It has been reported that the two stents technique is not superior to a provisional stent when treating bifurcations. However, the optimal approach to rescue a secondary branch (SB) when initially opting for provisional stenting has not been established. 

The aim of this study was to determine angioplasty indication using balloon or stent for SB in patients receiving a drug-eluting stent in the main branch of a bifurcation including the left coronary trunk. After implanting the stent in the main branch, patients were randomized 1:1 to a conservative strategy (CE) or an aggressive one (AE) to treat the side branch, these criteria were different as were for the left main coronary trunk or not. The left coronary trunk was only rescued if the SB residual stenosis was > 75% in the CE group or > 50% in the AE. After balloon and kissing, a second stent was implanted only if a lesion persisted >50% or dissection in CE or > 30% or dissection in AE. Injuries that were not left coronary trunk were only rescued if SB was TIMI flow 75% for AE. After balloon and kissing, a second stent was implanted only if injury persisted > 75% in the CE or > 50% in the AE group.

The study randomized 258 patients of which 114, (44%), had bifurcation in the left coronary trunk. There was no clinical or angiographic difference between the two groups.

The stents used were sirolimus or everolimus eluting with no differences between groups. The primary end point was a composite of death, myocardial infarction and target vessel revascularization at 12 months. Of course, balloon followed by kissing was used most frequently in the AE group, (68.5% versus 25.8% p <0.001), as well as the use of a second stent, (30% versus 7% respectively, p <0.001). The AE group was associated with increased incidence of periprocedural myocardial infarction, (17.7% versus 5.5% p = 0.002). In the following year there was no difference in the primary end point, (9.2% versus EC EA 9.4% p = 0.97).

Angiographic follow-up was performed at 9 months with 218 patients, (104 CE and 114 AE). There was no difference in late lumen loss and binary restenosis of the main vessel, (6.1% versus 5.6% p> 0.99), or between the two strategies for both angioplasty of left coronary trunk. However, binary restenosis of the side branch was higher with the conservative strategy group, (42.6% versus 18.2% p = 0.003).

Conclusion 

The conservative strategy for provisional stenting showed equal year clinical outcomes and a lower rate of periprocedural myocardial infarction but more side branch restenosis that the aggressive strategy.

Editorial Comment:

This study assumed that a provisional standard stent for bifurcations, (including left main coronary artery), gives us objective tools to help decide whether to rescue a secondary branch. It did not take into account more subjective parameters commonly used in the cath lab, such as angina in a referred patient. Note that the low event rate in the conservative group has a low statistical power (42%), which makes it impossible to identify subgroup findings such as left trunk left circumflex coronary dominance.

SOLACI.ORG

Original title: Randomized Comparison of Conservative Versus Aggressive Strategy for Provisional Side Branch Intervention in Coronary Bifurcation Lesions Results From the SMART-STRATEGY (SMart Angioplasty Research Team– Optimal STRATEGY for Side Branch Intervention in Coronary Bifurcation Lesions) Randomized Trial. 

Reference: Young Bin Song et al. J Am Coll Cardiol Intv 2012;5:1133– 40.