Aim: Bifurcation-PCI is performed frequently, although without extensive evidence to back up a definitive solution for its complexity. We set out to identify factors associated with 1- and 12-month mortality after bifurcation-PCI between 2017 and 2021 in our tertiary center in Wales, UK. Results: Of 732 bifurcation PCI cases (mean age 69; 25% female), 67% were in ACS, 42% were left main PCI and 25.3% involved two-stent strategy. 30-day and 12-month mortality were 1.9 and 8.2%, respectively. Age, diabetes, smoking and renal failure are associated with mortality after bifurcation-PCI, while the choice between provisional and 2-stent strategies did not impact mortality/TLR. Conclusion: Awareness of ‘real-world’ outcomes of bifurcation-PCI should be used for appropriate patient selection, technique planning and procedural consent.

Keywords:

Papers of special note have been highlighted as: • of interest; •• of considerable interest

References

1. Louvard Y, Thomas M, Dzavik V et al. Classification of coronary artery bifurcation lesions and treatments: time for a consensus! Catheter. Cardiovasc. Interv. 71(2), 175–183 (2008).
MedlineGoogle Scholar
2. Giannoglou GD, Antoniadis AP, Koskinas KC, Chatzizisis YS. Flow and atherosclerosis in coronary bifurcations. EuroIntervention 6(Suppl. J), J16–J23 (2010).
MedlineGoogle Scholar
3. Serruys PW, Onuma Y, Garg S et al. 5-year clinical outcomes of the ARTS II (Arterial Revascularization Therapies Study II) of the sirolimus-eluting stent in the treatment of patients with multivessel de novo coronary artery lesions. J. Am. Coll. Cardiol. 55(11), 1093–1101 (2010).
MedlineGoogle Scholar
4. Rigatelli G, Zuin M, Vassilev D, Rodino G, Marchese G, Pasquetto G. Technical complications of coronary bifurcation percutaneous interventions. J. Clin. Med. 11(22), 6801 (2022).
MedlineGoogle Scholar
5. Rigatelli G, Zuin M, Gianese F et al. Ultrathin biodegradable-polymer orsiro drug-eluting stent performance in real practice challenging settings. Cardiovasc. Revasc. Med. 30, 12–17 (2021).
MedlineGoogle Scholar
6. Garot P, Lefevre T, Savage M et al. Nine-month outcome of patients treated by percutaneous coronary interventions for bifurcation lesions in the recent era: a report from the Prevention of Restenosis with Tranilast and its Outcomes (PRESTO) trial. J. Am. Coll. Cardiol. 46(4), 606–612 (2005).
MedlineGoogle Scholar
7. Tan S, Ramzy J, Burgess S, Zaman S. Percutaneous coronary intervention for coronary bifurcation lesions: latest evidence. Curr. Treat. Options Cardiovasc. Med. 22(2), 6 (2020).
MedlineGoogle Scholar
8. Araujo Leite Medeiros P, Braga C, Campos I et al. Managing bifurcations: are two stents better than one? Eur. Heart J. 42(Suppl. 1), doi:10.1093/eurheartj/ehab724.2160 (2021).
MedlineGoogle Scholar
9. Hildick-Smith D. The stepwise provisional approach to left main stem bifurcations in Europe. Eur. Heart J. 43(21), 2079 (2022).
MedlineGoogle Scholar
10. Wassef AWA, Liu S, Yanagawa B, Verma S, Cheema AN. Percutaneous management of coronary bifurcation lesions: current perspective. Curr. Opin. Cardiol. 35(5), 574–582 (2020).
MedlineGoogle Scholar
11. Bricker RS, Valle JA, Plomondon ME, Armstrong EJ, Waldo SW. Causes of mortality after percutaneous coronary intervention. Circ. Cardiovasc. Qual. Outcomes 12(5), e005355 (2019).
MedlineGoogle Scholar
12. Zhang JJ, Ye F, Xu K et al. Multicentre, randomized comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial. Eur. Heart J. 41(27), 2523–2536 (2020). • This key study demonstrated using randomized controlled trials that the systematic two-stent approach was associated with a significant improvement in clinical outcomes compared with the provisional stenting approach.
MedlineGoogle Scholar
13. Carande EJ, Protty MB, Verhemel S et al. Predictors of 30-day and 12-month mortality in left main stem percutaneous coronary intervention 2016–2020: a study from two UK centers. Catheter. Cardiovasc. Interv. 100(4), 585–592 (2022).
MedlineGoogle Scholar
14. Lee JM, Lee SH, Kim J et al. Ten-year trends in coronary bifurcation percutaneous coronary intervention: prognostic effects of patient and lesion characteristics, devices, and techniques. J. Am. Heart Assoc. 10(18), e021632 (2021). •• This paper is important in showing that over time (2004–2015), the outcomes of bifurcation percutaneous coronary intervention (PCI) improved due to better devices and more widespread adoption of procedural optimization techniques and appropriate treatment strategies.
MedlineGoogle Scholar
15. Mohamed MO, Lamellas P, Roguin A et al. Clinical outcomes of percutaneous coronary intervention for bifurcation lesions according to medina classification. J. Am. Heart Assoc. 11(17), e025459 (2022).
MedlineGoogle Scholar
16. Di Gioia G, Sonck J, Ferenc M et al. Clinical outcomes following coronary bifurcation PCI techniques: a systematic review and network meta-analysis comprising 5,711 patients. JACC Cardiovasc. Interv. 13(12), 1432–1444 (2020). •• In this network meta-analysis, different techniques of bifurcation stenting (two-stent and one-stent) are directly and indirectly compared against each other using elegant statistical modelling.
MedlineGoogle Scholar
17. Head SJ, Kaul S, Mack MJ et al. The rationale for Heart Team decision-making for patients with stable, complex coronary artery disease. Eur. Heart J. 34(32), 2510–2518 (2013).
MedlineGoogle Scholar
18. Jakubiak GK, Pawlas N, Cieslar G, Stanek A. Pathogenesis and clinical significance of in-stent restenosis in patients with diabetes. Int. J. Environ. Res. Public Health 18(22), 11970 (2021).
Medline CASGoogle Scholar
19. Protty M, Sharp ASP, Gallagher S et al. Defining percutaneous coronary intervention complexity and risk: an analysis of the United Kingdom BCIS database 2006–2016. JACC Cardiovasc Interv. 15(1), 39–49 (2022).
MedlineGoogle Scholar
20. Newman AB, Naydeck BL, Sutton-Tyrrell K, Feldman A, Edmundowicz D, Kuller LH. Coronary artery calcification in older adults to age 99: prevalence and risk factors. Circulation 104(22), 2679–2684 (2001).
Medline CASGoogle Scholar
21. Cano-Megias M, Guisado-Vasco P, Bouarich H et al. Coronary calcification as a predictor of cardiovascular mortality in advanced chronic kidney disease: a prospective long-term follow-up study. BMC Nephrol. 20(1), 188 (2019).
MedlineGoogle Scholar
22. Liu W, Zhang Y, Yu CM et al. Current understanding of coronary artery calcification. J. Geriatr. Cardiol. 12(6), 668–675 (2015).
Medline CASGoogle Scholar
23. Holroyd EW, Sirker A, Kwok CS et al. The relationship of body mass index to percutaneous coronary intervention outcomes: does the obesity paradox exist in contemporary percutaneous coronary intervention cohorts? Insights from the British Cardiovascular Intervention Society Registry. JACC Cardiovasc. Interv. 10(13), 1283–1292 (2017).
MedlineGoogle Scholar
24. Mamas MA, Anderson SG, O'Kane PD et al. Impact of left ventricular function in relation to procedural outcomes following percutaneous coronary intervention: insights from the British Cardiovascular Intervention Society. Eur. Heart J. 35(43), 3004–3012a (2014).
Medline CASGoogle Scholar
25. Blankenship JC, Gigliotti OS, Feldman DN et al. Ad hoc percutaneous coronary intervention: a consensus statement from the Society for Cardiovascular Angiography and Interventions. Catheter. Cardiovasc. Interv. 81(5), 748–758 (2013).
MedlineGoogle Scholar
26. Kinnaird T, Johnson T, Anderson R et al. Intravascular imaging and 12-month mortality after unprotected left main stem PCI: an analysis from the British Cardiovascular Intervention Society Database. JACC Cardiovasc. Interv. 13(3), 346–357 (2020).
MedlineGoogle Scholar
27. Sgueglia GA, Todaro D, Bisciglia A, Conte M, Stipo A, Pucci E. Kissing inflation is feasible with all second-generation drug-eluting balloons. Cardiovasc. Revasc. Med. 12(5), 280–285 (2011).
MedlineGoogle Scholar
28. Yang JH, Lee JM, Park TK et al. The proximal optimization technique improves clinical outcomes when treated without kissing ballooning in patients with a bifurcation lesion. Korean Circ. J. 49(6), 485–494 (2019).
MedlineGoogle Scholar
29. Banning AP, Lassen JF, Burzotta F et al. Percutaneous coronary intervention for obstructive bifurcation lesions: the 14th consensus document from the European Bifurcation Club. EuroIntervention 15(1), 90–98 (2019).
MedlineGoogle Scholar
30. Chen X, Li X, Zhang JJ et al. 3-year outcomes of the DKCRUSH-V trial comparing DK crush with provisional stenting for left main bifurcation lesions. JACC Cardiovasc. Interv. 12(19), 1927–1937 (2019). • Seminal trial demonstrating the value of 2-stent double kiss (DK)-crush technique in left main bifurcations.
MedlineGoogle Scholar
31. Ferenc M, Neumann FJ. Complex stenting for complex lesions: DKCRUSH-V calling for novel treatment strategies for bifurcation lesions. JACC Cardiovasc. Interv. 12(19), 1938–1940 (2019).
MedlineGoogle Scholar
32. Kinnaird T, Gallagher S, Anderson R et al. Are higher operator volumes for unprotected left main stem percutaneous coronary intervention associated with improved patient outcomes? A survival analysis of 6724 procedures from the British Cardiovascular Intervention Society National Database. Circ. Cardiovasc. Interv. 13(6), e008782 (2020).
MedlineGoogle Scholar

Vol. 19, No. 6

Supplemental Materials

Metrics

Downloaded 22 times

History

Received 27 April 2023

Accepted 23 June 2023

Published online 14 July 2023

Published in print May 2023

Information

Keywords

Supplementary data

To view the supplementary data that accompany this paper please visit the journal website at: www.futuremedicine.com/doi/suppl/10.2217/fca-2023-0058

Author contributions

MB Protty, A Choudhury and A Hailan led on conceptualization and developed methodology. T Valenzuela, A Sharaf, J Shome and S Hasan carried out data curation. MB Protty, T Valenzuela, A Sharaf, J Shome and S Hasan carried out initial data analysis. All authors contributed to original drafting as well as review and editing of manuscript. A Choudhury and A Hailan provided overall supervision.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research

The study design was approved by the local clinical governance board as a quality governance project.

PDF download