Advertisement

Provisional Versus Dual Stenting of Left Main Coronary Artery Bifurcation Lesions (from a Comprehensive Meta-Analysis)

Published:October 13, 2022DOI:https://doi.org/10.1016/j.amjcard.2022.09.012
      The optimal technique for bifurcation of left main coronary artery (LMCA) stenting has been a subject of controversy since the inception of drug-eluting stents. We searched PubMed, Clinical Trials Registry, and the Cochrane Central Register of Controlled Trials from January 2002 through October 2021. A total of 13 studies comparing the use of provisional versus dual stenting in patients with LMCA bifurcation lesions were included. Any major adverse cardiac event (MACE) was considered the primary composite end point. The secondary end points included individual components of MACE, including death, myocardial infarction, and target lesion revascularization. The treatment effect was defined as the log odds ratio (OR) of provisional over dual stenting for cumulative event rate at 3 years. In 12 studies with 8,377 patients included for MACE, the use of a provisional-stenting strategy was associated with a significant reduction of 3-year MACE (OR 0.64, 95% confidence interval [CI] 0.46 to 0.88) compared with a dual-stenting strategy, primarily driven by target lesion revascularization (OR 0.51, 95% CI 0.36 to 0.73). No significant difference was found regarding death (OR 0.88; 95% CI 0.65 to 1.21) or myocardial infarction (OR 0.97, 95% Cl 0.61 to 1.54). In conclusion, our meta-analysis suggests that provisional stenting should be the preferred technique over dual stenting when treating LMCA bifurcation lesions with drug-eluting stents. Further randomized controlled studies compounded with intracoronary imaging comparing the 2 strategies are warranted.

      Graphical abstract

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Fihn SD
        • Blankenship JC
        • Alexander KP
        • Bittl JA
        • Byrne JG
        • Fletcher BJ
        • Fonarow GC
        • Lange RA
        • Levine GN
        • Maddox TM
        • Naidu SS
        • Ohman EM
        • Smith PK.
        2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
        J Am Coll Cardiol. 2014; 64: 1929-1949
        • Stone GW
        • Kappetein AP
        • Sabik JF
        • Pocock SJ
        • Morice MC
        • Puskas J
        • Kandzari DE
        • Karmpaliotis D
        • Brown WM
        • Lembo NJ
        • Banning A
        • Merkely B
        • Horkay F
        • Boonstra PW
        • van Boven AJ
        • Ungi I
        • Bogáts G
        • Mansour S
        • Noiseux N
        • Sabaté M
        • Pomar J
        • Hickey M
        • Gershlick A
        • Buszman PE
        • Bochenek A
        • Schampaert E
        • Pagé P
        • Modolo R
        • Gregson J
        • Simonton CA
        • Mehran R
        • Kosmidou I
        • Généreux P
        • Crowley A
        • Dressler O
        • Serruys PW
        EXCEL Trial Investigators. Five-year outcomes after PCI or CABG for left main coronary disease.
        N Engl J Med. 2019; 381: 1820-1830
        • Holm NR
        • Mäkikallio T
        • Lindsay MM
        • Spence MS
        • Erglis A
        • Menown IBA
        • Trovik T
        • Kellerth T
        • Kalinauskas G
        • Mogensen LJH
        • Nielsen PH
        • Niemelä M
        • Lassen JF
        • Oldroyd K
        • Berg G
        • Stradins P
        • Walsh SJ
        • Graham ANJ
        • Endresen PC
        • Fröbert O
        • Trivedi U
        • Anttila V
        • Hildick-Smith D
        • Thuesen L
        • Christiansen EH
        • investigators NOBLE
        Percutaneous coronary angioplasty versus coronary artery bypass grafting in the treatment of unprotected left main stenosis: updated 5-year outcomes from the randomised, non-inferiority NOBLE trial.
        Lancet. 2020; 395: 191-199
        • Gallo M
        • Blitzer D
        • Laforgia PL
        • Doulamis IP
        • Perrin N
        • Bortolussi G
        • Guariento A
        • Putzu A.
        Percutaneous coronary intervention versus coronary artery bypass graft for left main coronary artery disease: a meta-analysis.
        J Thorac Cardiovasc Surg. 2022; 163 (e15): 94-105
        • Erglis A
        • Kumsars I
        • Niemelä M
        • Kervinen K
        • Maeng M
        • Lassen JF
        • Gunnes P
        • Stavnes S
        • Jensen JS
        • Galløe A
        • Narbute I
        • Sondore D
        • Mäkikallio T
        • Ylitalo K
        • Christiansen EH
        • Ravkilde J
        • Steigen TK
        • Mannsverk J
        • Thayssen P
        • Hansen KN
        • Syvänne M
        • Helqvist S
        • Kjell N
        • Wiseth R
        • Aarøe J
        • Puhakka M
        • Thuesen L
        Nordic PCI Study Group. Randomized comparison of coronary bifurcation stenting with the crush versus the culotte technique using sirolimus eluting stents: the Nordic stent technique study.
        Circ Cardiovasc Interv. 2009; 2: 27-34
        • Rab T
        • Sheiban I
        • Louvard Y
        • Sawaya FJ
        • Zhang JJ
        • Chen SL.
        Current interventions for the left main bifurcation.
        JACC Cardiovasc Interv. 2017; 10: 849-865
        • Lassen JF
        • Burzotta F
        • Banning AP
        • Lefèvre T
        • Darremont O
        • Hildick-Smith D
        • Chieffo A
        • Pan M
        • Holm NR
        • Louvard Y
        • Stankovic G.
        Percutaneous coronary intervention for the left main stem and other bifurcation lesions: 12th Consensus Document from the European Bifurcation Club.
        EuroIntervention. 2018; 13: 1540-1553
        • Chen SL
        • Xu B
        • Han YL
        • Sheiban I
        • Zhang JJ
        • Ye F
        • Kwan TW
        • Paiboon C
        • Zhou YJ
        • Lv SZ
        • Dangas GD
        • Xu YW
        • Wen SY
        • Hong L
        • Zhang RY
        • Wang HC
        • Jiang TM
        • Wang Y
        • Sansoto T
        • Chen F
        • Yuan ZY
        • Li WM
        • Leon MB.
        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 Cardiovasc Interv. 2015; 8: 1335-1342
        • Palmerini T
        • Marzocchi A
        • Tamburino C
        • Sheiban I
        • Margheri M
        • Vecchi G
        • Sangiorgi G
        • Santarelli A
        • Bartorelli A
        • Briguori C
        • Vignali L
        • Di Pede F
        • Ramondo A
        • Inglese L
        • De Carlo M
        • Falsini G
        • Benassi A
        • Palmieri C
        • Filippone V
        • Sangiorgi D
        • Barlocco F
        • De Servi S.
        Impact of bifurcation technique on 2-year clinical outcomes in 773 patients with distal unprotected left main coronary artery stenosis treated with drug-eluting stents.
        Circ Cardiovasc Interv. 2008; 1: 185-192
        • Karrowni W
        • Makki N
        • Dhaliwal AS
        • Vyas A
        • Blevins A
        • Dughman S
        • Girotra S
        • Cram P
        • Horwitz PA.
        Single versus double stenting for unprotected left main coronary artery bifurcation lesions: a systematic review and meta-analysis.
        J Invasive Cardiol. 2014; 26: 229-233
        • Chen X
        • Li X
        • Zhang JJ
        • Han Y
        • Kan J
        • Chen L
        • Qiu C
        • Santoso T
        • Paiboon C
        • Kwan TW
        • Sheiban I
        • Leon MB
        • Stone GW
        • Chen SL
        • Investigators DKCRUSH-V
        3-year outcomes of the DKCRUSH-V trial comparing DK crush with provisional stenting for left main bifurcation lesions.
        JACC Cardiovasc Interv. 2019; 12: 1927-1937
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        • PRISMA Group
        Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement.
        BMJ. 2009; 339: b2535
        • Wang J
        • Guan C
        • Chen J
        • Dou K
        • Tang Y
        • Yang W
        • Shi Y
        • Hu F
        • Song L
        • Yuan J
        • Cui J
        • Zhang M
        • Hou S
        • Wu Y
        • Yang Y
        • Qiao S
        • Xu B.
        Validation of bifurcation definition criteria and comparison of stenting strategies in true left main bifurcation lesions.
        Sci Rep. 2020; 10: 10461
        • Rhee TM
        • Park KW
        • Kim CH
        • Kang J
        • Han JK
        • Yang HM
        • Kang HJ
        • Koo BK
        • Kim HS.
        Dual antiplatelet therapy duration determines outcome after 2- but not 1-stent strategy in left main bifurcation percutaneous coronary intervention.
        JACC Cardiovasc Interv. 2018; 11: 2453-2463
        • D'Ascenzo F
        • Iannaccone M
        • Giordana F
        • Chieffo A
        • Connor SO
        • Napp LC
        • Chandran S
        • de la Torre Hernández JM
        • Chen SL
        • Varbella F
        • Omedè P
        • Taha S
        • Meliga E
        • Kawamoto H
        • Montefusco A
        • Chong M
        • Garot P
        • Sin L
        • Gasparetto V
        • Abdirashid M
        • Cerrato E
        • Biondi-Zoccai G
        • Gaita F
        • Escaned J
        • Hiddick Smith D
        • Lefèvre T
        • Colombo A
        • Sheiban I
        • Moretti C
        Provisional vs. two-stent technique for unprotected left main coronary artery disease after ten years follow up: a propensity matched analysis.
        Int J Cardiol. 2016; 211: 37-42
        • Kim WJ
        • Kim YH
        • Park DW
        • Yun SC
        • Lee JY
        • Kang SJ
        • Lee SW
        • Lee CW
        • Park SW
        • Park SJ.
        Comparison of single- versus two-stent techniques in treatment of unprotected left main coronary bifurcation disease.
        Catheter Cardiovasc Interv. 2011; 77: 775-782
        • Toyofuku M
        • Kimura T
        • Morimoto T
        • Hayashi Y
        • Ueda H
        • Kawai K
        • Nozaki Y
        • Hiramatsu S
        • Miura A
        • Yokoi Y
        • Toyoshima S
        • Nakashima H
        • Haze K
        • Tanaka M
        • Take S
        • Saito S
        • Isshiki T
        • Mitsudo K
        • j-Cypher Registry Investigators
        Three-year outcomes after sirolimus-eluting stent implantation for unprotected left main coronary artery disease: insights from the j-Cypher registry.
        Circulation. 2009; 120: 1866-1874
        • Hildick-Smith D
        • Egred M
        • Banning A
        • Brunel P
        • Ferenc M
        • Hovasse T
        • Wlodarczak A
        • Pan M
        • Schmitz T
        • Silvestri M
        • Erglis A
        • Kretov E
        • Lassen JF
        • Chieffo A
        • Lefèvre T
        • Burzotta F
        • Cockburn J
        • Darremont O
        • Stankovic G
        • Morice MC
        • Louvard Y.
        The European Bifurcation Club Left Main Coronary Stent Study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN).
        Eur Heart J. 2021; 42: 3829-3839
        • Gao L
        • Gao Z
        • Song Y
        • Guan C
        • Xu B
        • Chen J
        • Liu H
        • Qin X
        • Yao M
        • Yuan J
        • Wu Y
        • Hu F
        • Qian J
        • Tang Y
        • Dou K
        • Yang W
        • Qiu H
        • Mu C
        • Dai J
        • Qiao S
        • Chen J
        • Gao R
        • Yang Y.
        Long-term clinical outcomes of unprotected left main percutaneous coronary intervention: a large single-centre experience.
        J Interv Cardiol. 2021; 2021: 8829686
        • Duval S
        • Tweedie R.
        Trim and fill: a simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis.
        Biometrics. 2000; 56: 455-463
        • Duval S
        • Tweedie R.
        A nonparametric “trim and fill” method of accounting for publication bias in meta-analysis.
        J Am Stat Assoc. 2000; 95: 89-98
        • Peters JL
        • Sutton AJ
        • Jones DR
        • Abrams KR
        • Rushton L.
        Contour-enhanced meta-analysis funnel plots help distinguish publication bias from other causes of asymmetry.
        J Clin Epidemiol. 2008; 61: 991-996
        • Zhang F
        • Dong L
        • Ge J.
        Simple versus complex stenting strategy for coronary artery bifurcation lesions in the drug-eluting stent era: a meta-analysis of randomised trials.
        Heart. 2009; 95: 1676-1681
        • Valgimigli M
        • Malagutti P
        • Rodriguez Granillo GA
        • Tsuchida K
        • Garcia-Garcia HM
        • van Mieghem CA
        • Van der Giessen WJ
        • De Feyter P
        • de Jaegere P
        • Van Domburg RT
        • Serruys PW
        Single-vessel versus bifurcation stenting for the treatment of distal left main coronary artery disease in the drug-eluting stenting era. Clinical and angiographic insights into the Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital (RESEARCH) and Taxus-Stent Evaluated at Rotterdam Cardiology Hospital (T-SEARCH) registries.
        Am Heart J. 2006; 152: 896-902
        • Kandzari DE
        • Gershlick AH
        • Serruys PW
        • Leon MB
        • Morice MC
        • Simonton CA
        • Lembo NJ
        • Banning AP
        • Merkely B
        • van Boven AJ
        • Ungi I
        • Kappetein AP
        • Sabik JF
        • Généreux P
        • Dressler O
        • Stone GW.
        Outcomes among patients undergoing distal left main percutaneous coronary intervention.
        Circ Cardiovasc Interv. 2018; 11e007007
        • Song YB
        • Hahn JY
        • Yang JH
        • Choi SH
        • Choi JH
        • Lee SH
        • Jeong MH
        • Kim HS
        • Lee JH
        • Yu CW
        • Rha SW
        • Jang Y
        • Yoon JH
        • Tahk SJ
        • Seung KB
        • Oh JH
        • Park JS
        • Gwon HC.
        Differential prognostic impact of treatment strategy among patients with left main versus non-left main bifurcation lesions undergoing percutaneous coronary intervention: results from the COBIS (Coronary Bifurcation Stenting) Registry II.
        JACC Cardiovasc Interv. 2014; 7: 255-263
        • Kawamoto H
        • Chieffo A
        • D'Ascenzo F
        • Jabbour RJ
        • Naganuma T
        • Cerrato E
        • Ugo F
        • Pavani M
        • Varbella F
        • Boccuzzi G
        • Pennone M
        • Garbo R
        • Conrotto F
        • Biondi-Zoccai G
        • D'Amico M
        • Moretti C
        • Escaned J
        • Gaita F
        • Nakamura S
        • Colombo A
        Provisional versus elective two-stent strategy for unprotected true left main bifurcation lesions: insights from a FAILS-2 sub-study.
        Int J Cardiol. 2018; 250: 80-85
        • Cho S
        • Kang TS
        • Kim JS
        • Hong SJ
        • Shin DH
        • Ahn CM
        • Kim BK
        • Ko YG
        • Choi D
        • Song YB
        • Hahn JY
        • Choi SH
        • Gwon HC
        • Hong MK
        • Jang Y.
        Long-term clinical outcomes and optimal stent strategy in left main coronary bifurcation stenting.
        JACC Cardiovasc Interv. 2018; 11: 1247-1258
        • Lee CH
        • Ahn JM
        • Kang DY
        • Han M
        • Park H
        • Lee PH
        • Lee SW
        • Park SW
        • Park DW
        • Park SJ.
        Comparison of simple versus complex stenting in patients with true distal left main bifurcation lesions.
        Catheter Cardiovasc Interv. 2021; 97: 776-785
        • Ferenc M
        • Banholzer N
        • Hochholzer W
        • Mashayekhi K
        • Comberg T
        • Rothe J
        • Valina CM
        • Toma A
        • Löffelhardt N
        • Gick M
        • Neumann FJ
        • Nührenberg TG.
        Long-term results after PCI of unprotected distal left main coronary artery stenosis: the Bifurcations Bad Krozingen (BBK)-Left Main Registry.
        Clin Res Cardiol. 2019; 108: 175-184
        • Choi KH
        • Song YB
        • Lee JM
        • Park TK
        • Yang JH
        • Hahn JY
        • Choi JH
        • Choi SH
        • Kim HS
        • Chun WJ
        • Hur SH
        • Han SH
        • Rha SW
        • Chae IH
        • Jeong JO
        • Heo JH
        • Yoon J
        • Lim DS
        • Park JS
        • Hong MK
        • Doh JH
        • Cha KS
        • Kim DI
        • Lee SY
        • Chang K
        • Hwang BH
        • Choi SY
        • Jeong MH
        • Hong SJ
        • Nam CW
        • Koo BK
        • Gwon HC.
        Prognostic effects of treatment strategies for left main versus non-left main bifurcation percutaneous coronary intervention with current-generation drug-eluting stent.
        Circ Cardiovasc Interv. 2020; 13e008543
        • Lassen JF
        • Holm NR
        • Stankovic G
        • Lefèvre T
        • Chieffo A
        • Hildick-Smith D
        • Pan M
        • Darremont O
        • Albiero R
        • Ferenc M
        • Louvard Y.
        Percutaneous coronary intervention for coronary bifurcation disease: consensus from the first 10 years of the European Bifurcation Club meetings.
        EuroIntervention. 2014; 10: 545-560
        • Palmerini T
        • Sangiorgi D
        • Marzocchi A
        • Tamburino C
        • Sheiban I
        • Margheri M
        • Vecchi G
        • Sangiorgi G
        • Ruffini M
        • Bartorelli AL
        • Briguori C
        • Vignali L
        • Di Pede F
        • Ramondo A
        • Inglese L
        • De Carlo M
        • Bolognese L
        • Benassi A
        • Palmieri C
        • Filippone V
        • Barlocco F
        • Lauria G
        • De Servi S.
        Ostial and midshaft lesions vs. bifurcation lesions in 1111 patients with unprotected left main coronary artery stenosis treated with drug-eluting stents: results of the survey from the Italian Society of Invasive Cardiology.
        Eur Heart J. 2009; 30: 2087-2094
        • Chen SL
        • Sheiban I
        • Xu B
        • Jepson N
        • Paiboon C
        • Zhang JJ
        • Ye F
        • Sansoto T
        • Kwan TW
        • Lee M
        • Han YL
        • Lv SZ
        • Wen SY
        • Zhang Q
        • Wang HC
        • Jiang TM
        • Wang Y
        • Chen LL
        • Tian NL
        • Cao F
        • Qiu CG
        • Zhang YJ
        • Leon MB.
        Impact of the complexity of bifurcation lesions treated with drug-eluting stents: the DEFINITION study (Definitions and impact of complEx biFurcation lesions on clinical outcomes after percutaNeous coronary IntervenTIOn using drug-eluting steNts).
        JACC Cardiovasc Interv. 2014; 7: 1266-1276
        • Burzotta F
        • Lassen JF
        • Lefèvre T
        • Banning AP
        • Chatzizisis YS
        • Johnson TW
        • Ferenc M
        • Rathore S
        • Albiero R
        • Pan M
        • Darremont O
        • Hildick-Smith D
        • Chieffo A
        • Zimarino M
        • Louvard Y
        • Stankovic G.
        Percutaneous coronary intervention for bifurcation coronary lesions: the 15th consensus document from the European Bifurcation Club.
        EuroIntervention. 2021; 16: 1307-1317
        • Prati F
        • Regar E
        • Mintz GS
        • Arbustini E
        • Di Mario C
        • Jang IK
        • Akasaka T
        • Costa M
        • Guagliumi G
        • Grube E
        • Ozaki Y
        • Pinto F
        • Serruys PW.
        Expert’s OCT Review Document. Expert review document on methodology, terminology, and clinical applications of optical coherence tomography: physical principles, methodology of image acquisition, and clinical application for assessment of coronary arteries and atherosclerosis.
        Eur Heart J. 2010; 31: 401-415
        • Chen SL
        • Ye F
        • Zhang JJ
        • Tian NL
        • Liu ZZ
        • Santoso T
        • Zhou YJ
        • Jiang TM
        • Wen SY
        • Kwan TW.
        Intravascular ultrasound-guided systematic two-stent techniques for coronary bifurcation lesions and reduced late stent thrombosis.
        Catheter Cardiovasc Interv. 2013; 81: 456-463
        • Kinnaird T
        • Johnson T
        • Anderson R
        • Gallagher S
        • Sirker A
        • Ludman P
        • de Belder M
        • Copt S
        • Oldroyd K
        • Banning A
        • Mamas M
        • Curzen N.
        Intravascular imaging and 12-month mortality after unprotected left main stem PCI: an analysis from the British Cardiovascular Intervention Society database.
        JACC Cardiovasc Interv. 2020; 13: 346-357
        • Park DW
        • Ahn JM
        • Park H
        • Yun SC
        • Kang DY
        • Lee PH
        • Kim YH
        • Lim DS
        • Rha SW
        • Park GM
        • Gwon HC
        • Kim HS
        • Chae IH
        • Jang Y
        • Jeong MH
        • Tahk SJ
        • Seung KB
        • Park SJ
        • Investigators PRECOMBAT
        Ten-year outcomes after drug-eluting stents versus coronary artery bypass grafting for left main coronary disease: extended follow-up of the PRECOMBAT trial.
        Circulation. 2020; 141: 1437-1446
        • Wang Y
        • Mintz GS
        • Gu Z
        • Qi Y
        • Wang Y
        • Liu M
        • Wu X.
        Meta-analysis and systematic review of intravascular ultrasound versus angiography-guided drug eluting stent implantation in left main coronary disease in 4592 patients.
        BMC Cardiovasc Disord. 2018; 18: 115
        • Ladwiniec A
        • Walsh SJ
        • Holm NR
        • Hanratty CG
        • Mäkikallio T
        • Kellerth T
        • Hildick-Smith D
        • Mogensen LJH
        • Hartikainen J
        • Menown IBA
        • Erglis A
        • Eriksen E
        • Spence MS
        • Thuesen L
        • Christiansen EH.
        Intravascular ultrasound to guide left main stem intervention: a noble trial substudy.
        EuroIntervention. 2020; 16: 201-209
        • Kim S-Y
        • Maehara A
        • Merkely B
        • Ungi I
        • Van Boven A
        • Schampaert E
        • Mehran R
        • Ben-Yehuda O
        • Dressler O
        • Kappetein AP
        • Sabik J
        • Serruys P
        • Mintz G
        • Stone G.
        TCT-44 frequency and impact of acute stent deformation after PCI of left main coronary artery disease: an EXCEL trial intravascular ultrasound substudy.
        J Am Coll Cardiol. 2017; 70: B19