Single versus Double Stenting in NSTEMI Patients with Complex Left Main Bifurcation Disease
Gianluca Rigatelli1, Marco Zuin2, Filippo Gianese1
1Cardiovascular Diagnosis and Endoluminal Interventions, Department of Specialistic Medicine, Rovigo General Hospital, 45100 Rovigo, Italy.
Insights
For patients with non-ST-segment elevation myocardial infarction (NSTEMI) and left main (LM) bifurcation disease, both single and double stenting strategies showed low long-term risks. A single stent approach demonstrated a slightly better outcome than a double stent strategy.
Area of Science:
- Interventional Cardiology
- Cardiovascular Medicine
- Medical Devices
Background:
- Left main (LM) bifurcation disease in patients with non-ST-segment elevation myocardial infarction (NSTEMI) presents significant clinical and technical challenges.
- Optimal revascularization strategies for these complex lesions are crucial for improving patient outcomes.
Purpose of the Study:
- To evaluate and compare the long-term outcomes of single versus double stent strategies in NSTEMI patients with LM bifurcation culprit lesions.
- To identify predictors of target lesion failure (TLF) in this patient cohort.
Main Methods:
- Retrospective analysis of 445 NSTEMI patients with LM bifurcation disease treated between 2008 and 2018.
- Patients were treated with either single stenting or various double stenting techniques (provisional, T/TAP, Culotte, NIT).
- Primary endpoint was target lesion failure (TLF), defined as cardiovascular death, target-vessel myocardial infarction, or clinically driven target lesion revascularization.
Main Results:
- A total of 445 patients (mean age 70.3 years) were analyzed; 34.8% received a single stent.
- After a mean follow-up of 37.1 months, the overall TLF rate was 8.7%.
- TLF rates varied by strategy: 3.2% (single stent), 18.8% (T/TAP), 15.7% (Culotte), and 6.7% (NIT). Cardiovascular mortality was 2.9% and stent thrombosis was 0.89%.
Conclusions:
- Both single and double stent strategies offer low long-term rates of TLF, cardiovascular death, and stent thrombosis in NSTEMI patients with LM bifurcation disease unsuitable for surgery.
- A single stent strategy appeared to yield slightly superior outcomes compared to a double stent approach in this study.
- Independent predictors of TLF included dyslipidemia, high Syntax score, triple vessel disease, additional LM ostial/body lesions, and Rotablator use.
Abstract:
Background: Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long-term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion. Methods: We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T-and-Protrusion (TAP), Culotte, and Nano-inverted-T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target-vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR). Results: Four hundred and forty-five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow-up of 37.1 months (IQR 22.1-39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF. Conclusions: Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long-term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2-stent strategy.
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