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Comparison of Different Stenting Techniques in Left Main Bifurcation Disease: Evidence From a Network Meta-Analysis
Giovanni Maria Vescovo1, Juan Guido Chiabrando, Carlo Zivelonghi
1Department of Cardiology, Hartcentrum, Ziekenhuis Netwerk Antwerpen (ZNA) Middelheim, Antwerp, Belgium. gm.vescovo@libero.it.
Insights
The double kissing (DK)-crush technique significantly reduces adverse events like cardiac death, myocardial infarction, and stent thrombosis compared to provisional stenting in unprotected left-main (LM) percutaneous coronary intervention (PCI). DK-crush is identified as the optimal strategy for LM bifurcation PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Technology
Background:
- Provisional stenting has been the standard for left-main (LM) bifurcation percutaneous coronary intervention (PCI).
- Emerging evidence suggests the double kissing (DK)-crush technique may offer superior outcomes.
- This study compares the efficacy of different stenting techniques in LM bifurcation PCI.
Purpose of the Study:
- To determine the optimal bifurcation stenting technique for unprotected left-main (LM) percutaneous coronary intervention (PCI).
- To compare the safety and efficacy of DK-crush versus other techniques like provisional stenting, crush, and culotte.
Main Methods:
- A frequentist network meta-analysis was conducted, including randomized and non-randomized trials.
- Searches were performed across major databases (PubMed, Embase, Cochrane, ClinicalTrials.gov).
- Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated for key clinical outcomes.
Main Results:
- The DK-crush technique was associated with significantly lower rates of cardiac death, myocardial infarction, stent thrombosis, target-vessel revascularization, and target-lesion revascularization compared to provisional stenting.
- DK-crush also demonstrated superiority over standard crush and culotte techniques for specific adverse events.
- Analysis included 10 studies with a total of 2364 patients.
Conclusions:
- The double kissing (DK)-crush technique is the preferred and most effective method for unprotected left-main bifurcation PCI.
- This finding challenges the long-standing preference for provisional stenting in this complex coronary anatomy.
- DK-crush offers significant improvements in patient outcomes and procedural safety.
Objectives:
We aimed to assess which bifurcation technique performs best in unprotected left-main (LM) percutaneous coronary intervention (PCI).
Background:
Provisional stenting was considered the preferred technique for LM bifurcation PCI due to the supposed lower risks of thrombosis and restenosis. However, recent studies showed potential advantages of double kissing (DK)-crush technique over the other strategies.
Methods:
We performed a frequentist network meta-analysis comparing different stenting techniques in the setting of LM bifurcation. PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were searched. Both randomized clinical trials and non-randomized clinical trials were considered eligible for inclusion. Incidence rate ratios (IRRs) were computed using a random-effects model for death, cardiac death, myocardial infarction, target-vessel revascularization, target-lesion revascularization, and stent thrombosis, including 95% confidence intervals (CIs).
Results:
A total of 10 studies (2364 patients) were included. Compared with provisional stenting, DK-crush was associated with fewer cardiac deaths (IRR, 0.34; 95% CI, 0.17-0.70; P<.01), myocardial infarctions (IRR, 0.19; 95% CI, 0.08-0.44; P<.001), stent thromboses (IRR, 0.31; 95% CI, 0.14-0.69; P<.01), target-vessel revascularizations (IRR, 0.25; 95% CI, 0.14-0.46; P<.001), and target-lesion revascularizations (IRR, 0.25; 95% CI, 0.14-0.46; P<.001). DK-crush was also associated with a lower risk of myocardial infarction (IRR, 0.19; 95% CI, 0.05-0.76; P=.02) when compared with standard crush and lower risk of target-lesion revascularization when compared with culotte (IRR, 0.32; 95% CI, 0.12-0.83; P=.02) and crush (IRR, 0.07; 95% CI, 0.02-0.28; P<.001).
Conclusions:
DK-crush is the best technique for unprotected LM bifurcation PCI.
