Randomized Trial of Simple Versus Complex Drug-Eluting Stenting for Bifurcation Lesions The British Bifurcation Coronary Study: Old, New, and Evolving Strategies

Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton, BN8 5QH, UK.
Circulation (Impact Factor: 14.43). 03/2010; 121(10):1235-43. DOI: 10.1161/CIRCULATIONAHA.109.888297
Source: PubMed


The optimal strategy for treating coronary bifurcation lesions remains a subject of debate. With bare-metal stents, single-stent approaches appear to be superior to systematic 2-stent strategies. Drug-eluting stents, however, have low rates of restenosis and might offer improved outcomes with complex stenting techniques.
Patients with significant coronary bifurcation lesions were randomized to either a simple or complex stenting strategy with drug-eluting stents. In the simple strategy, the main vessel was stented, followed by optional kissing balloon dilatation/T-stent. In the complex strategy, both vessels were systematically stented (culotte or crush techniques) with mandatory kissing balloon dilatation. Five hundred patients 64+/-10 years old were randomized; 77% were male. Eighty-two percent of lesions were true bifurcations (>50% narrowing in both vessels). In the simple group (n=250), 66 patients (26%) had kissing balloons in addition to main-vessel stenting, and 7 (3%) had T stenting. In the complex group (n=250), 89% of culotte (n=75) and 72% of crush (n=169) cases were completed successfully with final kissing balloon inflations. The primary end point (a composite at 9 months of death, myocardial infarction, and target-vessel failure) occurred in 8.0% of the simple group versus 15.2% of the complex group (hazard ratio 2.02, 95% confidence interval 1.17 to 3.47, P=0.009). Myocardial infarction occurred in 3.6% versus 11.2%, respectively (P=0.001), and in-hospital major adverse cardiovascular events occurred in 2.0% versus 8.0% (P=0.002), respectively. Procedure duration and x-ray dose favored the simple approach.
When coronary bifurcation lesions are treated, a systematic 2-stent technique results in higher rates of in-hospital and 9-month major adverse cardiovascular events. This difference is largely driven by periprocedural myocardial infarction. Procedure duration is longer, and x-ray dose is higher. The provisional technique should remain the preferred strategy in the majority of cases. Clinical Trial Registration Information- URL: Unique identifier: NCT 00351260.

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    • "Coronary bifurcation lesions are regarded as challenging by coronary intervention specialists even in the present era of DESs [11,12]. The unique characteristics of bifurcation lesions render complex procedures no more effective than simple procedures, and the restenosis rate at the ostium of the side branch is high after performance of complex procedures [2,5,13]. A better understanding of this lesional subset is required before complex procedures are applied. "
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    ABSTRACT: Background/Aims Although complex bifurcation stenting in patients with non-left main (LM) bifurcation lesions has not yielded better clinical outcomes than simpler procedures, the utility of complex bifurcation stenting to treat LM bifurcation lesions has not yet been adequately explored. Methods In the present study, patients who underwent LM-to-left anterior descending (LAD) coronary artery simple crossover stenting to treat significant de novo distal LM or ostial LAD disease, in the absence of angiographically significant ostial left circumflex (LCX) coronary artery disease, were consecutively enrolled. The frequencies of 3-year major adverse cardiovascular events (MACEs; cardiac death, myocardial infarction, and target lesion revascularization), were analyzed. Results Of 105 eligible consecutive patients, only 12 (11.4%) required additional procedures to treat ostial LCX disease after main vessel stenting. The mean percentage diameter of ostial LCX stenosis increased from 22.5% ± 15.2% to 32.3% ± 16.3% (p < 0.001) after LM-to-LAD simple crossover stenting. The 3-year incidence of MACEs was 9.7% (cardiac death 2.2%; myocardial infarction 2.2%; target lesion revascularization 8.6%), and that of stent thrombosis 1.1%. Of seven cases (7.5%) requiring restenosis, pure ostial LCX-related repeat revascularization was required by only two. Conclusions Simple crossover LM-to-LAD stenting without opening of a strut on the LCX ostium was associated with acceptable long-term clinical outcomes.
    The Korean Journal of Internal Medicine 09/2014; 29(5):597-602. DOI:10.3904/kjim.2014.29.5.597 · 1.43 Impact Factor
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    • "Recent studies [4-7] have shown that a simpler strategy with stenting of only the main branch offers a better outcome than using two stents. "
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    ABSTRACT: BACKGROUND: Treatment of coronary bifurcation lesions is a complex problem. METHODS: This retrospective single-center study included all consecutive patients with PCI of coronary bifurcations with stent covering of the side branch (SB) between January 2008 - August 2011.Two methods were compared: group A represented patients without treatment of SB, group B were patients with treatment of SB. RESULTS: Our study group (n = 98) was group A (n = 64, 65.3%) and group B (n = 34, 34.7%). Mean follow-up was 14.1 (group A) vs 12.3 (group B, p = ns) months.Mean age (years) was 70.3 (group A) vs. 67.0 (group B, p = ns), NSTEMI/STEMI was present in 54.7% (group A) vs. 41,2% (group B, p = ns).Duration of x-raying (min, group A vs group B) and the amount of contrast medium (ml) were significantly lower in group A: 18.1 min vs 20.1 min and 225.8 ml vs 307.4 ml (p < 0.05).Final TIMI flow III inside the MB was reached in 98.4% (group A) vs. 97.1% (group B, p = ns), inside the SB in 84.4% vs. 94.1% (p = ns).Target lesion revascularization and target vessel revascularization was seen in 15.9% (group A) vs 32.4% (group B, p = 0.07), cardiac death in 7.9% (group A) vs 14.7% (group B, p = 0.3).All MACE revealed were: 23.8% (group A) vs. 47.1% (group B, p = 0.02). CONCLUSION: In patients with coronary bifurcations a simpler strategy has a significantly lower MACE.Trial registration: Identifier: NCT01538186.
    BMC Cardiovascular Disorders 04/2013; 13(1):27. DOI:10.1186/1471-2261-13-27 · 1.88 Impact Factor
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    • "Different criteria and different portions of side branch stenting in a provisional arm of recent major randomized clinical trials.[5],[7],[47],[48] "
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    ABSTRACT: Percutaneous coronary intervention (PCI) for coronary bifurcation lesions has been associated with lower procedural success rates and worse clinical outcomes compared with PCI for simple coronary lesions. Angiographic evaluation alone is sometimes inaccurate and does not reflect the functional significance of bifurcation lesions. The fractional flow reserve (FFR) is an easily obtainable, reliable, and reproducible physiologic parameter. This parameter is epicardial lesion specific and reflects both degree of stenosis and the myocardial territory supplied by the specific artery. Recent studies have shown that FFR-guided provisional side branch intervention strategy for bifurcation lesions is feasible and effective and can reduce unnecessary complex interventions and related complications. However, an adequate understanding of coronary physiology and the pitfalls of FFR is essential to properly use FFR for PCI of complex bifurcation lesions.
    Journal of Geriatric Cardiology 09/2012; 9(3):278-84. DOI:10.3724/SP.J.1263.2012.05091 · 1.40 Impact Factor
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