Despite the use of current-generation drug-eluting stents, percutaneous coronary intervention (PCI) for bifurcation lesions is still challenging.1,2
Although single stenting for the main branch and kissing balloon dilatation of the side branch are simple and widely adopted strategies for bifurcation stenting, especially non-left main bifurcation, side-branch stenting may be necessary in the case of a large side branch with a true bifurcation lesion. In this issue of the Journal, Okabe and co-workers3
retrospectively investigate the 1-year outcomes of non-left main trunk bifurcation lesions with a 2-stent strategy using 2 different everolimus-eluting (EES) stents with different stent platforms: Xience with a 3-link configuration and PROMUS element with a 2-link stent platform. The overall incidence of in-stent restenosis (ISR) was 15.9% and that of target lesion revascularization was 3.5%. Long side branch and use of 3-link EES were independent predictors of 1-year post-procedural ISR. Presence of a link over the side-branch ostium is a known predictor of ISR, and therefore it is reasonable that a 3-link stent platform has a higher chance of residual link over the side-branch ostium. Although this study has clinical implications with respect to the selection of stent platform for non-left main bifurcation lesions, there are several unanswered questions or limitations. First, the numbers of links is not the only difference between the 2 EES. The stent material (PROMUS element: platinum-chromium vs. Xience: cobalt chromium), and overall design other than the number of links might have affected the results. Second, the 2-link stent used in this study has been replaced with a modified version with a 4-link connection between the proximal hoops (PROMUS premier), possibly because of the higher risk for stent deformation.4
More recently, the Synergy stent, which has similar design to PROMUS premier but with thinner stent struts with a bioabsorbable polymer applied to the abluminal stent surface only, replaced the PROMUS premier stent and is clinically available in Japan. Therefore, the results of this study may not be applicable to currently used stents. Third, the 2-stent strategy used in this study was mainly Culotte stenting. Therefore, it is unknown if the number of links affects the results after stenting with other techniques. Fourth, intravascular ultrasound (IVUS) was used in about one-third of the patients. Currently, IVUS is more frequently used during PCI and is associated with better outcomes after stenting.5–8
Furthermore, optical coherence tomography (OCT) has become increasingly used during bifurcation stenting because of several advantages.9–15
For example, OCT may be useful to predict side-branch complications15
or antegrade wiring failure12
for the side branch. Moreover, OCT is useful to confirm the guide wire recrossing point,10
and may contribute to successful bifurcation stenting. Therefore, it is unknown if universal use of IVUS or use of OCT affected the results. Finally, it is still unknown whether the 2-stent strategy used in this study was better than a single-stent strategy. Nevertheless, it is clinically important to suggest that less links may be more useful for non-left main bifurcation lesions. Further randomized study to compare 2-link and 3-link stent platforms under OCT guidance is expected.
Article p ????
H.O. is a member of
Circulation Journal’s Editorial Team.
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