Two Stents for Non-Left Main Bifurcation Lesion　― Less Is More? ―

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 ????

Disclosure

H.O. is a member of Circulation Journal’s Editorial Team.

References

• 1.   Burzotta F, Lassen JF, Lefevre T, Banning AP, Chatzizisis YS, Johnson TW, et al. Percutaneous coronary intervention for bifurcation coronary lesions: The 15(th) consensus document from the European Bifurcation Club. EuroIntervention 2021; 16: 1307–1317.
• 2.   Murasato Y. Optimal duration of dual antiplatelet therapy after two-stent treatment in coronary bifurcation lesions. Circ J, doi:10.1253/circj.CJ-21-0456.
• 3.   Okabe K, Ohya M, Ikuta A, Takamatsu M, Osakada K, Shimada T, et al. Outcomes at 1 year of non-left main trunk bifurcation lesions treated with a 2-stent strategy using newer-generation everolimus-eluting stents. Circ J, doi:10.1253/circj.CJ-20-1281.
• 4.   Yamada R, Okura H, Kume T, Fukuhara K, Koyama T, Higa T, et al. Impact of stent platform on longitudinal stent deformation: An in vivo frequency domain optical coherence tomography study. Cardiovasc Interv Ther 2017; 32: 199–205.
• 5.   Saito Y, Kobayashi Y, Fujii K, Sonoda S, Tsujita K, Hibi K, et al. Clinical expert consensus document on standards for measurements and assessment of intravascular ultrasound from the Japanese Association of Cardiovascular Intervention and Therapeutics. Cardiovasc Interv Ther 2020; 35: 1–12.
• 6.   Sonoda S, Hibi K, Okura H, Fujii K, Honda Y, Kobayashi Y. Current clinical use of intravascular ultrasound imaging to guide percutaneous coronary interventions. Cardiovasc Interv Ther 2020; 35: 30–36.
• 7.   Okura H, Watanabe M, Miura A, Kurokawa M, Ueda T, Soeda T, et al. Comparison of quantitative measurements between two different intravascular ultrasound catheters and consoles: In vitro and in vivo studies. Cardiovasc Interv Ther, doi:10.1007/s12928-021-00759-6.
• 8.   Takagi K, Nagoshi R, Kim BK, Kim W, Kinoshita Y, Shite J, et al. Efficacy of coronary imaging on bifurcation intervention. Cardiovasc Interv Ther 2021; 36: 54–66.
• 9.   Onuma Y, Okamura T, Muramatsu T, Uemura S, Serruys PW. New implication of three-dimensional optical coherence tomography in optimising bifurcation PCI. EuroIntervention 2015; 11(Suppl V): V71–V74.
• 10.   Okamura T, Nagoshi R, Fujimura T, Murasato Y, Yamawaki M, Ono S, et al. Impact of guidewire recrossing point into stent jailed side branch for optimal kissing balloon dilatation: Core lab 3D optical coherence tomography analysis. EuroIntervention 2018; 13: e1785–e1793.
• 11.   Onuma Y, Katagiri Y, Burzotta F, Holm NR, Amabile N, Okamura T, et al. Joint consensus on the use of OCT in coronary bifurcation lesions by the European and Japanese bifurcation clubs. EuroIntervention 2019; 14: e1568–e1577.
• 12.   Watanabe M, Okura H, Okamura A, Iwai S, Keshi A, Kamon D, et al. Usefulness of longitudinal reconstructed optical coherence tomography images for predicting the need for the reverse wire technique during coronary bifurcation interventions. Catheter Cardiovasc Interv 2019; 94: E54–E60.
• 13.   Fujimura T, Okamura T, Furuya K, Miyazaki Y, Takenaka H, Tateishi H, et al. Comparison of diagnostic performance in assessing the rewiring position into a jailed side branch between online 3D reconstruction systems version 1.1 and 1.2 derived from optical frequency domain imaging. Cardiovasc Interv Ther 2020; 35: 336–342.
• 14.   Fujii K, Kubo T, Otake H, Nakazawa G, Sonoda S, Hibi K, et al. Expert consensus statement for quantitative measurement and morphological assessment of optical coherence tomography. Cardiovasc Interv Ther 2020; 35: 13–18.
• 15.   Watanabe M, Uemura S, Sugawara Y, Ueda T, Soeda T, Takeda Y, et al. Side branch complication after a single-stent crossover technique: Prediction with frequency domain optical coherence tomography. Coron Artery Dis 2014; 25: 321–329.