Meta-Analysis of Provisional Versus Systematic Double-Stenting Strategy for Left Main Bifurcation Lesions
Affiliation:
1. Department of Medicine, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA;2. Faculty of Medicine, Ain Shams University, Cairo, Egypt;3. Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA;4. Division of Cardiology, Rush University Medical Center, Chicago, IL, USA;5. Department of Cardiovascular Medicine, Debakey Heart and Vascular Institute, Houston Methodist Hospital, Houston, TX, USA;6. Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, CT, USA;7. Department of Cardiovascular Medicine, Baylor Scott & White, The Heart Hospital, Plano, TX, USA;8. Department of Cardiovascular Medicine, Gagnon Cardiovascular Institute, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA;9. Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA;10. Cardiology Department, Hospital Universitario de La Princesa, IIS-IP, CIBER-CV, Madrid, Spain;1. Department of Cardiology, Santa Maria della Misericordia Hospital, viale Tre Martiri, 45100 Rovigo, Italy;2. Department of Translational Medicine, University of Ferrara, Ferrara, Italy;1. Duke University School of Medicine, Durham, NC, United States of America;2. Duke Clinical Research Institute, Durham, NC, United States of America;3. Columbia University Irving Medical Center, New York, United States of America;4. US Food and Drug Administration, Silver Spring, MD, United States of America;5. Boston Scientific Corporation, Marlborough, MA, United States of America;6. Mercator MedSystems, Inc., Emeryvlle, CA, United States of America;7. CeloNova BioSciences, San Antonio, TX, United States of America;1. Department of Medicine, University of Minnesota, Minneapolis, MN, United States of America;2. Regions Hospital, St Paul, MN, United States of America
Abstract:
ObjectiveWe sought to compare the clinical outcomes with provisional versus double-stenting strategy for left main (LM) bifurcation percutaneous coronary intervention (PCI).BackgroundDespite two recent randomized controlled trials (RCTs) and several observational reports, the optimal LM bifurcation PCI technique remains controversial.MethodsPubMed, Cochrane Central Register of Controlled-Trials (CENTRAL), Clinicaltrials.gov, International Clinical Trial Registry Platform were leveraged for studies comparing PCI bifurcation techniques for LM coronary lesions using second-generation drug eluting stents (DES). The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), target vessel or lesion revascularization, and stent thrombosis.ResultsTwo RCTs and 10 observational studies with 7105 patients were included. Median follow-up duration was 42 months (IQR: 25.7). Double stenting was associated with a trend towards higher incidence of MACE (odds ratio [OR] 1.20; 95 % confidence interval [CI] 0.94 to 1.53) compared with provisional stenting. This was mainly driven by higher rates of target lesion revascularization (TLR) (OR 1.50; 95 % CI 1.07 to 2.11). There were no statistically significant differences in the incidence of all-cause mortality, cardiovascular mortality, MI, or stent thrombosis. On subgroup analysis according to the study type, provisional stenting was associated with lower MACE and TLR in observational studies, but not in RCTs.ConclusionFor LM bifurcation PCI using second-generation DES, a provisional stenting strategy was associated with a trend towards lower incidence of MACE driven by statistically significant lower rates of TLR, compared with systematic double stenting. These differences were primarily driven by observational studies. Further RCTs are warranted to confirm these findings.
