Background: Bifurcation lesions pose a high risk for adverse events after
percutaneous coronary intervention (PCI). Evidence supporting the benefits of
the two-stent strategy (2SS) for treating coronary bifurcation lesions in India
is limited. This study aimed to evaluate the clinical outcomes of various 2SSs
for percutaneous transluminal coronary angioplasty for bifurcation lesions in
India. Materials and Methods: This retrospective, observational,
multicentric, real-world study included 64 patients over 8 years. Data on
demographics, medical history, PCI procedures, and outcomes were recorded.
Descriptive statistics were computed using the SPSS software. Results: Patients (n=64) had an average age of 65.3±11.1
years, with 78.1% males. Acute coronary syndrome was reported in 18.8%, chronic
stable angina in 40.6%, and unstable angina in 34.4% of participants.
Two-vessel disease was observed in 98.4% of patients, and 99.4% had true
bifurcation lesions. The commonly involved vessels were the left anterior
descending artery (50%), left circumflex coronary artery (34.4%), and first
diagonal artery (43.8%). Mean percent diameter stenosis was 87.2% ±10.1%.
The mean number of stents used was 2.00±0.34.
The 2SS techniques included the T and small protrusion (TAP) (39.1%), double
kissing (DK) crush (18.8%), and the culotte techniques (14.1%). Procedural
References
[1]
Zhang, J.J., Gao, X.F., Han, Y.L., Kan, J., Tao, L., Ge, Z., Tresukosol, D., et al. (2018) 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, 8, e020019.
https://doi.org/10.1136/bmjopen-2017-020019corr1
[2]
Feldman, D., Beerkens, F., Nicolas, J., Satish, M., Jones, D., Johnson, J.W., et al. (2022) Defining Key Features of Complex Coronary Lesions: An Evidence Based Review of Clinical Practice. Part I: Bifurcations, Left Main Disease, and Calcifications. Reviews in Cardiovascular Medicine, 23, Article No. 197.
https://doi.org/10.31083/j.rcm2306197
[3]
Park, D.Y., An, S., Jolly, N., Attanasio, S., Yadav, N., Rao, S., et al. (2022) Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention. Journal of the American Heart Association, 11, e025394. https://doi.org/10.1161/JAHA.122.025394
[4]
Yurtdas, M., Asoglu, R., Ozdemir, M., and Asoglu, E. (2020) An Upfront Two-Stent Strategy for True Coronary Bifurcation Lesions with a Large Side Branch in Acute Coronary Syndrome: A Two-Year Follow-Up Study. Medicina, 56, Article 102.
https://doi.org/10.3390/medicina56030102
[5]
Jabir, A., Malviya, A., Thomas, J., Vijaykumar, S. Mandalay, A., Joseph, J. and Mathew, R. (2021) Rationale, Design, and Implications of Bifurcation Coronary Stenting: Insight from the Indian Bifurcation Stenting (IBIS) Registry. Cureus, 13, e18027.
https://doi.org/10.7759/cureus.18027
Choo, G H., and Gurupparan, K. (2022) Provisional Stenting: A Contemporary Relook at the Strategy and Lingering Issues. Cardiology Discovery, 2, 191-196.
https://doi.org/10.1097/CD9.0000000000000064
[8]
Chandrasekhar, J., Martin, K., and Mehran, R. (2016) Role of Coronary Drug-Eluting Stents in Current Clinical Practice. Clinical Pharmacist, 8, 16-23
[9]
Vinayakumar, D., Mohanan, K.S., and Goyal, K.K. (2018) Balloon Embedded Bifurcation Stenting with Single Stent for Side Branch Protection—Preliminary Results from an Indian Population. Indian Heart Journal, 70, S299-S302.
https://doi.org/10.1016/j.ihj.2018.06.004
[10]
Mohamed, M.O., Mamas, M.A., Nagaraja, V., Alraies, M.C., Lamelas, P., Tzemos, N., et al. (2019) Dedicated Bifurcation Stents for Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials. Journal of Invasive Cardiology, 31, E344-E355.
[11]
Lim, Y., Kim, M.C., Ahn, Y., Sim, D.S., Hong, Y.J., Kim, J.H., et al. (2022) Effect of Stenting Strategy on the Outcome in Patients with Non-Left Main Bifurcation Lesions. Journal of Clinical Medicine, 11, Article No. 5658.
https://doi.org/10.3390/jcm11195658
[12]
Zhang, J.J., Ye, F., Xu, K., Kan, J., Tao, L., Santoso, T., et al. (2020) Multicentre, Randomized Comparison of Two-Stent and Provisional Stenting Techniques in Patients with Complex Coronary Bifurcation Lesions: The DEFINITION II Trial. European Heart Journal, 41, 2523-2536. https://doi.org/10.1093/eurheartj/ehaa543
[13]
Steigen, T.K., Maeng, M., Wiseth, R., Erglis, A., Kumsars, I., Narbute, I., et al. (2006) Randomized Study on Simple versus Complex Stenting of Coronary Artery Bifurcation Lesions: The Nordic Bifurcation Study. Circulation, 114, 1955-1961.
https://doi.org/10.1161/CIRCULATIONAHA.106.664920
[14]
Hildick-Smith, D., de Belder, A.J., Cooter, N., Curzen, N.P., Clayton, T.C., Oldroyd, K.G., et al. (2010) Randomized Trial of Simple versus Complex Drug-Eluting Stenting for Bifurcation Lesions: The British Bifurcation Coronary Study: Old, New, and Evolving Strategies. Circulation, 121, 1235-1243.
https://doi.org/10.1161/CIRCULATIONAHA.109.888297
[15]
Alasnag, M., Bharadwaj, A. and Al-Shaibi, K. (2019) Commentary on the Nordic-Baltic Bifurcation Study IV (Randomised Comparison of Provisional Side Branch Stenting versus a Two-Stent Strategy for Treatment of True Coronary bifurcation Lesions Involving a Large Side Branch). Open Heart, 6, e001168.
https://doi.org/10.1136/openhrt-2019-001168
[16]
Lassen, J.F., Albiero, R., Johnson, T.W., Burzotta, F., Lefèvre, T., Iles, T.L., et al. (2022) Treatment of Coronary Bifurcation Lesions, Part II: Implanting Two Stents. The 16th Expert Consensus Document of the European Bifurcation Club. EuroIntervention, 18, 457-470. https://doi.org/10.4244/EIJ-D-22-00166
[17]
Hildick-Smith, D., Behan, M.W., Lassen, J.F., Chieffo, A., Lefevre, T., Stankovic, G., et al. (2016) The EBC TWO Study (European Bifurcation Coronary TWO): A Randomized Comparison of Provisional T-Stenting versus a Systematic 2 Stent Culotte Strategy in Large Caliber True Bifurcations. Circulation: Cardiovascular Interventions, 9, e003643.
https://doi.org/10.1161/CIRCINTERVENTIONS.115.003643
[18]
Kumsars, I., Holm, N.R., Niemela, M., Erglis, A., Kervinen, K., Christiansen, E.H., et al. (2020) Randomised Comparison of Provisional Side Branch Stenting versus a Two-Stent Strategy for Treatment of True Coronary Bifurcation Lesions Involving a Large Side Branch: The Nordic-Baltic Bifurcation Study IV. Open Heart, 7, e000947.
https://doi.org/10.1136/openhrt-2018-000947
[19]
Pan, M., de Lezo, J.S., Medina, A., Romero, M., Segura, J., Pavlovic, D., et al. (2004) Rapamycin-Eluting Stents for the Treatment of Bifurcated Coronary Lesions: A Randomized Comparison of a Simple versus Complex Strategy. American Heart Journal, 148, 857-864. https://doi.org/10.1016/j.ahj.2004.05.029
[20]
Colombo, A., Moses, J.W., Morice, M.C., Ludwig, J., Holmes Jr., D.R., Spanos, V., et al. (2004) Randomized Study to Evaluate Sirolimus-Eluting Stents Implanted at Coronary Bifurcation Lesions. Circulation, 109, 1244-1249.
https://doi.org/10.1161/01.CIR.0000118474.71662.E3
[21]
Chen, S.L., Zhang, J.J., Ye, F., Chen, Y.D., Patel, T., Kawajiri, K., et al. (2008) Study Comparing the Double Kissing (DK) Crush with Classical Crush for the Treatment of Coronary Bifurcation Lesions: The DKCRUSH-1 Bifurcation Study with Drug-Eluting Stents. European Journal of Clinical Investigation, 38, 361-371.
https://doi.org/10.1111/j.1365-2362.2008.01949.x
[22]
Colombo, A., Bramucci, E., Saccà, S., Violini, R., Lettieri, C., Zanini, R., et al. (2009) Randomized Study of the Crush Technique versus Provisional Side-Branch Stenting in True Coronary Bifurcations: The CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents) Study. Circulation, 119, 71-78. https://doi.org/10.1161/CIRCULATIONAHA.108.808402
[23]
Chen, S.L., Santoso, T., Zhang, J.J., Ye, F., Xu, Y.W., Fu, Q., et al. (2011) A Randomized Clinical Study Comparing Double Kissing Crush with Provisional Stenting for Treatment of Coronary Bifurcation Lesions: Results from the DKCRUSH-II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) Trial. Journal of the American College of Cardiology, 57, 914-920. https://doi.org/10.1016/j.jacc.2010.10.023
[24]
Ye, F., S. Chen, L., Zhang, J.J., Zhu Z.-S., Kan, J., Tian, N.-L., et al. (2012) Hemodynamic Changes of Fractional Flow Reserve after Double Kissing Crush and Provisional Stenting Technique for True Bifurcation Lesions. Chinese Medical Journal (English), 125, 2658-2662.
[25]
Kervinen, K., Niemela, M., Romppanen, H., Erglis, A., Kumsars, I., Maeng, M., et al. (2013) Clinical Outcome after Crush versus Culotte Stenting of Coronary Artery Bifurcation Lesions: The Nordic Stent Technique Study 36-Month Follow-Up Results. JACC: Cardiovascular Interventions, 6, 1160-1165.
https://doi.org/10.1016/j.jcin.2013.06.009
[26]
Maeng, M., Holm, N.R., Erglis, A., Kumsars, I., Niemela, M., Kervinen, K., et al. (2013) Long-Term Results after Simple versus Complex Stenting of Coronary Artery Bifurcation Lesions: Nordic Bifurcation Study 5-Year Follow-Up Results. Journal of the American College of Cardiology, 62, 30-34.
https://doi.org/10.1016/j.jacc.2013.04.015
[27]
Ruiz-Salmeron, R.J., Valenzuela, L.F., Perez, I., Fuentes, M., Rodriguez-Leiras, S., Vizcaino, M., et al. (2013) Approach to Coronary Bifurcation Lesions Using the Everolimus-Eluting Stent: Comparison between a Simple Strategy and a Complex Strategy with T-Stenting. Revista Espacola de Cardiología (English Edition), 66, 636-643. https://doi.org/10.1016/j.rec.2013.03.005
[28]
Chen, S.L., Xu, B., Han, Y.L., Sheiban, I., Zhang, J.J., Ye, F., et al. (2015) Clinical Outcome after DK Crush versus Culotte Stenting of Distal Left Main Bifurcation Lesions: The 3-Year Follow-Up Results of the DKCRUSH-III Study. JACC: Cardiovascular Intervention, 8, 1335-1342. https://doi.org/10.1016/j.jcin.2015.05.017
[29]
Ferenc, M., Ayoub, M., Buttner, H.J., Gick, M., Comberg, T., Rothe, J., et al. (2015) Long-Term Outcomes of Routine versus Provisional T-Stenting for de Novo Coronary Bifurcation Lesions: Five-Year Results of the Bifurcations Bad Krozingen I Study. EuroIntervention, 11, 856-859. https://doi.org/10.4244/EIJV11I8A175
[30]
Kim, Y.H., Lee, J.H., Roh, J.H., Ahn, J.M., Yoon, S.H., Park, D.W., et al. (2015) Randomized Comparisons between Different Stenting Approaches for Bifurcation Coronary Lesions with or without Side Branch Stenosis. JACC: Cardiovascular Intervention, 8, 550-560. https://doi.org/10.1016/j.jcin.2015.01.016
[31]
Zhang, L., Zhong W., Luo, Y. and Chen, L. (2016) A Pilot Study on Culottes versus Crossover Single Stenting for True Coronary Bifurcation Lesions. Acta Cardiological Sinica, 32, 450-459.
[32]
Ferenc, M., Gick, M., Comberg, T., Rothe, J., Valina, C., Toma, A., et al. (2016) Culotte Stenting vs. TAP Stenting for Treatment of de-Novo Coronary Bifurcation Lesions with the Need for Side-Branch Stenting: The Bifurcations Bad Krozingen (BBK) II Angiographic Trial. European Heart Journal, 37, 3399-3405.
https://doi.org/10.1093/eurheartj/ehw345
[33]
Zheng, X.W., Zhao, D.H., Peng, H.Y., Fan, Q., Ma, Q., Xu, Z.Y., et al. (2016) Randomized Comparison of the Crush versus the Culotte Stenting for Coronary Artery Bifurcation Lesions. Chinese Medical Journal (English), 129, 505-510.
https://doi.org/10.4103/0366-6999.176997
[34]
Chen, S.-L., Santoso, T., Zhang, J.-J., Ye, F., Xu, Y.-W., Fu, Q., et al. (2017) Clinical Outcome of Double Kissing Crush versus Provisional Stenting of Coronary Artery Bifurcation Lesions: The 5-Year Follow-Up Results from a Randomized and Multicenter DKCRUSH-II Study (Randomized Study on Double Kissing Crush Technique versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions). Circulation: Cardiovascular Interventions, 10, e004497.
https://doi.org/10.1161/CIRCINTERVENTIONS.116.004497
[35]
Chen, X., Li, X., Zhang, J.J., Han, Y., Kan, J., Chen, L., et al. (2019) DKCRUSH-V Investigators. 3-Year Outcomes of the DKCRUSH-V Trial Comparing DK Crush With Provisional Stenting for Left Main Bifurcation Lesions. JACC: Cardiovascular Intervention, 12, 1927-1937. https://doi.org/10.1016/j.jcin.2019.04.056
[36]
Zhang, J.-J., Ye, F., Xu, K., Kan, J., Tao, L., Santoso, T., et al. (2020) Multicentre, Randomized Comparison of Two-Stent and Provisional Stenting Techniques in Patients with Complex Coronary Bifurcation Lesions: The DEFINITION II Trial. European Heart Journal, 41, 2523-2536. https://doi.org/10.1093/eurheartj/ehaa543
[37]
Kim, J., Lee, J.M., Park, T.K., Yang, J.H., Hahn, J.Y., Choi, J.H., et al. (2021) Optimal Strategy for Side Branch Treatment in Patients with Left Main Coronary Bifurcation Lesions. Revista Espacola de Cardiología (English Edition), 74, 691-699.
https://doi.org/10.1016/j.rec.2020.06.011
[38]
Hildick-Smith, D., Egred, M., Banning, A., Brunel, P., Ferenc, M., Hovasse, T., et al. (2021) The European Bifurcation Club Left Main Coronary Stent study: A Randomized Comparison of Stepwise Provisional vs. Systematic Dual Stenting Strategies (EBC MAIN). European Heart Journal, 42, 3829-3839.
https://doi.org/10.1093/eurheartj/ehab283
[39]
Kan, J., Luo, S., Wang, D., Cai, D., Zhang, X. and Kan, J. (2022) Impact of Side Branch Lesion Length on Clinical Outcome after Coronary Stenting Techniques in Patients with Coronary Artery Bifurcation Disease: A Meta-Analysis. Cardiology Discovery, 2, Article 157173. https://doi.org/10.1097/CD9.0000000000000066
[40]
Ford, T.J., McCartney, P., Corcoran, D., Collison, D., Hennigan, B., McEntegart, M., et al. (2018) Single- versus 2-Stent Strategies for Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis of Randomized Trials with Long-Term Follow-Up. Journal of the American Heart Association, 7, e008730.
https://doi.org/10.1161/JAHA.118.008730
[41]
Fujisaki, T., Kuno, T., Numasawa, Y., Takagi, H., Briasoulis, A., Kwan, T., et al. (2022) Provisional or 2-Stent Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era. Journal of the Society for Cardiovascular Angiography and Interventions, 1, Article 100410. https://doi.org/10.1016/j.jscai.2022.100410
[42]
Wang, S., Liang, C., Wang, Y., Sun, S., Wang, Y., Suo, M., et al. (2022) The Long-Term Clinical Outcomes of Intravascular Ultrasound-Guided versus Angiography-Guided Coronary Drug Eluting Stent Implantation in long de novo Coronary Lesions: A Systematic Review and Meta-Analysis. Frontiers in Cardiovascular Medicine, 9, 944143. https://doi.org/10.3389/fcvm.2022.944143
[43]
Di Gioia, G., Sonck, J., Ferenc, M., Chen, S.L., Colaiori, I., Gallinoro, E., et al. (2020) Clinical Outcomes Following Coronary Bifurcation PCI Techniques: A Systematic Review and Network Meta-Analysis Comprising 5,711 Patients. JACC: Cardiovascular Interventions, 13, 1432-1444. https://doi.org/10.1016/j.jcin.2020.03.054
[44]
Klein, L.W. and Krone, R.J. (2008) Angiographic Characterization of Lesion Morphology. Cardiac Interventions Today, 8, 44-49.
[45]
Banning, A.P., Lassen, J.F., Burzotta, F., Lefèvre, T., Darremont, O., Hildick-Smith, D., et al. (2019) Percutaneous Coronary Intervention for Obstructive Bifurcation Lesions: The 14th Consensus Document from the European Bifurcation Club. EuroIntervention, 15, 90-98. https://doi.org/10.4244/EIJ-D-19-00144
[46]
Sgueglia, G.A. and Chevalier, B. (2012) Kissing Balloon Inflation in Percutaneous Coronary Interventions. JACC: Cardiovascular Interventions, 5, 803-811.
https://doi.org/10.1016/j.jcin.2012.06.005
[47]
Jyotsna, M. (2020) Coronary Bifurcation Lesion-Management. Indian Journal of Cardiovascular Disease in Women—WINCARS, 5, 137-154.
https://doi.org/10.1055/s-0040-1713963
[48]
Lee, S.Y., Choi, K.H., Song, Y.B. and Park, T.K. (2022) Use of Intravascular Ultrasound and Long-Term Cardiac Death or Myocardial Infarction in Patients Receiving Current Generation Drug-Eluting Stents. Scientific Reports, 12, Article No. 8237.
https://doi.org/10.1038/s41598-022-04807-w
