Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention

Abstract

Background Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive. Methods and Results Extensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta-analysis produced pooled relative risk (RR) and 95% CI of 2-stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta-analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta-analysis showed no significant differences in all-cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2-stent techniques and provisional stenting. Frequentist network meta-analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38-0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39-0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39-0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28-0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2-stent techniques, including T-stent or T and protrusion, dedicated bifurcation stent, and culotte. Conclusions Double kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2-stent techniques. Superiority of 2-stent strategy over provisional stenting was observed in subgroup meta-analysis stratified to side branch lesion length ≥10 mm.

Keywords: DK crush; bifurcation technique; coronary; percutaneous coronary intervention; provisional; stent; two‐stent.

Figure 1. Flow diagram of the search for relevant trials.

The flow diagram illustrates the process of searching and screening the databases to identify trials that meet the prespecified inclusion criteria.

Figure 2. Network plot of selected trials.

The network plot demonstrates the number of studies and patients included among trials that compared double kissing crush, dedicated bifurcation stent, culotte, crush, provisional stenting, and T‐stent or T and protrusion. The size of the blue circles and blue lines are proportional to the total sample size and number of relevant studies, respectively. DBS indicates dedicated bifurcation stent; DK, double kissing; PS, provisional stenting; and T/TAP, T‐stent or T and protrusion.

Figure 3. Network meta‐analysis of bifurcation techniques with provisional stenting as reference.

The figures show the relative risk of each bifurcation technique compared to provisional stenting for 7 different outcomes. The vertical line inside the blue box represents the relative risk and the perpendicular horizontal line represents the 95% CI. Relative risk above 1 favors provisional stenting (red arrow) whereas that below 1 favors the compared bifurcation technique (blue arrow). DBS indicates dedicated bifurcation stent; DK, double kissing; RR, relative risk; and T/TAP, T‐stent or T and protrusion.

Figure 4. Bar graph showing P‐scores of each bifurcation technique for every outcome.

The bar graphs show the P‐scores of provisional stenting (gray), culotte (lavender), DK crush (blue), dedicated bifurcation stent (green), T‐stent or T and protrusion (orange), and crush (red) from the frequentist network meta‐analysis for each outcome. P‐scores measure the extent of certainty that the bifurcation technique is better than competing techniques. DBS indicates dedicated bifurcation stent; DK, double kissing; and T/TAP, T‐stent or T and protrusion.

Figure 5. Rank probability analysis for outcomes of interest.

Displayed as rankograms, results of rank probability analysis show the probability of culotte (lavendar), double kissing crush (blue), dedicated bifurcation stent (green), crush (red), T‐stent or T and protrusion (orange), and provisional stenting (gray) being the best, second, third, fourth, fifth, and sixth for each of the outcomes. The x‐axis and y‐axis represent the rank and probability, respectively. DBS indicates dedicated bifurcation stent; DK, double kissing; PS, provisional stenting; and T/TAP, T‐stent or T and protrusion.