Abstract
Background
Provisional T-stenting (PS) is generally recommended to treat patients with coronary
bifurcation disease (CBD) percutaneously, but PS may not fit all complex bifurcation
anatomies. Therefore, several types of up-front 2-stent techniques have been described.
We aimed to identify the best percutaneous coronary intervention (PCI) technique to
manage patients with CBD.
Methods
We systematically reviewed randomized controlled trials (RCTs) including patients
undergoing CBD PCI which included several types of PCI techniques—PS, double-kissing
(DK) crush, T-stenting and protrusion, culotte, dedicated bifurcation stents, crushing,
and T-stenting—and we compared device-oriented clinical events (DOCEs), a composite
of cardiac death, target-vessel myocardial infarction, stent thrombosis, and target-lesion
or target-vessel revascularization, in a network meta-analysis. We included 26 RCTs,
leading to a pooled population of 10,339 patient-years and a total of 1229 DOCEs.
Results
The DK-crush technique was associated with the lowest DOCE rate, with a relative risk
of 0.62 (95% CI 0.42-0.92) compared with the PS technique. DK-crush had the highest
probability (model likelihood 90.2%, area under the cumulative ranking curve 98.0%)
of being the best technique among those explored to reduce DOCEs in patients receiving
CBD PCI.
Conclusions
When a 2-stent strategy is considered in a patient with CBD, the DK-crush technique
reduces DOCEs compared with other bifurcation techniques based on all available RCTs.
Résumé
Introduction
L’implantation d’une endoprothèse en T provisionnelle (EP) est généralement recommandée
pour traiter par voie percutanée les patients ayant une bifurcation coronaire (BC),
mais l’EP ne convient pas à toutes les anatomies complexes de bifurcation. Par conséquent,
plusieurs types de techniques de base à deux endoprothèses ont été décrites. Nous
avions pour objectif de déterminer la meilleure technique d’intervention coronarienne
percutanée (ICP) pour prendre en charge les patients ayant une BC.
Méthodes
Nous avons passé en revue de manière systématique des essais cliniques à répartition
aléatoire (ECRA) composés de patients qui avaient subi une ICP BC, notamment les nombreuses
techniques d’ICP suivantes : l’EP, le double-kissing (DK) crush, l’endoprothèse en T et la protrusion, la culotte, les endoprothèses de bifurcation
spécialisées, le crushing et l’endoprothèse en T. Puis nous avons comparé les événements
cliniques liés au dispositif (ÉCD), un critère composite de mort d’origine cardiaque,
l’infarctus du myocarde du vaisseau cible, la thrombose sur endoprothèse, et la revascularisation
de la lésion cible ou du vaisseau cible d’une méta-analyse en réseau. Les 26 ECRA
que nous avons choisis regroupaient au total une population de 10 339 patients-années
et 1 229 ÉCD.
Résultats
La technique de DK crush était associée au taux le plus faible d’ÉCD, et à un risque relatif de 0,62 (IC à
95 % 0,42-0,92) comparativement à la technique EP. La technique de DK crush montrait la probabilité la plus élevée (vraisemblance du modèle 90,2 %, surface sous
la courbe cumulative 98,0 %) d’être la meilleure technique parmi les techniques étudiées
pour réduire les ÉCD chez les patients qui subissent une ICP BC.
Conclusions
Lorsqu’une stratégie à deux endoprothèses est envisagée chez un patient ayant une
BC, la technique du DK-crush permet de réduire les ÉCD comparativement aux autres techniques de bifurcation selon
tous les ECRA disponibles.
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Article info
Publication history
Published online: September 09, 2019
Accepted:
September 5,
2019
Received:
May 13,
2019
Footnotes
See editorial by Rey and Jolicoeur, pages 799-801 of this issue.
See page 912 for disclosure information.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Double-Kissing Nanocrush for Bifurcation Lesions: Development, Bioengineering, Fluid Dynamics, and Initial Clinical TestingCanadian Journal of CardiologyVol. 36Issue 6
- PreviewWhen possible, a single-stent technique to treat coronary bifurcation disease is preferable. However, when 2 stents are required, there is scope to improve on existing techniques. The crush technique has already been improved with the introduction of double-kissing (DK) and minicrush. We sought to refine and simplify the minicrush technique, retaining its advantages while avoiding its disadvantages, by developing a DK nanocrush technique.
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- Preview
- Have a Crush, Kiss Twice, and Tell: How to Optimize Intervention for Coronary Bifurcation LesionsCanadian Journal of CardiologyVol. 36Issue 6
- PreviewBifurcation lesions account for 20% of all percutaneous coronary interventions (PCIs), are technically challenging, and are associated with worse outcome compared with simple epicardial stenoses.1 For simpler bifurcation anatomies, a single stent approach is recommended (in the main branch only) with the provisional use of a second stent when flow becomes compromised in the untreated side branch owing to plaque shift or dissection.2 A 2-stent strategy becomes necessary in complex bifurcation anatomies, such as when the large side branch is compromised by a severe, long stenosis at the ostium, when there is an acute-angled takeoff, or when a true distal left main bifurcation is present.
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- Preview
