Major predictors of long-term clinical outcomes after percutaneous coronary intervention for coronary bifurcation lesions with 2-stent strategy: patient-level analysis of the Korean bifurcation pooled cohorts

Selected in JACC Cardiovascular Interventions by M Bollati



Song PS, Song YB, Lee JM, Hahn JY, Choi SH, Choi JH, Lee SH, Park KW, Kim HS, Jang Y, Seung KB, Oh JH, Gwon HC


JACC Cardiovasc Interv. 2016 Sep 26;9(18):1879-86


September 2016


Read the abstract

My Comment

What is known

  • Coronary bifurcation percutaneous intervention (PCI) occurs quite often (up to 20%) in real world practice.
  • The safer and preferred approach is a single stent approach (“provisional”), reserving a 2 stent approach only in case of failed provisional technique.
  • In case of true bifurcation subset (Medina 1,1,1) with a large viable myocardium supplied by side branch (or after failed provisional approach), the two stents strategy may be the best choice.
  • No long term data are available in this special subset.

The study by Sang Song et al pooled the data from COBIS II, Excellent and Resolute Korea trials, with the aim to understand the independent predictors of adverse outcomes after implantation of DES in bifurcation lesions with the 2-stent strategy. The primary endpoint was the target vessel failure (TVF, intended as composite of cardiac death, myocardial infarction, stent thrombosis, and target vessel revascularization). 

Major findings

  • In the pooled data, true bifurcation was observed in 73.2% of lesions and the treated lesion was the left main in 39.1%.
  • The most used technique was the crush (44%) and the final kissing was performed in more than 80%.
  • The 3-year cumulative incidence of target vessel failure, cardiac death, myocardial infarction, stent thrombosis, and target vessel revascularization was 17.0%, 2.3%, 2.5%, 1.7%, and 14.3%, respectively.
  • The independent TVF predicators were: left main bifurcation (HR: 2.09; 95% [CI]: 1.43 to 3.03), SYNTAX score >32 (HR: 2.00; 95% CI: 1.28 to 3.14), diabetes mellitus (HR: 1.41; 95% CI: 1.00 to 1.99), second-generation DES (HR: 0.26; 95% CI: 0.12 to 0.57), use of noncompliant balloon (HR: 0.53, 95% CI: 0.36 to 0.79), and final kissing ballooning (HR: 0.44; 95% CI: 0.29 to 0.68).

The Authors concluded that 2 stent bifurcation PCI is related to acceptable 3 years results, with relevant procedural independent predictors.

My comment

Everybody knows that simpler is better. Especially when you are doing PCI.

Following this philosophy, the preferred bifurcation PCI approach is the provisional one, but just in case one stent is enough, without real comparison between one and two stent approach in true bifurcation or in complicated provisional approach. The registry by Sang Song does it. With good results.

But several caveat have to be declared:

First, the data derive from pooled analysis of different registries (with different population and inclusion criteria).

Second, the second generation DES usage is not so widely applied (just in less than 30%).

Moreover, no double kissing is reported, a technique with mid and long term event reduction. Final kissing (FK) occurred in no more than 83% of lesions: considering the subset complexity (bifurcation, two stent approach, left main PCI) it has to be mandatory.

Concluding, this study is a good incitement for future researches in homogeneous patients, using updated techniques, stent, and more intravascular imaging (IVUS, OCT). Maybe considering also scaffold bifurcation PCI results.

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