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Meta-Analysis
. 2018 May 25;7(11):e008730.
doi: 10.1161/JAHA.118.008730.

Single- Versus 2-Stent Strategies for Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis of Randomized Trials With Long-Term Follow-up

Thomas J Ford  1   2   3 , Peter McCartney  1   2 , David Corcoran  1   2 , Damien Collison  1   2 , Barry Hennigan  1   2 , Margaret McEntegart  1   2 , David Hildick-Smith  4 , Keith G Oldroyd  1   2 , Colin Berry  5   2
Affiliations
Meta-Analysis

Single- Versus 2-Stent Strategies for Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis of Randomized Trials With Long-Term Follow-up

Thomas J Ford et al. J Am Heart Assoc. .

Abstract

Background: The majority of coronary bifurcation lesions are treated with a provisional single-stent strategy rather than an up-front 2-stent strategy. This approach is supported by multiple randomized controlled clinical trials with short- to medium-term follow-up; however, long-term follow-up data is evolving from many data sets.

Methods and results: Meta-analysis of randomized controlled trials evaluating long-term outcomes (≥1 year) according to treatment strategy for coronary bifurcation lesions. Nine randomized controlled trials with 3265 patients reported long-term clinical outcomes at mean weighted follow-up of 3.1±1.8 years. Provisional single stenting was associated with lower all-cause mortality (2.94% versus 4.23%; risk ratio: 0.69; 95% confidence interval, 0.48-1.00; P=0.049; I2=0). There was no difference in major adverse cardiac events (15.8% versus 15.4%; P=0.79), myocardial infarction (4.8% versus 5.5%; P=0.51), target lesion revascularization (9.3% versus 7.6%; P=0.19), or stent thrombosis (1.8% versus 1.6%; P=0.28) between the groups. Prespecified sensitivity analysis of long-term mortality at a mean of 4.7 years of follow-up showed that the provisional single-stent strategy was associated with reduced all-cause mortality (3.9% versus 6.2%; risk ratio: 0.63; 95% confidence interval, 0.42-0.97; P=0.036; I2=0).

Conclusions: Coronary bifurcation percutaneous coronary intervention using a provisional single-stent strategy is associated with a reduction in all-cause mortality at long-term follow-up.

Keywords: bifurcation; bifurcation intervention; bifurcation lesion; provisional stenting.

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Figures

Figure 1
Figure 1
Risk of bias summary—Cochrane risk tool.
Figure 2
Figure 2
Forest plot of primary outcome: all‐cause mortality according to bifurcation treatment strategy. Nordic 2013,10 BBK,11, 12 PERFECT,13 Nordic‐Baltic Bifurcation IV,14 BBC1,15, 16 EBC2,17 Smart‐Strategy,18 DK Crush II 2017,4 DK Crush V.5 CI indicates confidence interval; M‐H, Mantel‐Haenszel test.
Figure 3
Figure 3
A, All‐cause mortality according to bifurcation treatment strategy. 3265 patients were enrolled in 9 randomized trials with weighted mean follow‐up of 3.1 years. The total loss to follow‐up of patients in the study was < 1%. Nordic 2013,10 BBK,11, 12 PERFECT,13 Nordic‐Baltic Bifurcation IV,14 BBC1,15, 16 EBC2,17 Smart‐Strategy,18 DK Crush II 2017,4 DK Crush V.5 B, Long‐term health outcomes of provisional stenting vs a complex strategy for treatment of coronary bifurcation lesions. *Long‐term mortality incorporating trials with ≥3 years of clinical follow‐up: A prespecified sensitivity analysis was carried out of five studies including 1713 patients followed up for an average of 4.7 years. DK CrushII,4 Nordic,10 BBK,12 BBC1,15 Smart‐Strategy.18 CI indicates confidence interval; MACE, major adverse cardiac events; MI, myocardial infarction; RRR, relative risk reduction with provisional vs 2‐stent strategies; TLR, target lesion revascularization.
Figure 4
Figure 4
Forest plots for secondary end points. A, Major adverse cardiac events (MACE). B, Myocardial infarction (MI). C, Target lesion revascularization (TLR). D, Stent thrombosis (ST).
Figure 5
Figure 5
Central illustration (graphic summary of study). f/u indicates follow‐up; PCI, percutaneous coronary intervention; RCTs, randomized controlled trials; RRR, relative risk ratio. *Denotes P=0.049
See this image and copyright information in PMC

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