Background: The ideal approach to coronary bifurcation lesions in the drug eluting stent era is a matter of debate between simple (main branch plus provisional side branch stenting) and complex (main branch plus routine side branch stenting) strategies. The purpose of this study was to perform a systematic review of randomized controlled trials in the drug eluting stent era comparing a strategy of simple versus complex coronary bifurcation lesion stenting.
Methods: PubMed, Cardiosource, MyAHA, and other databases were searched from 2003 for randomized controlled trials comparing simple versus complex bifurcation lesion stenting strategies. Published randomized trials comparing simple and complex bifurcation lesion stenting strategies using drug eluting stents were included. Patients were adults with stable or unstable angina pectoris. Studies were excluded if they enrolled acute ST elevation myocardial infarction, restenotic lesions, heavily calcified or thrombus laden disease. Outcomes of interest included 1) the composite of major cardiac events (MACE-cardiac death, non-fatal myocardial infarction, target lesion revascularization, and stent thrombosis), 2) the individual MACE components, and 3) restenosis rates. Quality assessment was performed. Meta-analyses are presented as odds ratio (OR) using fixed effect model. Heterogeneity between trials was assessed.
Results: Four randomized trials were included in the analysis. A total of 791 patients were randomized to
simple versus complex coronary bifurcation lesion stenting using the Sirolimus stent platform. Clinical and angiographic outcomes data were available up to 1 year of follow-up. There was no difference in MACE between the simple and complex bifurcation lesion stenting strategy. There were 9.2 % and 6.9% adverse events in the complex and simple stenting strategy, respectively (OR for MACE 1.11 [95% Cl 0.64-1.92], p=0.71). Likewise, there was no difference between strategies with regards to the individual MACE components and restenosis rates.
Conclusion: A strategy of complex bifurcation lesion stenting, even with the use of Sirolimus drug eluting stent, is not associated with a reduction in MACE and restenosis rates.
Plain Language Summary:. In the drug eluting stent era, patients who undergo stenting for coronary bifurcation lesions do not derive any benefit from more aggressive revascularization of both main and side branches. Therefore, side branch stenting should not be routinely performed unless there is a specific indication to intervene on the side branch.