Long-term results after PCI of unprotected distal left main coronary artery stenosis: the Bifurcations Bad Krozingen (BBK)-Left Main Registry
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Percutaneous coronary intervention (PCI) of unprotected distal left main stenosis (UDLM) is increasingly performed as an alternative to surgical treatment. The optimal strategy for stenting in this setting is still a matter of debate. Therefore, this analysis investigated the long-term clinical outcome of a single- versus a double-stenting strategy for treatment of UDLM.
Methods and results
From a large registry, 867 consecutive patients with UDLM undergoing either single or double stenting with drug-eluting stents (DES) were identified. Follow-up was up to 10 (median 3.1, interquartile range 1.1–5.3) years. Primary endpoint was MACE consisting of all-cause death, myocardial infarction, or target lesion re-intervention (TLR). Secondary clinical endpoints included these single endpoints and stent thrombosis. MACE occurred in 41.5% after single and in 49.0% after double stenting (P = 0.03). TLR was lower after single (17.4%) as compared to double stenting (27.2%; P < 0.01). Between single and double stenting, there were no significant differences for death (26.4 versus 23.3%; P = 0.31), death or myocardial infarction (29.1 versus 27.2%; P = 0.55), or definite/probable stent thrombosis (1.3 versus 2.1%; P = 0.42).
Compared with single stenting, double stenting was associated with a significantly higher long-term risk of MACE. This was driven by a higher incidence of TLR, whereas the risk of death, MI, or stent thrombosis was similar between the two strategies.
KeywordsDistal left main stenosis Bifurcation TAP stenting Drug-eluting stents Restenosis Reintervention
We thank doctors from the catheterization laboratory staff for their enthusiasm in supporting the registry; Monika Bockstatt, Rita Höwisch-Pengel, Barbara Steiger and Elke Maurer for dedicated support in data collection.
No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.
Compliance with ethical standards
Conflict of interest
Dr. Ferenc received speaker honoraria from Abbott Vascular, Biotronik, Boston Scientific, Daiichi Sankyo, Medtronic and Terumo. Dr. Hochholzer reports receiving consulting and lecture fees from AstraZeneca, Boehringer Ingelheim, Daiichi Sankyo and the Medicines Company. Dr. Mashayekhi received consulting/speaker honoraria from Abbott Vascular, Asahi Intecc, Biotronik, Boston Scientific, Daiichi Sankyo, Nitiloop, Terumo and Vascular Solutions. The other authors report no conflicts of interest.
- 1.Ahn JM, Roh JH, Kim YH, Park DW, Yun SC, Lee PH, Chang M, Park HW, Lee SW, Lee CW, Park SW, Choo SJ, Chung C, Lee J, Lim DS, Rha SW, Lee SG, Gwon HC, Kim HS, Chae IH, Jang Y, Jeong MH, Tahk SJ, Seung KB, Park SJ (2015) Randomized trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT Study. J Am Coll Cardiol 65(20):2198–2206. https://doi.org/10.1016/j.jacc.2015.03.033 CrossRefGoogle Scholar
- 2.Makikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, Trovik T, Eskola M, Romppanen H, Kellerth T, Ravkilde J, Jensen LO, Kalinauskas G, Linder RB, Pentikainen M, Hervold A, Banning A, Zaman A, Cotton J, Eriksen E, Margus S, Sorensen HT, Nielsen PH, Niemela M, Kervinen K, Lassen JF, Maeng M, Oldroyd K, Berg G, Walsh SJ, Hanratty CG, Kumsars I, Stradins P, Steigen TK, Frobert O, Graham AN, Endresen PC, Corbascio M, Kajander O, Trivedi U, Hartikainen J, Anttila V, Hildick-Smith D, Thuesen L, Christiansen EH, investigators Ns (2016) Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 388(10061):2743–2752. https://doi.org/10.1016/S0140-6736(16)32052-9 CrossRefGoogle Scholar
- 3.Mohr FW, Morice MC, Kappetein AP, Feldman TE, Stahle E, Colombo A, Mack MJ, Holmes DR Jr, Morel MA, Van Dyck N, Houle VM, Dawkins KD, Serruys PW (2013) Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 381(9867):629–638. https://doi.org/10.1016/S0140-6736(13)60141-5 CrossRefGoogle Scholar
- 4.Chen SL, Zhang JJ, Han Y, Kan J, Chen L, Qiu C, Jiang T, Tao L, Zeng H, Li L, Xia Y, Gao C, Santoso T, Paiboon C, Wang Y, Kwan TW, Ye F, Tian N, Liu Z, Lin S, Lu C, Wen S, Hong L, Zhang Q, Sheiban I, Xu Y, Wang L, Rab TS, Li Z, Cheng G, Cui L, Leon MB, Stone GW (2017) Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial. J Am Coll Cardiol 70(21):2605–2617. https://doi.org/10.1016/j.jacc.2017.09.1066 CrossRefGoogle Scholar
- 5.Park DW, Seung KB, Kim YH, Lee JY, Kim WJ, Kang SJ, Lee SW, Lee CW, Park SW, Yun SC, Gwon HC, Jeong MH, Jang YS, Kim HS, Kim PJ, Seong IW, Park HS, Ahn T, Chae IH, Tahk SJ, Chung WS, Park SJ (2010) Long-term safety and efficacy of stenting versus coronary artery bypass grafting for unprotected left main coronary artery disease: 5-year results from the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) registry. J Am Coll Cardiol 56(2):117–124. https://doi.org/10.1016/j.jacc.2010.04.004 CrossRefGoogle Scholar
- 6.Stone GW, Sabik JF, Serruys PW, Simonton CA, Genereux P, Puskas J, Kandzari DE, Morice MC, Lembo N, Brown WM 3rd, Taggart DP, Banning A, Merkely B, Horkay F, Boonstra PW, van Boven AJ, Ungi I, Bogats G, Mansour S, Noiseux N, Sabate M, Pomar J, Hickey M, Gershlick A, Buszman P, Bochenek A, Schampaert E, Page P, Dressler O, Kosmidou I, Mehran R, Pocock SJ, Kappetein AP, Investigators ET (2016) Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med 375(23):2223–2235. https://doi.org/10.1056/NEJMoa1610227 CrossRefGoogle Scholar
- 7.Lassen JF, Burzotta F, Banning AP, Lefevre T, Darremont O, Hildick-Smith D, Chieffo A, Pan M, Holm NR, Louvard Y, Stankovic G (2018) Percutaneous coronary intervention for the left main stem and other bifurcation lesions: 12th consensus document from the European Bifurcation Club. EuroIntervention 13(13):1540–1553. https://doi.org/10.4244/EIJ-D-17-00622 CrossRefGoogle Scholar
- 8.Chen SL, Zhang Y, Xu B, Ye F, Zhang J, Tian N, Liu Z, Qian X, Ding S, Li F, Zhang A, Liu Y, Lin S (2012) Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique. EuroIntervention 8(7):803–814. https://doi.org/10.4244/EIJV8I7A123 CrossRefGoogle Scholar
- 9.Ferenc M, Buettner HJ, Gick M, Comberg T, Rothe J, Khoury F, Valina C, Toma A, Kuebler P, Riede F, Neumann FJ (2016) Clinical outcome after percutaneous treatment of de novo coronary bifurcation lesions using first or second generation of drug-eluting stents. Clin Res Cardiol 105(3):230–238. https://doi.org/10.1007/s00392-015-0911-7 CrossRefGoogle Scholar
- 10.Karrowni W, Makki N, Dhaliwal AS, Vyas A, Blevins A, Dughman S, Girotra S, Cram P, Horwitz PA (2014) Single versus double stenting for unprotected left main coronary artery bifurcation lesions: a systematic review and meta-analysis. J Invasive Cardiol 26(6):229–233Google Scholar
- 11.Palmerini T, Marzocchi A, Tamburino C, Sheiban I, Margheri M, Vecchi G, Sangiorgi G, Santarelli A, Bartorelli A, Briguori C, Vignali L, Di Pede F, Ramondo A, Inglese L, De Carlo M, Falsini G, Benassi A, Palmieri C, Filippone V, Sangiorgi D, Barlocco F, De Servi S (2008) Impact of bifurcation technique on 2-year clinical outcomes in 773 patients with distal unprotected left main coronary artery stenosis treated with drug-eluting stents. Circ Cardiovasc Interv 1(3):185–192. https://doi.org/10.1161/CIRCINTERVENTIONS.108.800631 CrossRefGoogle Scholar
- 12.Toyofuku M, Kimura T, Morimoto T, Hayashi Y, Ueda H, Kawai K, Nozaki Y, Hiramatsu S, Miura A, Yokoi Y, Toyoshima S, Nakashima H, Haze K, Tanaka M, Take S, Saito S, Isshiki T, Mitsudo K, j-Cypher Registry I (2009) Three-year outcomes after sirolimus-eluting stent implantation for unprotected left main coronary artery disease: insights from the j-Cypher registry. Circulation 120(19):1866–1874. https://doi.org/10.1161/CIRCULATIONAHA.109.873349 CrossRefGoogle Scholar
- 13.Kang SH, Lee CW, Baek S, Lee PH, Ahn JM, Park DW, Kang SJ, Lee SW, Kim YH, Park SW, Park SJ (2017) Impact of left main coronary artery disease on long-term mortality in patients undergoing drug-eluting stent implantation. Clin Res Cardiol 106(12):953–959. https://doi.org/10.1007/s00392-017-1145-7 CrossRefGoogle Scholar
- 14.D’Ascenzo F, Iannaccone M, Giordana F, Chieffo A, Connor SO, Napp LC, Chandran S, de la Torre Hernandez JM, Chen SL, Varbella F, Omede P, Taha S, Meliga E, Kawamoto H, Montefusco A, Chong M, Garot P, Sin L, Gasparetto V, Abdirashid M, Cerrato E, Biondi-Zoccai G, Gaita F, Escaned J, Hiddick Smith D, Lefevre T, Colombo A, Sheiban I, Moretti C (2016) Provisional vs. two-stent technique for unprotected left main coronary artery disease after ten years follow up: a propensity matched analysis. Int J Cardiol 211:37–42. https://doi.org/10.1016/j.ijcard.2016.02.136 CrossRefGoogle Scholar
- 15.Lassen JF, Holm NR, Stankovic G, Lefevre T, Chieffo A, Hildick-Smith D, Pan M, Darremont O, Albiero R, Ferenc M, Louvard Y (2014) Percutaneous coronary intervention for coronary bifurcation disease: consensus from the first 10 years of the European Bifurcation Club meetings. EuroIntervention 10(5):545–560. https://doi.org/10.4244/EIJV10I5A97 CrossRefGoogle Scholar
- 16.Cutlip DE, Windecker S, Mehran R, Boam A, Cohen DJ, van Es GA, Steg PG, Morel MA, Mauri L, Vranckx P, McFadden E, Lansky A, Hamon M, Krucoff MW, Serruys PW, Academic Research C (2007) Clinical end points in coronary stent trials: a case for standardized definitions. Circulation 115(17):2344–2351. https://doi.org/10.1161/CIRCULATIONAHA.106.685313 CrossRefGoogle Scholar
- 17.Cassese S, Kufner S, Xhepa E, Byrne RA, Kreutzer J, Ibrahim T, Tiroch K, Valgimigli M, Tolg R, Fusaro M, Schunkert H, Laugwitz KL, Mehilli J, Kastrati A (2016) Three-year efficacy and safety of new- versus early-generation drug-eluting stents for unprotected left main coronary artery disease insights from the ISAR-LEFT MAIN and ISAR-LEFT MAIN 2 trials. Clin Res Cardiol 105(7):575–584. https://doi.org/10.1007/s00392-015-0953-x CrossRefGoogle Scholar
- 18.Kim WJ, Kim YH, Park DW, Yun SC, Lee JY, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ (2011) Comparison of single- versus two-stent techniques in treatment of unprotected left main coronary bifurcation disease. Catheter Cardiovasc Interv 77(6):775–782. https://doi.org/10.1002/ccd.22915 CrossRefGoogle Scholar
- 19.Gao Z, Xu B, Yang Y, Qiao S, Wu Y, Chen T, Xu L, Yuan J, Chen J, Gao RL (2015) Comparison between one-stent versus two-stent technique for treatment of left main bifurcation lesions: a large single-center data. Catheter Cardiovasc Interv 85(7):1132–1138. https://doi.org/10.1002/ccd.25849 CrossRefGoogle Scholar
- 20.Chen SL, Xu B, Han YL, Sheiban I, Zhang JJ, Ye F, Kwan TW, Paiboon C, Zhou YJ, Lv SZ, Dangas GD, Xu YW, Wen SY, Hong L, Zhang RY, Wang HC, Jiang TM, Wang Y, Chen F, Yuan ZY, Li WM, Leon MB (2013) Comparison of double kissing crush versus Culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol 61(14):1482–1488. https://doi.org/10.1016/j.jacc.2013.01.023 CrossRefGoogle Scholar
- 21.Chieffo A, Hildick-Smith D (2016) The European Bifurcation Club Left Main Study (EBC MAIN): rationale and design of an international, multicentre, randomised comparison of two stent strategies for the treatment of left main coronary bifurcation disease. EuroIntervention 12(1):47–52. https://doi.org/10.4244/EIJV12I1A8 CrossRefGoogle Scholar