5-Year Outcome of Simple Crossover Stenting in Coronary Bifurcation Lesions Compared With Side Branch Opening

Abstract

Background: The optimal side branch (SB) treatment strategy after simple crossover stenting in bifurcation lesions is still controversial.

Objectives: The purpose of this study was to compare the long-term outcomes of a 1-stent strategy with simple crossover alone versus with an additional SB-opening procedure in patients with left main (LM) and non-LM coronary bifurcation lesions.

Methods: Patients who underwent percutaneous coronary intervention with a 1-stent strategy for bifurcation lesions including LM were selected from the COBIS (Coronary Bifurcation Stenting) III registry and divided into the simple crossover-alone group and SB-opening group. Clinical outcomes were assessed by the 5-year rate of target lesion failure (a composite of cardiac death, target vessel myocardial infarction, and target lesion repeat revascularization).

Results: Among 2,194 patients who underwent the 1-stent strategy, 1,685 (76.8%) patients were treated with simple crossover alone, and 509 (23.2%) patients were treated with an additional SB-opening procedure. Although the baseline SB angiographic disease was more severe in the SB-opening group, the final lumen diameter of the SB was larger. The 5-year observed target lesion failure rate was similar between the 2 groups (7.0% in the simple crossover vs. 6.7% in SB-opening group; hazard ratio: 0.99; 95% confidence interval: 0.66 to 1.48; p = 0.947), even in the subgroup analyses including LM (9.5% vs. 11.3%; p = 0.442) and true bifurcation (5.3% vs. 7.8%; p = 0.362). The results were not changed after an inverse probability of treatment weighting adjustment. There was no difference in the overall and SB-related target lesion revascularization rate in both groups.

Conclusions: The long-term clinical outcome of the 1-stent strategy with simple crossover alone for coronary bifurcation lesions was acceptable compared to those of additional SB-opening procedures. (Korean Coronary Bifurcation Stenting [COBIS] Registry III [COBIS III]; NCT03068494).

Keywords: CI, confidence interval; DES, drug-eluting stent(s); DS, diameter stenosis; FKI, final kissing inflation; HR, hazard ratio; IPTW, inverse probability of treatment weighting; LM, left main; MI, myocardial infarction; MLD, minimum lumen diameter; MV, main vessel; PCI, percutaneous coronary intervention; POT, proximal optimizing technique; QCA, quantitative coronary angiography; RVD, reference vessel diameter; SB, side branch; TLF, target lesion failure; TLR, target lesion repeat revascularization; bifurcation disease; clinical outcome; percutaneous coronary intervention.

Conflict of interest statement

This work was supported by the Korean Bifurcation Club and Korean Society of Interventional Cardiology. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

© 2021 The Authors.

Figures

Graphical abstract

Figure 1

Study Flow Chart COBIS = Coronary Bifurcation Stenting; DES = drug-eluting stent; FKI = final kissing inflation; LM = left main; MI = myocardial infarction; PCI = percutaneous coronary intervention; POT = proximal optimization technique; SB = side branch.

Figure 2

Outcomes According to Additional SB Opening After Simple Crossover Stenting The 5-year cumulative-incidence curves are shown for target-lesion failures according to an additional SB-opening procedure after the 1-stent strategy with simple crossover. Target-lesion failure was defined as a composite of death from (A) cardiac causes, target vessel MI, or target vessel revascularization; (B) cardiac death; (C) target vessel MI, (D) and target lesion revascularization. Abbreviations as in Figure 1.

Figure 3

Subgroup Analysis Hazard ratios are for the SB opening compared to the simple crossover. ACS = acute coronary syndrome; BES = biolimus-eluting stent; CI = confidence interval; EES = everolimus-eluting stent; IVUS = intravascular ultrasound; ZES = zotarolimus-eluting stent; other abbreviations as in Figure 1.

Figure 4

Analysis of SB Restenosis SB = side branch; TLR = target lesion repeat revascularization.

Figure 5

Outcomes According to Additional SB Opening, Stratified by LM and True Bifurcation Lesions In each figure, the 5-year of cumulative-incidence curves are shown for the target lesion failure according to an additional SB-opening procedure after the 1-stent strategy with simple crossover. Target lesion failure was defined as a composite of death from cardiac causes, target vessel myocardial infractions, or target-vessel revascularization with (A) LM bifurcation lesions, (B) non-LM bifurcation lesions, (C) true bifurcation lesions, and (D) non–true bifurcation lesions. Abbreviations as in Figure 1.

Central Illustration

Outcomes After Simple Crossover Stenting in Coronary Bifurcation Lesions According to Additional Side Branch Opening An additional side branch–opening procedure after simple main vessel stenting for coronary bifurcation lesions did not exhibit an improvement in the 5-year observed target lesion failure rate compared to simple crossover alone. Furthermore, similar overall and SB-related target lesion revascularization rates were seen in both groups. Therefore, the long-term clinical outcomes after the 1-stent strategy with simple crossover for coronary bifurcation lesions was acceptable.