Non-Left Main Bifurcation Lesion PCI Strategies

Non-Left Main Bifurcation Lesion PCI Strategies

Bifurcation lesions may be noted in almost one third of cases for percutaneous coronary intervention. Outcomes for bifurcation lesions are worse compared to non-bifurcation lesions. The two important strategies for addressing a coronary bifurcation lesion are planned one stent strategy or provisional stenting and elective two stent strategy. In provisional stenting, side branch is stented only if unavoidable.

A multicenter registry of 2044 patients compared the two strategies in non-left main bifurcation lesions. There were 1551 bifurcation lesions of left anterior descending coronary artery and 493 non-LAD bifurcation lesions. Target lesion failure was the primary outcome evaluated in the study. It was a composite of cardiac death, myocardial infarction and target lesion revascularization. Over a follow up period of 38 months, non-LAD bifurcation lesions treated with two stent strategy had more frequent target lesion failure (20.7% vs. 6.3%, p < 0.01) and target lesion revascularization (18.2% vs. 6.3%, p < 0.01). There was no significant difference in the outcome among LAD bifurcation lesions between the two strategies [1].

Authors of the report suggested three possible reasons for the difference between LAD and non-LAD lesions in their study. (1) Less frequent use of final kissing balloon inflation in the non-LAD group. (2) Less frequent use of intravascular ultrasound guided PCI (3)  Difference in the angle between parent vessel, main branch and side branch. The angle between parent vessel and main branch was wider in non-LAD bifurcation lesions compared the the LAD bifurcation group [1].

15th consensus document from the European Bifurcation Club published prior to this report had also mentioned that while using a two stent strategy, failure to perform a final kissing balloon inflation may jeopardise clinical outcome. They had also highlighted the importance of intracoronary imaging in bifurcation stenting [2].

RAIN (veRy thin stents for patients with left mAIn or bifurcatioN in real life) registry was a retrospective multicenter registry enrolling patients with coronary bifurcation lesions or left main disease treated with thin-strut drug eluting stents. A RAIN subanalysis had 1803 patients with non-left main bifurcation lesions, of which 59% had acute coronary syndrome and 41% stable coronary artery disease. After multivariate adjustment, postdilation and provisional stenting were associated with lower target vessel revascularization. Use of final kissing balloon was associated with a lower incidence of target vessel revascularization in the two stent subgroup [3].

A previous study had reported two year outcomes of non-left main coronary bifurcation lesions treated with two stent strategy using second generation drug eluting stents. They concluded that bifurcation location in the left anterior descending artery and its diagonal branch was protective against target lesion revascularization. Multiple stents implanted in either the main branch or the side branch was associated with target vessel revascularization [4].

References

1. Lim Y, Kim MC, Ahn Y, Sim DS, Hong YJ, Kim JH, Jeong MH, Gwon HC, Kim HS, Rha SW, Yoon JH, Jang Y, Tahk SJ, Seung KB. Effect of Stenting Strategy on the Outcome in Patients with Non-Left Main Bifurcation Lesions. J Clin Med. 2022 Sep 26;11(19):5658. doi: 10.3390/jcm11195658. PMID: 36233526; PMCID: PMC9571815.
2. Burzotta F, Lassen JF, Lefèvre T, Banning AP, Chatzizisis YS, Johnson TW, Ferenc M, Rathore S, Albiero R, Pan M, Darremont O, Hildick-Smith D, Chieffo A, Zimarino M, Louvard Y, Stankovic G. Percutaneous coronary intervention for bifurcation coronary lesions: the 15^th consensus document from the European Bifurcation Club. EuroIntervention. 2021 Mar 19;16(16):1307-1317. doi: 10.4244/EIJ-D-20-00169. PMID: 33074152; PMCID: PMC8919527.
3. De Filippo O, D’Ascenzo F, Angelini F, Franchin L, Cerrato E, Pennacchi M, Nuñez-Gil I, Wojakowski W, Imori Y, Trabattoni D, Huczek Z, Venuti G, Muscoli S, Iannaccone M, Montabone A, Marengo G, Rognoni A, Parma R, Figini F, Mitomo S, Boccuzzi G, Mattesini A, Quadri G, Wańha W, Smolka G, Rolfo C, Cortese B, Ryan N, Capodanno D, Chieffo A, di Mario C, Varbella F, Romeo F, Sheiban I, Escaned J, Helft G, De Ferrari GM. Performance of Thin-Strut Stents in Non-Left Main Bifurcation Coronary Lesions: A RAIN Subanalysis. J Invasive Cardiol. 2021 Nov;33(11):E890-E899. PMID: 34735352.
4. Ohya M, Morimoto T, Kubo S, Habara S, Kuwayama A, Miura K, Shimada T, Amano H, Otsuru S, Tada T, Tanaka H, Fuku Y, Goto T, Kadota K. Two-Year Outcomes and Predictors of Target Lesion Revascularization for Non-Left Main Coronary Bifurcation Lesions Following Two-Stent Strategy With 2nd-Generation Drug-Eluting Stents. Circ J. 2018 Feb 23;82(3):798-806. doi: 10.1253/circj.CJ-17-1092. Epub 2017 Dec 19. PMID: 29269613.