Original title: Late Thrombosis After Double Versus Single Drug-Eluting Stent in the Treatment of Coronary Bifurcations A Meta-analysis of Randomized and Observational Studies. Reference: Marco Zimarino et al. J Am Coll Cardiol Intv 2013. Article in press.

In the era of drug-eluting stents, (DES), several randomized and observational studies have been conducted trying to find the best strategy to deal with a bifurcation. Since most of the individual studies failed to arrive at any definitive conclusions, meta-analyzes were performed to understand the association between a double drug-eluting stent technique at a bifurcation and an increased risk of stroke but the mechanisms behind this risk were not clear.

The hypothesis of this study is that the increased risk on events using a double stent would be related to the increased rate of thrombosis. Twelve studies, (five randomized trials and seven observational), were analyzed in this meta-analysis with a total of 6,961 patients, of whom 1,868 received DES and 5,093 one single DES to treat bifurcation lesions. 

The double DES group had a higher risk of thrombosis compared with the single DES group, (RR 2.31, 95% CI, 1.33 to 4.03). This significantly increased the risk of thrombosis according primarily to observational studies, while randomized studies only showed a trend in this direction. There was also an increased risk of stroke in the double stent group, (RR 1.86, 95% CI, 1.34 to 2.35), and this significant difference was observed in all jobs. Despite the above, the all-cause mortality was similar to target vessel revascularization. 

Conclusion: 

Routinely, two DES implants to treat a bifurcation is associated with an increased risk of myocardial infarction compared with the technique of a single stent in the main vessel and a provisional stent in the accessory vessel. The higher incidence of infarction appears to be related to increased thrombosis. 

Comment: 

With bifurcations, as ever, the conclusion is again less is more. The second stent should always be implemented taking into account that we are doubling the chance of thrombosis and also doubling the chance of restenosis. If it is necessary, we must consider a more aggressive platelet aggregation. 

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