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A stepwise strategy for the stent treatment of bifurcated coronary lesions
Manuel Pan1, José Suárez de Lezo, Alfonso Medina
1Department of Cardiology Reina Sofía Hospital, University of Córdoba, Córdoba, Spain. grupo_corpal@arrakis.es
Insights
A stepwise approach to treating coronary bifurcation lesions successfully managed most patients without side-branch stenting. This strategy offers good immediate and long-term outcomes for coronary artery disease.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- Coronary bifurcation lesions pose treatment challenges.
- Observational studies suggest better outcomes when side branches are not stented.
- Provisional side branch stenting is an attractive management strategy.
Purpose of the Study:
- To evaluate a three-step strategy for stenting bifurcated coronary lesions.
- To assess the efficacy of a stepwise approach in managing complex coronary bifurcations.
- To determine if side branch stenting can be avoided in most cases.
Main Methods:
- A prospective study of 126 patients with major coronary bifurcation stenosis.
- A three-step procedural strategy: parent vessel stenting, side branch balloon redilation, and optional side branch stenting.
- Progression to the next step was based on achieving <50% residual stenosis in the side branch.
Main Results:
- Immediate procedural success was achieved in 92% of patients (116/126).
- The stepwise approach avoided side branch stenting in the majority of patients.
- The 15-month major cardiac event-free survival rate was 78%, with 15% target vessel revascularization.
Conclusions:
- A unitary stepwise approach is effective for treating coronary bifurcation lesions.
- This strategy can minimize the need for side branch stent implantation.
- The approach yields favorable immediate and long-term clinical results.
Abstract:
Several observational studies have shown a better late outcome in patients with coronary bifurcation lesions treated with stents in whom the side branch was not stented. Balloon dilation and provisional stenting for the side branch seem an attractive strategy to manage these challenging types of lesions. This study evaluated the results of a three-step phase strategy in the stent treatment of bifurcated coronary lesions. We treated 126 patients, 58 +/- 11 years old, with major coronary bifurcation stenosis. The therapeutic procedure was undertaken following three phases; progression through each phase was triggered by the failure of one procedure to achieve a <50% residual stenosis at the side branch: in the first step, balloon angioplasty of the side branch followed by stenting of the parent vessel; in the second, balloon redilation of the side-branch origin across the metallic structure of the stent; in the third, stenting of the side-branch origin. Immediate success was achieved in 116 patients (92%). Angiographic results in each phase were as follows: in the first step, 35 patients (28%) had procedural success, 3 patients had failure, and 88 crossed to the next step; in the second, 76 patients (86%) had procedural success, 7 patients had failure, and 5 crossed to the next step; in the third, all 5 patients had procedural success. The overall major cardiac event-free probability at 15 months was 78%. Target vessel revascularization took place in 19 patients (15%) and when stratified by phases were 13% of patients treated in the first step, 16% of patients in the second step, and 20% of patients in the third step. Patients with coronary stenosis at major bifurcations may be treated following an unitary stepwise approach. This attitude may avoid side-branch stent implantation in most patients, providing good immediate and long-term results.