Clinical outcomes following coronary bifurcation PCI techniques: a systematic review and network meta-analysis comprising 5,711 patients

Selected in JACC: Cardiovascular Interventions by S. Brugaletta

The main message of this study is that DK-crush was associated with fewer MACE, driven by lower rates of repeat revascularisation, whereas no significant differences among techniques were observed for cardiac death, myocardial infarction and stent thrombosis.

Reviewer

Salvatore Brugaletta

@sbrugaletta

Interventional cardiologist / Cardiologist

Barcelona, Spain

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My Comment

Why this study? – the rationale/objective

Percutaneous coronary intervention (PCI) in bifurcations has been associated with a higher rate of adverse cardiac events compared with non-bifurcation lesions. The use of a 1-stent technique has been associated with better clinical outcomes compared with more complex 2-stent techniques. As bifurcation PCI techniques have evolved, new techniques have been described, aiming at improving clinical outcomes. Nevertheless, the best PCI bifurcation technique is still a matter of debate. The aim of this study was to compare the clinical outcomes of different bifurcation percutaneous coronary intervention (PCI) techniques.

How was it executed? – the methodology

PubMed and Scopus were searched for randomised controlled trials comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE). Secondary outcomes of interest were cardiac death, myocardial infarction, target vessel or lesion revascularisation and stent thrombosis. Summary odds ratios (ORs) were estimated using Bayesian network meta-analysis.

What is the main result?

Twenty-one randomised controlled trials including 5,711 patients treated using 5 bifurcation PCI techniques were included. Investigated techniques were provisional stenting, T stenting/T and protrusion, crush, culotte, and DK-crush. Median follow-up duration was 12 months (interquartile range: 9 to 36 months).

When all techniques were considered, patients treated using the DK-crush technique had less occurrence of MACE (OR: 0.39; 95% credible interval: 0.26 to 0.55) compared with those treated using provisional stenting, driven by a reduction in target lesion revascularisation (OR: 0.36; 95% credible interval: 0.22 to 0.57).

The benefit of 2-stent techniques was observed in bifurcation lesions with SB lesion length >10 mm. No differences were found in cardiac death, myocardial infarction, or stent thrombosis among analysed PCI techniques.

No differences in MACE were observed among provisional stenting, culotte, T stenting/T and protrusion, and crush.

In non–left main bifurcations, DK-crush reduced MACE (OR: 0.42; 95% credible interval: 0.24 to 0.66).

Illustration credit: JACC: Cardiovascular Interventions

Illustration credit: JACC: Cardiovascular Interventions

Critical reading and the relevance for clinical practice

The main message of this interesting paper is that DK-crush was associated with fewer MACE, driven by lower rates of repeat revascularisation, whereas no significant differences among techniques were observed for cardiac death, myocardial infarction, and stent thrombosis.

The authors should be congratulated for using the network metanalysis methodology for the comparison of various bifurcation techniques: this methodology has been classically used for comparison between various stents.

It is of note the finding that a clinical benefit of 2-stent techniques was observed over provisional stenting in bifurcation with side branch lesion length >10 mm. This means that bifurcation strategy should include a comprehensive evaluation of the bifurcation anatomy, specifically evaluating the side branch. The present paper only focused on lesion length but, I guess, other parameters, such as vessel diameter and myocardial territory supplied by the side branch should be taken into account to decide between 1 vs. 2 stent strategy.

In your practice, which is the preferred 2-stent strategy in bifurcation lesions?