Review of percutaneous therapy for bifurcation lesions in the era of drug-eluting stents

Abstract

Although recent advances in percutaneous coronary interventions (PCI) have led to dramatic expansions in procedural complexity, bifurcation lesions (BL) remain a serious challenge for the interventionalist. Turbulent flow dynamics and high shear stress likely predispose coronary bifurcations to development of atherosclerotic plaques. These lesions comprise 15% to 20% of the total number of coronary interventions. When compared with non-BL interventions, BL interventions demonstrate lower procedural success rates, higher procedural costs, longer hospitalizations, and higher clinical and angiographic restenosis rates. The recent introduction of drug-eluting stents (DES) has resulted in lower incidences of target lesion/ vessel revascularization and reduction of main branch restenosis in this anatomic subset, when compared to historical bare metal stent (BMS) controls. Nonetheless, DES have not resolved the bifurcation PCI problem; and several techniques employing either 1 or 2 stents have emerged. Stenting of the main vessel with provisional side branch stenting seems to be the prevailing approach. While no definitive single BL-PCI technique has been identified, the optimal approach is likely lesion-specific. This paper reviews different treatment modalities for this complex lesion subset, with particular emphasis on the use of DES, as well as new potential therapeutic approaches.