Strategy choice impacts long-term mortality in bifurcation stenting

By Laura Cowen

Using a provisional rather than a planned two-stent strategy for coronary bifurcation stenting may halve long-term mortality, pooled study data show.

Five-year mortality was 3.8% in the 447 patients with a bifurcation lesion who received a simple procedure (provisional T-stenting), compared with a significantly higher 7.0% among the 443 patients who underwent a more complex procedure (culotte, crush, and T-stenting).

This result "adds weight to the case that a provisional stent strategy should be used as the default approach for the treatment of coronary bifurcation lesions", say Miles Behan (Edinburgh Heart Centre, UK) and co-authors.

Behan and team pooled data from two large, randomised bifurcation coronary stenting trials that compared simple and complex techniques using drug-eluting stents (DES): the Nordic Bifurcation Study (NORDIC I) and the British Bifurcation Coronary Study: old, new, and evolving strategies (BBC ONE).

Overall, both the simple and complex groups were similar in terms of patient and lesion characteristics, with the exception of side branch diameter, which was significantly greater in the complex group (2.60 vs 2.55 mm). There was also no difference in procedural success rate (defined as less than 30% residual stenosis in the main vessel and TIMI III flow in the side branch) between the groups.

The researchers remark that although there was a significant difference in 5-year mortality between the groups, the actual mortality rates were reassuringly low. They also note that the Kaplan-Meier survival curves did not appear to separate until around 2 years.

"This indicates that the complex strategy yields elevated risk of events beyond the time at which technical procedural factors (under-deployment/edge dissection/value of GPIIbIIIa inhibitors etc) play a role", the authors write in the European Heart Journal.

Indeed, Behan et al say that although they recorded all-cause mortality rather than cardiac death, the randomisation and even distribution of clinical and lesion characteristics leads them to believe "that the difference in mortality rates may be attributed to associated cardiac events (stent thromboses)."

However, the use of first-generation DES may be a limitation of the current study, say the researchers, as it means we "cannot exclude the possibility that newer generation DES may lead to smaller long-term differences between the Simple and the Complex bifurcation strategies."

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