Two-stent techniques for the treatment of coronary bifurcations with drug-eluting stents

Ioannis Iakovou, Antonio Colombo
Hellenic Journal of Cardiology  
T he latest advances in percutaneous coronary interventions (PCI) and the recent introduction of drug-eluting stents (DES) have led to a dramatic increase in the number of patients treated percutaneously. [1] [2] [3] [4] [5] Bifurcation lesions are one of the complex lesion subsets that are now being confronted more frequently. Repeated studies have shown that bifurcation interventions, when compared to non-bifurcation procedures, have a lower rate of procedural success and a higher rate of
more » ... higher rate of restenosis. 6-8 Various techniques making use of one or two stents have been developed to optimise the treatment of this subset of lesions. 6-15 Paradoxically, while stenting of individual lesions has been shown to be superior to balloon angioplasty, stenting of both branches seems to offer no advantage over stenting of the main branch (MB) alone. 8 The recent introduction of DES has resulted in a lower event rate and a reduction of MB restenosis in comparison with historical controls. 16 However, side branch (SB) ostial restenosis remains a problem. DES and bifurcations Drug-eluting stents revolutionised the percutaneous treatment of coronary artery disease and are changing the way we treat bifurcation lesions. To date, there are only two randomised studies and some observational reports that specifically address the issue of bifurcation lesion treatment with DES. [16] [17] [18] The recently published sirolimuseluting stent bifurcation study has given us an important initial direction to help us structure our approach to the optimal treatment of bifurcation lesions. 16 This study was a five-centre randomised trial that involved 85 patients (86 lesions) and was designed to assess the feasibility and safety of treatment of patients with sirolimus-eluting stents (Cypherì, Cordis/ Johnson & Johnson, Warren, NJ) at true bifurcation lesions (>50% stenosis in both main vessel and ostium of side branch). Two different strategies were used in two patient groups: Group A, the elective use of two Cypher stents, and Group B, the implantation of a single Cypher stent in the MB with balloon dilatation across the stent struts for the SB. The protocol allowed the investigators to switch to double stenting if flow impairment or residual ostial stenosis >50% developed in the side branch. Twenty-two out of 43 patients randomised to group B crossed over and had two stents implanted. The total restenosis rate at 6 months was 25.7%, and it was not significantly different between the double-stenting (28.0%) and the provisional SB-stenting (18.7%) groups. In the majority of cases the restenosis occurred at the ostium of the SB and was focal. In the second randomised study (single centre, n=91) Pan et al compared stenting the MB and balloon dilatation for the SB to stenting for both branches. Similarly to the previous study, there 188 ñ HJC
pmid:15981554 fatcat:hmrnqdxhmzglpjn7nlp3eixfhi