Coronary bifurcation lesions: is less more?

Abstract

Coronary bifurcation lesions are frequent in everyday practise and account for up to 20% of all percutaneous coronary interventions (PCI) (1). The treatment of bifurcation lesions with drug-eluting stents (DES), especially when a double stent technique is used, remains challenging and is associated with a lower procedural success rate and a higher rate of long-term adverse cardiac events such as stent restenosis and thrombosis compared to non-bifurcation PCI (2). The question relating to a one or two stent strategy for bifurcation lesions has been a subject of many debates over recent years and numerous observational and randomized studies (3-6) have supplied data to this important though at times controversial subject.Recently, Behan et al. (7) presented the 5-year outcome data from a patient-level pooled analysis of coronary bifurcation lesions treated with simple or complex stenting in two pivotal studies (7): more specifically, pooled 5-year results of the NORDIC 1 (8) and the British Bifurcation Coronary Study: Old, New, and Evolving Strategies (BBC ONE) (4), both of similar magnitude and methodology (N=413 and 500, respectively), that compared all-cause mortality and other clinical endpoints after simple singlestent (provisional T stenting) versus complex two-stent (culotte, crush and T-stenting) techniques, using DES.Before looking at the results in more detail it is important to note that differences in bifurcation anatomy and disease severity are major determinants of treatment approach and remain at the discretion and judgement of the single operator. Several valuable bifurcation classifications have been proposed (9-11), none of them fully encompassing variations in anatomy, including vessel size, bifurcation angle and extent of disease in the side branch. From a practical point of view, the operator is generally speaking faced with one of two situations: in the first scenario, due to the severity of the disease at the bifurcation and extending in to large calibre branches, two stents are required from the outset. This type has typically not been represented (thus giving rise to selection bias) in the randomized studies to date comparing different strategies as operators are not willing to risk randomising these patients to a single-stent strategy. The second type of bifurcation lesion is where one or two stents can be used. For these bifurcation lesions, multiple randomized studies comparing a routine twostent strategy with a provisional strategy (single stent in the main vessel with additional side branch stent only if indicated) have shown comparable efficacy outcomes (target vessel/target lesion revascularization rates) between the two treatment strategies, although the provisional strategy resulted in lower rates of peri-procedural myocardial infarction (MI), less contrast use, lower X-ray doses and shorter procedural times (3,4,6). There is therefore, for this second type of lesion, a general consensus that it is better to Keep It as Simple and Safe as possible and implant one stent (KISS provis...

Long-term outcomes after percutaneous revascularization of complex coronary bifurcation lesions using a dedicated self-expanding biolimus-eluting stent system

“…By design, dedicated bifurcation devices offer solutions against the limitations of tubular stents by conforming to bifurcation anatomy and avoiding stent deformation and overlap. Theoretically, they represent a valid alternative to the ongoing controversy of single versus double tubular stent strategies to be used in a bifurcation scenario [15][16][17]. However, implantation of dedicated bifurcation stents is technically demanding and the learning curve relating to patient/lesion selection and technical implementation, both hamper breakthrough of the technique in daily practice as well as evaluation of its true value.…”

Modified balloon-stent kissing technique avoid side-branch compromise for simple true bifurcation lesions

“…Coronary bifurcations are frequent and account for approximately 20% of all percutaneous coronary interventions [1]. Nonetheless,they represent one of the remaining challenges in interventional cardiology and the uniform strategy is still the subject of substantial debate in terms of a lower procedural success rate,a higher risk of procedural complications, and increasing rates of long-term adverse cardiac events [2].…”

A Systematic Literature Review of Three Stenting Strategies for Bifurcation Lesions in Coronary Artery Disease

“… 7 The anatomy and the severity of the lesion, are important factors to take into account when deciding whether to use a provisional or a complex strategy. 8 A 2015 clinical trial found that patients undergoing PCI with true bifurcation lesions—defined as lesions affecting both the MV vessel and the ostium of the SB, Medina classification 1, 1, 1; 1, 0, 1; or 0, 1, 1, also involving a SB reference vessel diameter (RVD) of ≥ 2.3 mm—had worse clinical outcomes than patients without true bifurcation lesions. 2 , 9 The authors strongly recommend differentiating the two types of bifurcation lesions in future studies.…”