Slides

Intervention of Bifurcation Coronary Artery Disease
The optimal management strategy for complex set of bifurcation lesions continues to be the focus of intense interventional research and debate. In most bifurcation lesions, one stent is the treatment of choice. Although when necessary, this technique can be converted to a provisional T-stent when bailout of the side branch is necessary. Colombo et al. reported their results in 85 patients with 86 bifurcation lesions, all treated with sirolimus-eluting stents. The overall restenosis rate was higher for 2-stent approach ( 28% vs. 18.7%, p =0.053). The stent thrombosis rate was 3.5%, all in the main and side branch group. The restenosis rate in the main branch was quite low, approximately 5% in both groups. More recent data from the NORDIC collaborative group reported a large randomized trial comparing main branch and main plus side branch stenting (using any 2-stent technique). Unique to this study, 95% of the patients in each randomized group received their assigned therapy; there was little crossover. There were significantly longer procedural and fluoroscopy times and a larger volume of contrast used in the main plus side branch stenting group. Moreover, an elevation of CK-MB over three times the upper limit of normal value was significantly greater in the 2- stent group (18% vs. 8%, p=0.011). Clinical outcomes, such as death, MI, TVR or the composite of death, MI, and TVR were not different. Six-month stent thrombosis was low in both groups ( 0.5% main branch vs. 0% main plus side branch). These data suggest that a strategy of keeping it simple with one main vessel stent is preferred. However, it also suggests that if necessary , a two-stent approach provides acceptable outcomes. In a true bifurcation lesion (MEDINA 1,1,1; 1,0,1 or 0,1,1), the strategy of elective implantation of two stents may be considered, especially when side branch lesion is longer that 2 or 3 mm, but there are no consensus on which of the different two stent methods gives the best result on a long term basis. More data are still to be collected to define which is the strategy best adapted for each of the different anatomic situations.
REFERENCES
1. Colombo A, Moses JW, Morice MC, et al. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation 2004;109:1244-1249.
2. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: The Nordic Bifurcation Study. Circulation 2006;114:1955-1961.
3. Legrand V, Thomas M, Zelisko M, Bruyne BD, et al. Percutaneous coronary intervention of bifurcation lesions: state-of-the-art. Insight from the second meeting of the European Bifurcation Club. EuroInterv. 2007;3:44-49.

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