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Stenting of bifurcation lesions: classification, treatments, and results
T Lefèvre1, Y Louvard, M C Morice
1Institut Cardiovasculaire Paris Sud, Institut Hospitalier Jacques Cartier, Massy, France.
Insights
Systematic coronary stenting for bifurcation lesions, especially using tubular stents and kissing balloon inflation, improves outcomes. This strategy offers high procedural success and reduces major adverse cardiac events and target vessel revascularization rates.
Area of Science:
- Interventional Cardiology
- Cardiovascular Research
- Medical Device Technology
Background:
- Percutaneous transluminal balloon coronary angioplasty (PTCA) of coronary bifurcations historically has low success rates and high complication incidence.
- Target vessel revascularization (TVR) remains a significant concern following bifurcation interventions.
Purpose of the Study:
- To prospectively evaluate the efficacy and safety of systematic coronary stenting in bifurcation lesions with side branches >= 2.2 mm.
- To assess procedural success, in-hospital major adverse cardiac events (MACE), and 7-month follow-up outcomes including TVR.
Main Methods:
- A single-center observational study including 366 patients with 373 bifurcation lesions over 35 months.
- Systematic stenting of the main branch and, when indicated, the side branch, with procedural success defined by specific criteria.
- Analysis of outcomes comparing two study periods to evaluate the impact of evolving techniques like tubular stent use and kissing balloon inflation.
Main Results:
- High procedural success rates: 96.3% for both branches and 99.4% for the main branch.
- Low in-hospital MACE rate of 4.8%, with specific event rates detailed.
- At 7-month follow-up, TVR rate was 17.2%. A significant decrease in TVR (20.6% to 13.8%) and MACE (29.2% to 17.1%) was observed between study periods.
- Improved outcomes correlated with increased use of tubular stents and kissing balloon inflation.
Conclusions:
- Systematic coronary stenting is effective for treating complex bifurcation lesions.
- Technological advancements, specifically tubular stents and kissing balloon inflation, significantly improve procedural and follow-up results.
- Coronary bifurcation stenting can achieve high procedural success and acceptable long-term outcomes, influenced by technique and learning curve.
Abstract:
Percutaneous transluminal balloon coronary angioplasty (PTCA) of coronary bifurcations is associated with a low success rate, high rate of complications, and high incidence of target vessel revascularization (TVR). The strategy of systematic coronary stenting in bifurcation lesions involving a side branch >/= 2.2 mm in diameter was prospectively evaluated in a single-center observational study during a 35-month inclusion period. All patients meeting these criteria were consecutively included. Bifurcation lesions and treatment were predefined in the study. The study included 366 patients (12.1% of PTCA) with 373 bifurcation lesions, mean age 63.7 +/- 11.6 years, 79.2% male, 46.7% with unstable angina, and 8.3% acute MI. The left anterior descending/diagonal bifurcation was involved in 55.2% of cases, circumflex/marginal 22. 2%, PDA/PLA 10.4%, left main bifurcation in 6.8%, and others 5.4%. The main branch (2.78 +/- 0.42 mm reference diameter) was stented in 96.3% of cases and the side branch (2.44 +/- 0.43 mm) in 63.2% (the two branches were stented in 59.5% of cases). Procedural success was obtained in 96.3% in both branches and 99.4% in the main branch. At1-month follow-up, The major cardiac event rate (MACE) was 4.8% (death 1.1%, emergency CABG 0.6%, Q-wave MI 0.9%, acute or subacute closure 1.4%, repeat PTCA 1.1%, and non-Q-wave MI 2.3%). At 7-month follow-up, the total MACCE rate was 21.6%, including a TVR rate of 17.2%. Analysis of the 7-month outcome according to two study periods (period I, 1 January 1996 to 31 August 1997, 182 patients; period II, 1 September 1997 to 30 June 1998, 127 patients) showed that the TVR rate decreased from 20.6% to 13.8% (P = 0.04) and the MACE rate from 29.2% to 17.1% (P < 0.01) in period I and II, respectively. This was associated by univariate analysis with an increasing use of tubular stents deployed in the main branch (94.2% vs. 59.1%, P < 0.001) and kissing balloon inflation after coronary stenting (75.4% vs. 18.1%, P < 0.001). Bifurcation lesions are frequent. Procedural success of coronary stenting is high with a low rate of in-hospital MACE. TVR rate at follow-up is relatively low. In-hospital and follow-up results are influenced not only by the learning curve but also by the use of tubular stents in the main branch and final kissing balloon inflation.