Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: Latest Evidence
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Purpose of review
This paper provides a synopsis of the best evidence to guide bifurcation percutaneous coronary intervention (PCI), with a focus on recent studies. This is with the aim of guiding the interventional cardiologist in choosing the best, evidence-based technique, to treat commonly encountered coronary bifurcations.
Current evidence supports the use of provisional stenting for most anatomically suitable bifurcation lesions. Newer techniques for side branch protection in provisional stenting have been developed. When a two-stent strategy is required, use of a double-kissing crush technique is favoured, particularly in left main bifurcations. For bifurcation PCI, as in all complex procedures, intravascular imaging plays a key adjunctive role in improving procedural success.
PCI for coronary bifurcation lesions is an ever-growing field with significant advancements in techniques and technology.
KeywordsBifurcation Coronary artery disease Percutaneous coronary intervention
Dr. Zaman has been supported by a fellowship (101993) from the National Heart Foundation of Australia.
Compliance with Ethical Standards
Conflict of Interest
Sean Tan declares that he has no conflict of interest. John Ramzy declares that he has no conflict of interest. Sonya Burgess declares that she has no conflict of interest. Sarah Zaman declares that she has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.Shanmugam VB, Psaltis PJ, Tay L, et al. Procedural and clinical outcomes in management of bifurcational lesions in ST elevation myocardial infarction. Heart Lung and Circulation. 2019:10–1.Google Scholar
- 10.Zhou Y, Chen S, Huang L, Hildick-Smith D, Ferenc M, Jabbour RJ, et al. Definite stent thrombosis after drug-eluting stent implantation in coronary bifurcation lesions: a meta-analysis of 3,107 patients from 14 randomized trials. Catheter Cardiovasc Interv. 2018;92(4):680–91.PubMedCrossRefPubMedCentralGoogle Scholar
- 11.Kim MC, Ahn Y, Sun Sim D, Joon Hong Y, Han Kim J, Ho Jeong M, et al. Comparison of the planned one- and elective two-stent techniques in patients with coronary bifurcation lesions with or without acute coronary syndrome from the COBIS II registry. Catheter Cardiovasc Interv. 2018;92(6):1050–60.PubMedCrossRefPubMedCentralGoogle Scholar
- 13.Lee SH, Lee JM, Song YB, Park TK, Yang JH, Hahn JY, et al. Prediction of side branch occlusions in percutaneous coronary interventions by coronary computed tomography: the CT bifurcation score as a novel tool for predicting intraprocedural side branch occlusion. EuroIntervention. 2019;15(9):e788–95.PubMedCrossRefPubMedCentralGoogle Scholar
- 14.Bai J, Yue Y, Feng HQ, Hao SX, Peng L, Zhang M, et al. Impact of main vessel calcification on procedural and clinical outcomes of bifurcation lesion undergoing provisional single-stenting intervention: a multicenter, prospective, observational study. J Geriatr Cardiol. 2019;16(2):156–63.PubMedPubMedCentralGoogle Scholar
- 17.Mohsin M, Khan HS, Saleem M, Afzal A. Assessment of predictors of side branch occlusion after main vessel stenting in coronary bifurcation lesions in patients undergoing percutaneous coronary intervention. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2018;28(10):744–7.PubMedPubMedCentralGoogle Scholar
- 22.Burzotta F, Shoeib O, Aurigemma C, Porto I, Leone AM, Niccoli G, et al. Procedural impact of a kissing-balloon predilation (pre- kissing) technique in patients with complex bifurcations undergoing drug-eluting stenting. The Journal of Invasive Cardiology. 2019;31(4):80–8.PubMedPubMedCentralGoogle Scholar
- 28.Jurado-Román A, Rubio-Alonso B, García-Tejada J, et al. Systematic isolated post-dilatation of the side branch as part of the provisional stent technique in the percutaneous treatment of coronary bifurcations. CR12 registry. Cardiovascular Revascularization Medicine. 2018;19(5):493–7.PubMedCrossRefPubMedCentralGoogle Scholar
- 29.Zhong M, Tang B, Zhao Q, et al. Should kissing balloon inflation after main vessel stenting be routine in the one-stent approach? A systematic review and meta-analysis of randomized trials. PLoS One. 2018;13(6):1–11.Google Scholar
- 33.Omori H, Kawase Y, Hara M, et al. Feasibility and safety of jailed-pressure wire technique using durable optical fiber pressure wire for intervention of coronary bifurcation lesions. Catheter Cardiovasc Interv. 2019:9–10.Google Scholar
- 35.•• Crimi G, Mandurino-Mirizzi A, Gritti V, et al. Percutaneous coronary intervention techniques for bifurcation disease: a network meta-analysis reveals superiority of double kissing crush. Canadian J Cardiol. 2019. This meta-analysis compares clinical outcomes in patients undergoing provisional stenting, double kissing-Crush, T-and-protrusion, Culotte, dedicated bifurcation stents, original crush, and T-stenting.Google Scholar
- 37.• Yang JH, Lee JM, Park TK, et al. The proximal optimization technique improves clinical outcomes when treated without kissing ballooning in patients with a bifurcation lesion. Korean Circulation Journal. 2019;49(6):485. This study describes the efficacy of proximal optimisation technique in patients undergoing bifurcation percutaneous coronary intervention.PubMedPubMedCentralCrossRefGoogle Scholar
- 38.• Chen L, Xu T, Xue XJ, et al. Intravascular ultrasound-guided drug-eluting stent implantation is associated with improved clinical outcomes in patients with unstable angina and complex coronary artery true bifurcation lesions. International Journal of Cardiovascular Imaging. 2018;34(11):1685–96. This study describes the efficacy of utilising intravascular ultrasound in bifurcation percutaneous coronary intervention.PubMedCrossRefPubMedCentralGoogle Scholar
- 42.Stone GW, Kappetein AP, Sabik JF, et al. Five-year outcomes after PCI or CABG for left main coronary disease. New England Journal of Medicine. 2019.Google Scholar
- 43.Mäkikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388(10061):2743–52.PubMedCrossRefPubMedCentralGoogle Scholar
- 44.Chen SL, Xu B, Han YL, Sheiban I, Zhang JJ, Ye F, et al. Comparison of double kissing crush versus culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol. 2013;61(14):1482–8.PubMedCrossRefPubMedCentralGoogle Scholar
- 51.Triantafyllis AS, Bennett J, Pagourelias E, McCutcheon K, Adriaenssens T, Sinnaeve PR, et al. Long-term outcomes after percutaneous revascularization of complex coronary bifurcation lesions using a dedicated self-expanding biolimus-eluting stent system. Cardiol J. 2018;25(4):470–8.PubMedCrossRefPubMedCentralGoogle Scholar
- 53.Konigstein M, Srdanovic I, Gore AK, Rahim HM, Généreux P, Ben-Yehuda O, et al. Outcomes of the Tryton-dedicated bifurcation stent for the treatment of true coronary bifurcations: individual-patient-data pooled analysis. Catheter Cardiovasc Interv. 2019;93(7):1255–61.PubMedCrossRefPubMedCentralGoogle Scholar
- 58.Zhang JJ, Gao XF, Han YL, et al. Treatment effects of systematic two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: rationale and design of a prospective, randomised and multicentre DEFINITION II trial. BMJ Open. 2018;8(3):1–7.Google Scholar
- 60.Miyazaki Y, Muramatsu T, Asano T, et al. On-line three-dimensional OFDI guided PCI vs . angiography guided in bifurcation lesions : design and rationale of the randomized OPTIMUM trial. Eurointervention. 2019.Google Scholar