Author + information
- David Kandzari1,
- Anthony Gershlick2,
- Patrick Serruys3,
- Martin Leon4,
- Marie-Claude Morice5,
- Nicholas Lembo6,
- Adrian Banning7,
- Ad van Boven8,
- Imre Ungi9,
- A. Pieter Kappetein10,
- Joseph Sabik11,
- Ovidiu Dressler12 and
- Gregg Stone13
- 1Piedmont Heart Institute, Atlanta, Georgia, United States
- 2University of Leicester, Leicester, United Kingdom
- 3Imperial College, London, United Kingdom
- 4Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
- 5CERC, Massy, France
- 6Columbia University, New York, New York, United States
- 7John Radcliffe Hospital, Oxford, United Kingdom
- 8Medisch Centrum Leeuwarden, Haren, Netherlands
- 9University of Szeged, Szeged, Hungary
- 10Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- 11Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, United States
- 12Cardiovascular Research Foundation, New York, New York, United States
- 13Cardiovascular Research Foundation, Columbia University Medical Center/NewYork-Presbyterian Hospital, New York, New York, United States
Disease of the distal left main (LM) bifurcation increases PCI procedural complexity and is associated with worse outcomes than isolated ostial/shaft LM ds. The optimal treatment strategy for distal LM ds. is undetermined.
Among 925 pts with LM ds. randomized to PCI with everolimus-eluting stents (EES) in the EXCEL trial, those undergoing site-reported planned distal LM bifurcation PCI were identified. Clinical and angiographic characteristics, procedural methods and outcomes, and clinical events through 3-year follow-up were compared between pts undergoing distal LM PCI with a provisional vs planned 2-stent technique. Multivariable Cox proportional hazards regression was performed to adjust for differences in baseline characteristics including angiographic complexity.
Among 529 pts undergoing planned distal LM bifurcation PCI, 345 (65.2%) were treated with an intended provisional strategy, and 184 (34.8%) underwent a planned 2-stent technique. No significant differences in clinical characteristics were observed between treatment groups. In the provisional cohort, sidebranch angioplasty was frequent (70.7%), and sidebranch stent placement was required in 22.1% of pts. Among those with planned 2-stent methods, T-stent (51.1%) and Culotte techniques (23.3%) were most common. At 30 days, no significant differences were observed in either composite or individual endpoints of death, MI, stroke, or revascularization. By 3 years, the composite primary endpoint rate of death, MI, or stroke was significantly higher in pts treated with a planned 2-stent technique (14.4% vs 21.2%, adjusted hazard ratio [HR] 0.51, 95% confidence interval [0.32, 0.82], adjusted P=0.005). The difference was driven by higher rates of cardiovascular death (3.5% vs 7.9%, P=0.02) and MI (7.6% vs 13.2%, P=0.04). Ischemia-driven target lesion revascularization (TLR) was also significantly more common with the 2-stent technique (7.4% vs 16.7%, P=0.001). Rates of definite/probable stent thrombosis between treatment groups at 3 years were not significantly different (1.6% provisional vs 3.4% 2-stent, P=0.15).
Among pts undergoing distal LM bifurcation PCI with EES in the EXCEL trial, early clinical outcomes were similar with provisional and planned 2-stent treatment strategies. Over long-term follow-up, however, rates of cardiac death, MI, and TLR were more common with upfront planned 2-stent treatment compared with a single-stent provisional approach. These findings endorse a provisional stent strategy for distal LM bifurcation PCI when feasible.
CORONARY: Complex and Higher Risk Procedures for Indicated Patients (CHIP)