Coronary artery bifurcation stenosis is a technically challenging lesion subset that interventional cardiologists encounter on a routine basis. The optimal approach to this high-risk lesion subset remains debatable. A two-stent strategy involves planned deployment of a stent in the main vessel and side branch. A provisional or single stent technique is stenting of the main vessel with side branch balloon dilation or stenting reserved for a suboptimal result. Multiple randomized controlled trials have compared provisional stenting to a two-stent strategy in bifurcations lesions; however, the long-term outcomes with these two approaches remains understudied.

For a meta-analysis published in Heart, we sought to compare the long-term outcomes of a routine two-stent strategy with those of a provisional, single-stent strategy in non-left main bifurcation lesions. A total of 2,778 patients enrolled in 8 trials were included in the analysis.

At a mean follow-up of 3 years, we found a significantly lower risk of all-cause mortality with provisional stenting compared with a two-stent technique. In a sensitivity analysis limited to trials reporting at least 3 years of follow up, provisional stenting was associated with lower all-cause mortality, major adverse cardiovascular events, and myocardial infarction. However, meta-regression suggested an increased risk of major adverse cardiovascular events with provisional stenting compared with the two-stent strategy in patients presenting with acute coronary syndrome (ACS). This suggests that the thrombotic milieu may alter the risks and benefits of the bifurcation techniques and requires further study.

The findings of our meta-analysis indicate that in the majority of bifurcation lesions, a provisional stenting strategy provides superior outcomes to a two-stent strategy in the long term. A caveat is that we observed crossover to a two-stent strategy in 12% of the provisional stent group. In addition, there are situations in which a two-stent strategy is optimal, such as left main bifurcation lesions—as shown by the recently published DKCRUSH-V trial—and in large-caliber side branches with high-grade stenosis and compromised flow as recommended by guidelines. Lastly, our meta-regression analysis suggests that a two-stent strategy may be superior in ACS.

References

Nairooz R, Saad M, Elgendy I, et al. Long-term outcomes of provisional stenting compared with a two-stent strategy for bifurcation lesions: a meta-analysis of randomised trials. Heart. 2017;103(18):1427-1434. Available at http://heart.bmj.com/content/103/18/1427.

Chen S, Zhang J, Han Y, et al. Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial. J Am Coll Cardiol. 2017;70(21):2605-2617.

Levine G, Bates E, Blankenship J, et al. 2011 ACCF/AHA/SCAI guideline

for percutaneous coronary intervention: a report of the American College of Cardiology Foundation/American heart Association Task Force on Practice guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011;124:e574-e651.

Kwan T, Kan J , et al. Two-Year outcome of double kissing crush versus a provisional stenting technique for coronary bifurcation lesions (DKCRUSh II). A multicenter randomized clinical trial. J Clin Innov Cardiol. 2016;1:33-41.