Stenting techniques for coronary bifurcation lesions: Evidence from a network meta‐analysis of randomized clinical trials

Abstract

Objectives We conducted a systematic review and network meta‐analysis of available randomized clinical trials (RCTs) to compare cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions. Background Although provisional stenting of the main branch and balloon angioplasty of the side branch is considered the standard approach, the use of two stents is often pursued with a wide variety of bifurcation stenting techniques available. Methods We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov from inception to December 2018. We performed a frequentist network meta‐analysis to estimate relative risks (RR) of death, major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST) among different two stent bifurcation techniques. Results We identified 14 studies, yielding data on 4,285 patients. Double Kissing (DK) Crush and Mini‐crush were associated with significant reductions in MACE, TVR, and TLR when compared with the Provisional stenting (RR 0.31–0.55 [all p < .01] and RR 0.42–0.45 [all p < .02], respectively) and with the remaining bifurcation techniques (RR 0.44–0.55 [all p < .05] for DK Crush and RR 0.37–0.45 [all p < .05] for Mini‐crush). In addition, Culotte and Crush were associated with an increased risk for ST compared to Provisional stenting (RR 3.25–4.27 [both p < .05]) and to DK crush (RR 3.02–3.99 [both p < .05]). Conclusions DK crush and mini‐crush were found to be associated with fewer events and complications compared to the other techniques reviewed, including the Provisional approach. Further, Culotte and Crush were associated with an increased risk of stent thrombosis when compared to the Provisional approach.

Randomized non-inferiority TrIal comParing reverse T And Protrusion versus double-kissing and crush Stenting for the treatment of complex left main bifurcation lesions

“…Among the different 2-stent techniques (summarized in the MADS classification and its amendments [4]), the double-kissing and crush (DK-crush) has been shown to result in improved stent expansion at the side branch (SB) ostium, and in reduced neointimal proliferation during 8-month follow-up [5]. DK-crush was associated with lower rates of target-lesion revascularization as compared with provisional or culotte stenting in both non-left main and left main coronary bifurcation lesions [6][7][8][9]. As compared to older techniques, DK-crush requires an additional kissing balloon dilation prior to main branch (MB) stenting.…”

Comparison of Sequential POT-Side-POT and Kissing Balloon Techniquesin Patientswith Coronary Bifurcation Lesions Treatedwith Single-Stent Strategy; Which One is Simple and Safe? Propensity Score Analysis

“…In complex CBL, a two-stent bifurcation technique provides better results than provisional stenting, 12 while a single-stent approach should remain the preferred technique in the setting of simple bifurcations. 13 , 14 However, it is still controversial which technique should be preferred during single-stenting. The POT-side-POT sequence respects fractal geometry by reducing SB ostium stent-strut obstruction, providing perfect proximal stent apposition with almost perfect circularity, reducing ellipticity index, proximal area overstretch, and global strut malapposition.…”

A Review of Double Kissing Crush Stenting in Coronary Bifurcation Lesions

“…Several meta-analyses consistently demonstrated that DK crush was associated with fewer coronary events and complications than bifurcation techniques. [22][23][24][25] In a recent network meta-analysis, Di Gioia et al [23] analyzed 21 randomized studies of 5711 patients, which showed that the DK-crush stenting technique was associated with less occurrence of MACE than those treated using PS mainly driven by a reduction in TLR. More specifically, no significant differences among techniques were observed in cardiac death, MI, and stent thrombosis.…”

“…In recent times, an abundance of scientific and clinical evidence has been obtained to demonstrate the effectiveness and safety of this specific 2-stent technique. [14–27]…”