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Influence of technical strategies on the outcome of coronary bifurcation stenting
Thierry Lefèvre1, Marie-Claude Morice, Gunasekaran Sengottuvel
1Institut Cardiovasculaire Paris Sud, Massy, France.
Insights
The provisional T stenting strategy for side branches (SB) improves outcomes in coronary bifurcation stenting. This approach reduces major adverse cardiac events (MACE) and the need for repeat procedures at seven months.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Biomedical Engineering
Background:
- Coronary artery bifurcation stenting presents significant technical challenges.
- Limited large-scale prospective data exist on various stenting strategies for these complex lesions.
Purpose of the Study:
- To evaluate the immediate and mid-term outcomes of coronary bifurcation stenting using bare-metal stents.
- To identify predictors of adverse events in patients undergoing bifurcation stenting.
Main Methods:
- A prospective database of 1,149 patients treated for bifurcation lesions between 1996 and 2002 was analyzed.
- Seven-month follow-up data were obtained, with coronary angiography performed for clinical or stress test-indicated ischemia.
- Univariate and multivariate analyses identified predictors of acute and 7-month adverse events.
Main Results:
- Angiographic success was high (96.3% main branch, 92.9% side branch).
- In-hospital MACE rate was 4.6%. At 7 months, MACE was 18.1%, including 13.2% target vessel revascularization.
- Independent predictors of MACE included unstable angina, type 4 lesions, small main branch (<2.7mm), and side branch stenting. Non-use of provisional T stenting for the side branch was protective.
Conclusions:
- The provisional T stenting strategy for the side branch is a favorable predictor of outcomes in coronary bifurcation stenting.
- This strategy significantly reduces the rate of MACE and the need for repeat target vessel revascularization at 7-month follow-up.
Objectives:
The purpose of this study was to analyze from a large prospective database started in 1996, the immediate and mid term results of coronary bifurcation stenting using bare metal stents.
Background:
Stenting of bifurcation lesions remains a challenging subset. Various approaches have been advocated and no large prospective studies are available on this subject.
Methods:
Between 1996 and 2002, data were prospectively collected on all patients with bifurcation lesions treated with coronary stenting in our institution. Seven-month follow-up data were obtained in 96.7% of patients and coronary angiogram was performed in the presence of clinical or stress test ischemia. The database was analyzed to extract uni-variate and multivariate predictors of acute and 7 months adverse events.
Results:
A total of 1,149 patients were included, median age 65 years, 19% diabetic patients, unstable angina in 37.3% of cases and acute MI 10.5%. The target was the LAD-diagonal bifurcation in 53.2% of cases. Angiographic success (residual stenosis < 30%) was obtained in 96.3% of cases for the main branch (MB) and side branch (SB) 92.9 % (residual stenosis < 50%). The in-hospital MACE rate was 4.6 %. At seven months follow-up, a total MACE rate of 18.1% was observed including a target vessel revascularization rate of 13.2% and death rate of 1.6%. By multivariate analysis, independent predictors of MACE at seven month follow-up were unstable angina (OR 5.02 , p = 0.001, 95 % CI : 3.5 - 7.2), type 4 lesion (OR 3.31, p = 0.005, 95 % CI : 1.4 - 7.7), a MB < 2.7 mm (OR 1.8, p = 0.024, 95 % CI : 1.08 - 3.01), non use of a provisional T stenting strategy for the SB (OR 0.48, p = 0.006, 95 % CI : 0.40 - 0.86), and SB stenting (OR 1.48, p = 0.035, 95 % CI : 1.32 - 2.14).
Conclusion:
Provisional T stenting strategy applied to the SB is a predictor of favourable outcome after coronary bifurcation stenting using bare metal stents. It significantly reduces the rate of MACE as well as the need for repeat TVR at 7-month follow-up.
