Bifurcation Lesion in Distal Left Main Coronary Artery: One or Two Stents?

Courtesy of Dr. Carlos Fava.

Unprotected left main coronary artery (LMCA) angioplasty has become an important trend in the last few years.

One of the most significant unresolved questions about it is whether one stent is better than two in distal lesions, and how is their progress after treatment.

This study included 937 patients who underwent LMCA angioplasty for distal lesions. Only one stent was used in 608 of them, and two stents were used in the remaining 329 patients. First-generation drug-eluting stents (DES) were used in 689 patients, while 238 received second-generation DES.

Patients who received one stent tended to be older, diabetic, and with a history of previous angioplasties, and, in their case, angioplasty was more frequently guided through intravascular ultrasound (IVUS).

Patients who received 2 stents instead presented more frequently triple vessel lesions, untreated right coronary chronic occlusion, true bifurcation lesions, higher SYNTAX scores, longer stents, and a need for an intra-aortic balloon pump (IABP).

Peri-procedural infarction was more frequent among patients receiving 2 stents (6% vs. 11.9%; p = 0.01).

Follow-up was carried out at 1592 days (1127-2065 days) and angiographic control was performed in 85.5% of cases. Major adverse cardiovascular events (MACE) were more frequent in patients receiving two stents due to higher target lesion revascularization (TLR) in the secondary artery (ostial circumflex artery) without differences in the main artery. There were no differences regarding all-cause mortality, but cardiac mortality tended to be less frequent in patients receiving 2 stents. The rates of stent thrombosis and infarction were similar.

Differences between groups were compared through propensity score matching, with 139 resulting pairs. The peri-procedural infarction rate was higher among patients receiving 2 stents (5.5% vs. 14.6%), but there were no differences at follow-up in events such as MACE, cardiac death, all-cause death, or main artery revascularization.

The secondary artery revascularization rate was indeed higher for the group of patients receiving two stents (hazard ratio [HR]: 1.59; 95% confidence interval [CI]: 1.00-2.52; p = 0.05).

A sub-analysis of patients receiving second-generation DES (238 patients) did not show higher peri-procedural infarction rates for the group of patients receiving two-stents.

Conclusion

The difference between 1 stent and 2 stents in distal left main coronary artery angioplasty must be summarized as higher incidence of revascularization due to restenosis at the ostial circumflex artery in the group of patients receiving 2 stents.

Editorial

Unprotected left main coronary artery angioplasty has proven to be feasible and safe. Using one or two stents is still, in many occasions, left to the discretion of the operator. However, as a concept, it should be planned as well as all bifurcation lesions, for which provisional stents offer good results.

It should be taken into account that, sometimes, there is a true bifurcation lesion in which the circumflex artery diameter is >2.5 mm, which implies a higher tendency to use a second stent.

The use of non-compliant balloons, the proximal optimisation technique (POT), and follow-up through imaging surely improve outcomes.

Courtesy of Dr. Carlos Fava. Buenos Aires Favaloro Foundation, Argentina.

Original title: Comparison Between 1- and 2- Stent Strategies in Unprotected Distal Left Main Disease. The Milan and New – Tokyo Registry

Reference: Kensuke Takagi. Circ Cardiovas Interv 2016;9:e003359. 

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