Comparison of Coronary Bifurcation Lesions Stenting Techniques – A Network Meta-Analysis

Background
Coronary bifurcations lesions constitute a challenge in interventional cardiology with provisional strategy being preferred over two-stents technique. However, two-stent technique is used in up to 25% without clear advantage of one technique over another. Our aim was to compare different stenting techniques in coronary bifurcation lesions.

Methods
We performed a MEDLINE search for randomized controlled trials (RCT) comparing stenting techniques in coronary bifurcation lesions with reported clinical outcomes. Mixed treatment comparison model generation was performed to directly and indirectly compare cullote, T and protrusion (TAP), crush and provisional techniques.

Results
A total of 13 RCT were identified including 3,828 patients, among whom 821 were treated with cullote, 1,384 with crush, 432 with TAP and 1191 with provisional stenting. The Bayesian hierarchical random-effects model demonstrated reduction in target lesion revascularization (TLR) rate with crush techniques compared with provisional technique along with a trend for reduction in major adverse cardiovascular (MACE) events (figure 1). There were no statistically significant differences between stenting techniques in terms of myocardial infarction or mortality.

Discussion
Our findings suggest improved outcome with crush technique compared to other double stenting techniques in terms of TLR with a trend towards MACE reduction. Further research is required to determine the optimal stenting technique for coronary bifurcations lesions along with the utility of imaging and physiology in this complex subset.

Figure 1: Comparison of double stenting techniques with provisional stenting in terms of 1a MACE (Major adverse Cardiovascular events) and 1b TLR (Target lesion revascularization)