lesions in Percutaneous Transluminal Coronary Angioplasty: Real-World Evidence

“…The achievement of post procedure TIMI grade 3 flow in all patients suggests the absence of any ischemic myocardial areas. A similar finding was reported by Yurtdas et al [4].…”

“…The mean age of patients (65.3 ± 11.1 years) undergoing PCIs in this study falls within the confidence limits reported by other studies (58 ± 11 years to 71 ± 10 years; Table 5). The percentages of comorbidities, such as hypertension, DM, and smoking, reported in this study are also comparable to those in previous studies [4] [19]- [38]. Additionally, the percentages of patients presenting with CSA, UA, and ACS are similar to those of previous findings [15] [19] [41].…”

“…Percutaneous coronary intervention (PCI) or percutaneous transluminal coronary angioplasty (PTCA) is the preferred approach for treating bifurcation lesions [1]. Coronary bifurcation lesions (CBLs) occur in 15% -20% of all PCIs and are associated with greater probabilities of unfavorable outcomes as compared to non-bifurcation lesions [2] [3] [4]. According to data from the National Interventional Council (India, 2018), 4.32% of all PCIs in India required bifurcation coronary stenting [5].…”

“…The 2019 European Bifurcation Club (EBC) recommends the PS strategy technique as the preferred technique for treating CBLs and restricts the use of upfront 2SS in selected cases with adequate preparation of the lesion, proximal optimization technique (POT), and final kissing balloon inflation (FKBI) [3] (Park 2022). The presence of a large side branch (SB) in a bifurcation lesion also warrants treatment of the SB [4].…”

Management of Bifurcation Culprit Lesion in the Setting of Anterior ST Elevation Myocardial Infarction

“…We have higher percentage of kissing balloon inflation, more fluoroscopy time and contrast volumes in patients managed with two stents and this is consistent with the results of Salina et al [16], Dudek et al [18], Choi et al [19], Kwan et al [20] and Yurtdas et al [21]. In the present study, crush techniques and T stenting were the most utilized stenting techniques in patients managed with two stents and these findings are in line with Choi et al [19], Kwan et al [20] and Yurtdas et al [21].…”