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Canadian Journal of Cardiology

Percutaneous Coronary Intervention Techniques for Bifurcation Disease: Network Meta-analysis Reveals Superiority of Double-Kissing Crush

Published:September 09, 2019DOI:https://doi.org/10.1016/j.cjca.2019.09.002

      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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      Linked Article

      • Double-Kissing Nanocrush for Bifurcation Lesions: Development, Bioengineering, Fluid Dynamics, and Initial Clinical Testing
        Canadian Journal of CardiologyVol. 36Issue 6
        • Preview
          When 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.
        • Full-Text
        • PDF
        Open Access
      • Have a Crush, Kiss Twice, and Tell: How to Optimize Intervention for Coronary Bifurcation Lesions
        Canadian Journal of CardiologyVol. 36Issue 6
        • Preview
          Bifurcation 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.
        • Full-Text
        • PDF