Should kissing balloon inflation after main vessel stenting be routine in the one-stent approach? A systematic review and meta-analysis of randomized trials

Abstract

The KBI (kissing balloon inflation) technique is considered the default strategy for the two-stent approach in real world practice. Studies comparing KBI and No-KBI in patients undergoing the one-stent approach have reported conflicting results. The meta-analysis was performed to compare the clinical outcomes of the KBI strategy and the No-KBI strategy for coronary bifurcation lesions in the one-stent approach. Five randomized studies were included, and a total of 1264 patients were involved in the meta-analysis. The primary outcome was cardiac death. The secondary end points were stent thrombosis, MI (myocardial infarction), target lesion revascularization (TLR), target vessel revascularization (TVR), and main vessel and side branch restenosis. Compared with the No-KBI strategy, the KBI strategy was associated with a significant reduction in side branch restenosis (OR: 0.44, 95% CI: 0.30–0.64, p<0.001). A high risk of main vessel restenosis was found in the KBI group (OR: 2.96, 95% CI: 1.74–5.01, p<0.001). There were no significant differences in rates of cardiac death (OR: 1.89, 95% CI: 0.60–5.95, p = 0.28), stent thrombosis (OR: 0.98, 95% CI: 0.19–4.94, p = 0.98), MI (OR: 0.68, 95% CI: 0.33–1.44, p = 0.30), TLR (OR 1.14, 95% CI 0.68–1.90, p = 0.62), or TVR (OR 1.27, 95% CI 0.75–2.16, p = 0.38). Compared with the No-KBI strategy, the KBI strategy reduced the incidence of side branch restenosis and increased the risk of main branch restenosis in the one-stent approach. However, the clinical outcomes were similar between the KBI and No-KBI groups.

Comparison of diagnostic performance in assessing the rewiring position into a jailed side branch between online 3D reconstruction systems version 1.1 and 1.2 derived from optical frequency domain imaging

“…In the latest meta-analysis of five randomized studies of KBI, although the KBI strategy reduced the incidence of side branch restenosis, there was no significant difference in clinical outcomes such as cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization (TLR), and target vessel revascularization (TVR) between the KBI strategy and a no-KBI strategy for coronary bifurcation lesions in the one-stent approach [18]. However, the optimal rewiring afforded by a 3D reconstruction system with high diagnostic performance might be able to change the results of bifurcation PCIs.…”

Left Main Coronary Artery Disease—Current Management and Future Perspectives

“…Secondly, the PS protocol differed between the two studies—in EBC MAIN kissing balloon inflation (KBI) of the side vessel after stenting was a part of the procedure, whereas in DKCRUSH-V KBI was permitted only if residual DS of the side branch was >75%, or dissection ≥ type B, or Thrombolysis In Myocardial Infarction (TIMI) flow grade < 3 was present. As the studies comparing KBI with no-KBI in a one-stent approach provide non-consistent results, this difference in protocols presumably influenced the final outcomes of the aforementioned RCTs [ 119 ]. Lastly, it is noteworthy that operators included in the DKCRUSH-V study had to be well-experienced, as it was confirmed by sending three to five cases to the trial steering committee, which to some extent might have driven favorable DK crush outcomes.…”

Fundamentals of percutaneous coronary bifurcation interventions

“…In a recent meta-analysis, routine final KBI resulted in a significant reduction in SB restenosis, but an increase in MV restenosis rates with no significant differences in clinical outcomes[ 73 ]. Another recent larger meta-analysis of final KBI vs no-final KBI in PST trials also showed similar results in that there was no difference in terms of MACEs and other outcomes[ 74 ].…”