Side Branch Additional Treatment for Coronary Bifurcation Lesion Revascularization: Insights From the KISS Randomized
Bernard Chevalier1, Luc Cornillet2, Frederic Bouisset3
1Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France.
Insights
A conservative strategy for coronary bifurcation stenting without routine side branch intervention is noninferior to systematic intervention. This approach reduces procedural complications and resource use, offering a safe alternative for most patients.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Device Technology
Background:
- Provisional stenting is standard for coronary bifurcation lesions, but the necessity of additional side branch (SB) intervention is debated.
- Optimizing treatment strategies for bifurcation lesions aims to improve patient outcomes and procedural efficiency.
Purpose of the Study:
- To evaluate if a conservative strategy, avoiding routine SB intervention, is noninferior to systematic SB intervention in terms of periprocedural events.
- To compare procedural complications and 12-month clinical outcomes between the two strategies.
Main Methods:
- The multicenter KISS trial randomized 616 patients with non-left main bifurcation lesions to either no SB intervention (no-SBI) or systematic SB intervention (SBI).
- Both groups received main branch stenting with Resolute Onyx drug-eluting stents and proximal optimization technique.
- The primary endpoint was periprocedural myocardial infarction (MI) or myocardial injury; secondary endpoints included procedural complications and target lesion failure at 12 months.
Main Results:
- A conservative strategy (no-SBI) was noninferior to SBI regarding periprocedural MI or myocardial injury (4.1% vs 5.7%, P < 0.001 for noninferiority).
- The no-SBI group showed significantly lower procedure time, radiation dose, and contrast use.
- SB dissection was more frequent in the SBI group (2.9% vs 0.0%, P = 0.004), with no significant difference in 12-month target lesion failure (4.9% vs 6.4%, P = 0.442).
Conclusions:
- The KISS trial supports a conservative strategy for coronary bifurcation stenting, demonstrating its noninferiority to systematic SB intervention for periprocedural MI and myocardial injury.
- This approach is associated with very rare procedural complications and reduced resource utilization.
- The findings suggest that avoiding routine SB intervention is a safe and efficient strategy for managing coronary bifurcation lesions.
Background:
Although provisional stenting is the recommended strategy for most coronary bifurcation lesions, the clinical benefit of additional side branch (SB) intervention remains debated.
Objectives:
The aim of this study was to determine whether a conservative strategy without systematic SB intervention (SBI) is noninferior to systematic SB intervention regarding periprocedural events.
Methods:
The multicenter, international KISS (Keep Bifurcation Single Stenting Simple) trial randomized patients with non-left main bifurcation lesions to 2 groups: no SBI or SBI following main branch stenting with the Resolute Onyx drug-eluting stent and a proximal optimization technique without impairment of SB flow. The primary endpoint was periprocedural myocardial infarction (MI) or myocardial injury, according to the Academic Research Consortium 2 definition. Secondary endpoints included procedural complications and 12-month clinical outcomes, including target lesion failure, defined as the composite of cardiac death, target vessel MI, and target lesion revascularization.
Results:
Among the 616 included patients, 81% were treated for chronic coronary disease, and the bifurcation mainly involved was between the left anterior descending coronary artery and the diagonal. In the no-SBI group, an intervention on the SB was required in 2.0% of patients (n = 6). Periprocedural MI or myocardial injury occurred in 4.1% (n = 11) in the no-SBI group vs 5.7% (n = 16) in the SBI group (P < 0.001 for noninferiority; P = 0.38 for superiority). There was no significant interaction with age, sex, Medina classification, or SB residual stenosis. Procedure time, radiation dose, and contrast use were significantly lower in the no-SBI group. Procedural complications were rare, but SB dissection was more frequently observed in the SBI group (2.9% vs 0.0%; P = 0.004). There was no difference in target lesion failure at 1 year (4.9% [n = 15] vs 6.4% [n = 20] in the no-SBI and SBI groups respectively; P = 0.442).
Conclusions:
The KISS trial demonstrates that a conservative strategy without systematic SB intervention is associated with very rare procedural complications and is noninferior to a systematic SB intervention regarding periprocedural MI and myocardial injury.
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