279Clinical outcome after coronary bifurcation stenting: a systematic review and network meta-Analysis of PCI bifurcation techniques comprising 5572 patients

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
G Di Gioia ◽  
J Sonck ◽  
I Colaiori ◽  
T Mizukami ◽  
M Kodeboina ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Stent Thrombosis ◽  
Cardiac Death ◽  
Meta Analysis ◽  
Evaluation Framework ◽  
Left Main ◽  
Coronary Bifurcation ◽  
Bifurcation Lesions ◽  
Provisional Stenting ◽  
Crush Technique

Abstract Background The optimal PCI technique for bifurcation lesions remains a matter of debate. Several RCT have compared different bifurcation PCI techniques. Provisional stenting has been recommended as the default technique for most bifurcation lesions. However, emerging data suggests that double-kissing crush technique can be considered in true left main bifurcation lesions and has been endorsed by the European Society of Cardiology Guidelines. Purpose To compare the clinical outcome between different bifurcation PCI techniques. Methods We searched MEDLINE for randomized clinical trials (RCT) comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE) defined as the composite of cardiac death, myocardial infarction (MI) and target vessel or lesion revascularization (TVR/TLR), and the individual components of MACE. Stent thrombosis was assessed as defined by the ARC. Stratification based on left-main or distal bifurcations was performed. We evaluated the studies' risk of bias in accordance to the Cochrane Handbook for Systematic Reviews of Interventions, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis. Results We identified 263 studies and of these included 19 RCT including 5572 patients treated with 5 bifurcation PCI techniques namely provisional stenting, systematic T-stenting, crush, culotte and double-kissing crush. Median follow-up was 12 months (IQR 8 to 36). When all bifurcation lesions were combined, double-kissing crush technique reduced the occurrence of MACE (OR 0.42; CrI 0.28 to 0.61) compared to provisional stenting. This difference was driven by a reduction in TVR/TLR (OR 0.39; CrI 0.25 to 0.65). No differences were found in cardiac death, MI or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed between provisional stenting, systematic T-stenting, crush. In distal bifurcations (n=17 studies, 4634 patients), double-kissing crush also showed to reduce MACE (OR 0.48; CrI 0.29 to 0.67 vs. Provisional). In left-main bifurcations (n=3 studies, 938 patients) no differences in MACE were found between PCI techniques. Conclusions In this network meta-analysis, PCI bifurcation techniques were similar with respect to the occurrence of cardiac death, myocardial infarction and stent thrombosis. When all coronary bifurcations were combined, an advantage of double-kissing crush was observed in terms of MACE driven by lower rate of repeated revascularization. Further studies are required to define the best PCI bifurcation technique for left main coronary artery disease.

scholarly journals Crush is superior to Culotte in two-stent strategy for treatment of left main coronary artery bifurcations: A systematic review and meta-analysis

2020 ◽  
Vol 43 (2) ◽  
pp. E35-46
Author(s):  
Xiao-Rui Chen, MD Chen ◽  
Di-Yu Cui ◽  
Yun-Qing Chen, MD, PhD Chen ◽  
Tie-Sheng Niu
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery ◽  
Stent Thrombosis ◽  
Cardiac Death ◽  
Left Main Coronary Artery ◽  
Target Lesion ◽  
Left Main ◽  
Cardiac Events ◽  
Target Vessel Revascularization ◽  
Bifurcation Lesions

Purpose: Crush and Culotte techniques have been used increasingly to treat patients with complex unprotected left main coronary artery bifurcation lesions. This article compares published data on these two techniques. Methods: Databases, including PubMed, Embase, Cochrane Library, Wanfang Data and China National Knowledge Infrastructure, were searched for articles published before Aug 21, 2019 to identify all relevant studies on left main coronary artery bifurcation lesions treated by Crush versus Culotte techniques. The pooled data were analyzed using either fixed- or random-effects model depending on heterogeneity (assessed via the I2 index). The endpoints were major adverse cardiac events, target lesion revascularization, cardiac death, stent thrombosis, myocardial infarction and target vessel revascularization. Results: Eight articles with a total of 1,283 patients were included, and 710 patients were treated with Crush, and 573 ones with Culotte. Crush group was trend to decreased major adverse cardiac event compared with Culotte group [Relative ratio (RR) 0.63,95% confidence interval(CI) 0.39-1.04, I2 =72.7%], mainly driven by decreased cardiac death [RR 0.49, 95% CI(0.25-0.99), I2 =0%], decreased myocardial infarction [RR 0.40, 95% CI(0.21-0.76), I2 =21.6%],and lower stent thrombosis [RR 0.39, 95% CI(0.16-0.98), I2 =39.4%]. There was no significant difference in target lesion revascularization and target vessel revascularization between Crush and Culotte [RR 0.77, 95% CI 0.46-1.28, I2=61.1%; RR 0.78, 95% CI (0.30-2.02), I2 =73.1%, respectively]. Conclusion: Crush was superior to Culotte for treatment of left main coronary artery bifurcation lesions with a trend of lower incidence of long-term major adverse cardiac events, mainly derived from decreased myocardial infarction, stent thrombosis and cardiac death.

Abstract 14575: Systematic Review and Meta-analysis of Intravascular Ultrasound-guided Percutaneous Left-main Coronary Artery Intervention

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sameer Saleem ◽  
Shuaibahmed Arab ◽  
Waqas Ullah ◽  
Sundas Younas ◽  
Bashar Al hemyari ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Systematic Review ◽  
Coronary Artery ◽  
Stent Implantation ◽  
Cardiac Death ◽  
Left Main Coronary Artery ◽  
Meta Analysis ◽  
Ultrasound Guided ◽  
Left Main ◽  
Relative Odds

Introduction: Previous meta-analyses have reported reduced cardiovascular mortality and myocardial infarction in intravascular ultrasound-guided (IVUS) stent implantation in comparison to angiography-only approach. However, these studies have unanimously excluded patients with unprotected left-main coronary artery (LMCA) disease, questioning its widespread applicability. We performed a systematic review and meta-analysis to investigate the prognostic significance of IVUS-guided LMCA intervention. Methods: Studies comparing clinical outcomes between IVUS-guided and angiography-only percutaneous LMCA intervention were identified through PubMed, Cochrane and EMBASE databases until June, 2020. Data was analyzed using a random effect model to calculate the relative odds of all-cause death, cardiac death, left-main revascularization, myocardial infarction, stent thrombosis and stroke. Results: A total of 13 studies comprising 7680 patients were included. The odds of all-cause death (OR 0.6, 95%CI 0.47-0.78; p<0.0001), cardiac death (OR 0.37, 95%CI 0.26-0.54; p<0.00001), left-main revascularization (OR 0.63, 95%CI 0.45-0.89; p=0.009) and myocardial infarction (OR 0.77 [95%CI 0.60-0.98; p=0.04]) were significantly lower in patients who underwent IVUS-guided LMCA stent implantation compared to angiography-only approach. There was no significant difference observed in the relative odds of stent thrombosis (OR 0.57, 95%CI 0.31-1.05; p=0.07) and stroke (OR 1.7, 95%CI 0.56-5.14; p=0.35) between the two arms at least 1-year of the index procedure. A subgroup analysis based on study design and sensitivity analysis based on the characteristics of the included studies mirrored the pooled results. Conclusion: IVUS-guided LMCA intervention is associated with overall improved cardiovascular outcomes than angiography-only approach. Large scale randomized controlled trials are needed to validate our findings.

scholarly journals Multicentre, randomized comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial

2020 ◽  
Vol 41 (27) ◽  
pp. 2523-2536 ◽  
Author(s):  
Jun-Jie Zhang ◽  
Fei Ye ◽  
Kai Xu ◽  
Jing Kan ◽  
Ling Tao ◽  
...  
Keyword(s):  
Cardiac Death ◽  
Target Lesion ◽  
Stent Group ◽  
Coronary Bifurcation ◽  
Coronary Bifurcation Lesions ◽  
Safety Endpoint ◽  
Bifurcation Lesions ◽  
Provisional Stenting ◽  
Target Lesion Failure

Abstract Aim The present study aimed to assess the benefits of two-stent techniques for patients with DEFINITION criteria-defined complex coronary bifurcation lesions. Methods and results In total, 653 patients with complex bifurcation lesions at 49 international centres were randomly assigned to undergo the systematic two-stent technique (two-stent group) or provisional stenting (provisional group). The primary endpoint was the composite of target lesion failure (TLF) at the 1-year follow-up, including cardiac death, target vessel myocardial infarction (TVMI), and clinically driven target lesion revascularization (TLR). The safety endpoint was definite or probable stent thrombosis. At the 1-year follow-up, TLF occurred in 37 (11.4%) and 20 (6.1%) patients in the provisional and two-stent groups, respectively [77.8%: double-kissing crush; hazard ratio (HR) 0.52, 95% confidence interval (CI) 0.30–0.90; P = 0.019], largely driven by increased TVMI (7.1%, HR 0.43, 95% CI 0.20–0.90; P = 0.025) and clinically driven TLR (5.5%, HR 0.43, 95% CI 0.19–1.00; P = 0.049) in the provisional group. At the 1 year after indexed procedures, the incidence of cardiac death was 2.5% in the provisional group, non-significant to 2.1% in the two-stent group (HR 0.86, 95% CI 0.31–2.37; P = 0.772). Conclusion For DEFINITION criteria-defined complex coronary bifurcation lesions, the systematic two-stent approach was associated with a significant improvement in clinical outcomes compared with the provisional stenting approach. Further study is urgently warranted to identify the mechanisms contributing to the increased rate of TVMI after provisional stenting. Study registration http://www.clinicaltrials.com; Identifier: NCT02284750.

scholarly journals Stent strategies in left main bifurcation lesions: the simpler, the better?

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
G Oliveira Campos ◽  
L Leite ◽  
M Santos ◽  
L Paiva ◽  
E Jorge ◽  
...  
Keyword(s):  
Primary Endpoint ◽  
Cardiac Death ◽  
Global Analysis ◽  
Artery Bypass ◽  
Target Lesion ◽  
Target Lesion Revascularization ◽  
Syntax Score ◽  
Left Main ◽  
Bifurcation Lesions ◽  
Provisional Stenting

Abstract Introduction Although percutaneous coronary intervention (PCI) for ostial or midshaft lesions in left main (LM) disease has shown similar results as compared with coronary artery bypass grafting (CABG), distal LM bifurcations are associated with an increase in procedural complexity and higher rates of target lesion revascularization. Several studies have investigated the optimal stenting strategy in patients with coronary bifurcation lesions and showed no benefit for systematic two-stent approach in comparison with provisional stenting. This is reflected in the current guidelines that recommend provisional stenting of the side branch as the preferred approach for most bifurcation lesions. However, there is still debate about the optimal strategy according to lesion location. Objectives This analysis aimed to compare the clinical outcomes of LM bifurcation PCI using a provisional strategy versus a two-stent strategy. Methods Retrospective, observational study including patients submitted to LM bifurcation (Medina 1,1,1) PCI between January 2010 and December 2019. Data was collected from the emergency department and hospitalization registries. Patients were divided according to the stenting approach. We made a global analysis including baseline clinical and angiographic data. The primary endpoint was target lesion failure (TLF), defined as the composite of myocardial infarction, cardiac death, and target lesion revascularization (TLR). Secondary endpoints included the individual components. Results A total of 106 patients were included (median age 74 [66–82], 79 (74.5%) males), 57 (53.8%) submitted to provisional stenting and 49 (46.2%) to a two-stent technique. Baseline characteristics were well matched (table 1). The mean SYNTAX score was 29.6±10.0 and LM stenosis grade was ≥70% in all lesions. Median follow-up was 26.6 [12.0–48.6] months. No differences were found regarding the primary endpoint (TLF in provisional stenting was 21.7% vs 21.4%, HR 2.432; 95% confidence interval, 0.472–12.450; p=0.233.). Although target lesion revascularization within the LM complex was numerically higher in the two-stent group (10.2% vs. 3.5%, p=0.245), the opposite was found in cardiac death (provisional group 10.5% vs. 4.3%, p=0.289). Conclusions Besides being a “simpler” technique, provisional stenting had no significant differences in outcomes compared to two-stent techniques. Without further evidence, revascularization strategies should primarily rely on operator expertise. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals The increased main branch to stent diameter ratio is associated with side branch decreased coronary flow in "true" coronary artery bifurcations treated by "provisional" stenting - a two-dimensional quantitative coronary angiography study

2020 ◽  
Vol 77 (1) ◽  
pp. 53-59
Author(s):  
Ivan Ilic ◽  
Radosav Vidakovic ◽  
Aleksandra Janicijevic ◽  
Milica Stefanovic ◽  
Srdjan Kafedzic ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Flow ◽  
Quantitative Coronary Angiography ◽  
Side Branch ◽  
Diameter Ratio ◽  
Two Dimensional ◽  
Left Main ◽  
Bifurcation Lesions ◽  
Provisional Stenting ◽  
Stent Diameter

Background/Aim. Percutaneous coronary interventions (PCI) in bifurcation lesions having more than 50% stenosis of both the main branch (MB) and the side branch (SB) remain challenging. Measurements of the vessel diameters and angles using quantitative coronary angiography (QCA) software have been used in evaluating PCI outcomes. We investigated potential effects of provisional stenting of the MB on SB coronary blood flow by determining quantitative vessel parameters in ?true? non-left main coronary bifurcation lesions using conventional two-dimensional QCA. Methods. The study was prospective and conducted in a highvolume university PCI center. Study included patients with ?true? native coronary artery bifurcations (Medina 1.0.1; 0.1.1; 1.1.1) treated with ?provisional? stenting of the MB. Patients were excluded from the study if having left ventricular ejection fraction of less than 30%, having renal failure with creatinine clearance below 30 mL/kg/m2 or bifurcation lesions within the culprit artery causing myocardial infarction, grafted surgically or previously treated by PCI. QCA analysis included measurements of reference vessel diameters (RVD), diameter stenosis (DS) and bifurcation angles. Results. The study included 70 patients with 72 ?true? non-left main bifurcations. Most of the bifurcations were located in the left anterior descending (LAD) ? diagonal (Dg) territory. Compromise of the SB ostium defined as thrombolysis in myocardial infarction (TIMI) < 3 coronary flow occurred in 17/72 (23.6%) bifurcations. It was treated by either balloon angioplasty only of the SB ostium (9/17, 52.9%) or stent implantation [8/17 (47.1%)]. In a logistic regression analysis, including previously recognized predictors of SB compromise (bifurcation?s angles, RVD, DS and ratio of MB RVD to stent diameter ratio), only MB RVD to stent diameter ratio after PCI remained independent predictor of SB coronary flow compromise after stent implantation in the MB [OR 2.758 (95% CI 1.298?5.862); p = 0.008]. Conclusions. It appears that SB decreased coronary blood flow after ?provisional? stenting in ?true? non-left main bifurcations is associated with greater MB to stent diameter ratio.

Sign in / Sign up

Export Citation Format

Share Document