The influence of single-stent versus double-stent strategy for coronary bifurcation lesions prognosis: a meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

ZHU Yuhan ¹ ,  SHEN Xiaoxu ² , HAN Qingqing ¹ , ZHAO Jing ¹ , SHI Xiaolu ³ , CHEN Huiyang ¹ , BAI Yunhao ¹

1. Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, P.R.China;
2. Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100700, P.R.China;
3. Chinese Academy of Traditional Chinese Medicine, Beijing, 100029, P.R.China;

Corresponding author：

SHEN Xiaoxu, Email: 18810956732@163.com

Keywords：

Coronary bifurcation lesions; Single-stent strategy; Double-stent strategy; Systematic review; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.201708079

Video：

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ObjectivesTo systematically review the influence of single-stent versus double-stent strategy for coronary bifurcation lesions prognosis.MethodsPubMed, The Cochrane Library, EMbase, Web of Science, CBM, WanFang Data, VIP and CNKI databases were searched online to collect randomized controlled trials (RCTs) of single-stent versus double-stent strategy for coronary bifurcation lesions from inception to March, 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using Stata 12.0 software.ResultsA total of 23 RCTs involving 7 391 patients were included. The results of meta-analysis showed that: compared to the double-stent strategy, the single-stent strategy significantly reduced the myocardial infarction rate (RR=0.61, 95%CI 0.50 to 0.73, P<0.001). There were no significant differences between two groups in all cause mortality, cardiac mortality, main adverse coronary event (MACE), target lesion revascularization (TLR) and stent thrombosis. The results of subgroup analysis showed that: single-stent strategy for coronary bifurcation lesions was associated with lower all-cause mortality at five-years follow-up (RR=0.59, 95%CI 0.40 to 0.88,P=0.01).ConclusionsCurrent evidence shows that single-stent strategy for coronary bifurcation lesions could reduce the myocardial infarction rate and five-year mortality compared to double-stent strategy. Due to limited quality and quantity of the included studies, more high quality studies are needed to verify above conclusion.

Citation： ZHU Yuhan, SHEN Xiaoxu, HAN Qingqing, ZHAO Jing, SHI Xiaolu, CHEN Huiyang, BAI Yunhao. The influence of single-stent versus double-stent strategy for coronary bifurcation lesions prognosis: a meta-analysis. Chinese Journal of Evidence-Based Medicine, 2018, 18(2): 192-200. doi: 10.7507/1672-2531.201708079 Copy

1.	Lopez AD, Mathers CD, Ezzati M, et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet, 2006, 367(9524): 1747-1757.
2.	Louvard Y, Lefèvre T, Morice MC, et al. Percutaneous coronary intervention for bifurcation coronary disease. Heart, 2004, 90(6): 713-722.
3.	Colombo A, Moses JW, Morice MC, et al. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation, 2004, 109(10): 1244-1249.
4.	Zhang F, Dong L, Ge J, et al. Simple versus complex stenting strategy for coronary artery bifurcation lesions in the drug-eluting stent era: a meta-analysis of randomised trials. Heart, 2009, 95(20): 1676-1681.
5.	Hakeem A, Fmbhatti K. Provisional vs. complex stenting strategy for coronary bifurcation lesions: meta-analysis of randomized trials. J Inv Cardiol, 2009, 21(11): 589-595.
6.	Niccoli G, Ferrante G, Porto I, et al. Coronary bifurcation lesions: to stent one branch or both? A meta-analysis of patients treated with drug eluting stents. Int J Cardiol, 2010, 139(1): 80-91.
7.	Gao XF, Zhang YJ, Tian NL, et al. Stenting strategy for coronary artery bifurcation with drug-eluting stents: a meta-analysis of nine randomised trials and systematic review. Eurointervention, 2014, 10(5): 561-569.
8.	Koh YS, Kim PJ, Chang K, et al. Long-term clinical outcomes of the one-stent technique versus the two- stent technique for non-left main true coronary bifurcation disease in the era of drug-eluting stents. J Interv Cardiol, 2013, 26(3): 245-253.
9.	Chen SL, Santoso T, Zhang JJ, et al. A randomized clinical study comparing double kissing crush with provisional stenting for treatment of coronary bifurcation lesions: results from the DKCRUSH –II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial. J Am Coll Cardiol, 2011, 57(8): 914-920.
10.	Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0). Available at: http://www. cochrane-handbook.org.
11.	Pan M, de Lezo JS, Medina A, et al. Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy. Am Heart J, 2004, 148(5): 857-864.
12.	Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation, 2006, 114(18): 1955-1961.
13.	Ferenc M, Gick M, Kienzle RP, et al. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J, 2008, 29(23): 2859-2867.
14.	Jensen JS, Galløe A, Lassen JF, et al. Safety in simple versus complex stenting of coronary artery bifurcation lesions. The nordic bifurcation study 14-month follow-up results. EuroIntervention, 2008, 4(2): 229-233.
15.	Behan MW, Holm NR, de Belder AJ, et al. Coronary bifurcation lesions treated with simple or complex stenting: 5-year survival from patient-level pooled analysis of the Nordic bifurcation study and the British bifurcation coronary study. Eur Heart J, 2016, 37(24): 1923-1928.
16.	Korn HV, Yu J, Ohlow MA, et al. Interventional therapy of bifurcation lesions a TIMI flow-guided concept to treat side branches in bifurcation lesions-a prospective randomized clinical study (thueringer bifurcation study, THUEBIS study as pilot trial). Circ Cardiovasc Interv, 2009, 2(6): 535-542.
17.	Hildick-Smith D, Miles WB, Jens FL, et al. The EBC Two study (European Bifurcation Coronary Two) a randomized comparison of provisional t-stenting versus a systematic 2 stent culotte strategy in large caliber true bifurcations. Circ Cardiovasc Interv, 2016, 9(9): e003643.
18.	Zhang L, Zhong W, Luo Y, et al. A pilot study on culottes versus crossover single stenting for true coronary bifurcation lesions. Acta Cardiol Sin, 2016, 32(4): 450-459.
19.	Lin QF, Luo YC, Peng YF, et al. Choice of stenting strategy in true coronary artery bifurcation lesions. Coronary Artery Disease, 2010, 21(6): 345-351.
20.	Hildick-Smith D, de Belder AJ, Cooter N, et al. Randomized trial of simple versus complex drug-eluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies. Circulation, 2010, 121(10): 1235-1243.
21.	Behan MW, Holm NR, Curzen NP, et al. Simple or complex stenting for bifurcation coronary lesions: a patient-level pooled-analysis of the Nordic Bifurcation Study and the British Bifurcation Coronary Study. Circ Cardiovasc Interv, 2011, 4(1): 57-64.
22.	Fei Y, Chen SL, Zhang JJ, et al. Hemodynamic changes of fractional flow reserve after double kissing crush and provisional stenting technique for true bifurcation lesions. Chin Med J (Engl), 2012, 125(15): 2658-2662.
23.	vander Heijden LC, Kok MM, Lam MK, et al. Bifurcation treatment with novel, highly flexible drug-eluting coronary stents in all-comers: 2-year outcome in patients of the DUTCH PEERS trial. Clin Res Cardiol, 2016, 105(3): 206-215.
24.	Diletti R, Garciagarcia HM, Bourantas CV, et al. Clinical outcomes after zotarolimus and everolimus drug eluting stent implantation in coronary artery bifurcation lesions: insights from the RESOLUTE All Comers Trial. Heart, 2013, 99(99): 1267-1274.
25.	Maeng M, Holm NR, Erglis A, et al. Long-term results after simple versus complex stenting of coronary artery bifurcation lesions: Nordic Bifurcation Study 5-year follow-up results. J Am Coll Cardiol, 2013, 62(1): 30-34.
26.	Kim YH, Lee JH, Roh JH, et al. Randomized comparisons between different stenting approaches for bifurcation coronary lesions with or without side branch stenosis. JACC Cardiovasc Interv, 2015, 20, 8(4): 550-560.
27.	Ferenc M, Ayoub M, Büttner HJ, et al. Long-term outcomes of routine versus provisional T-stenting for de novo coronary bifurcation lesions: five-year results of the Bifurcations Bad Krozingen I study. EuroIntervention, 2015, 11(8): 856-859.
28.	Généreux P, Kumsars I, Lesiak M, et al. A randomized trial of a dedicated bifurcation stent versus provisional stenting in the treatment of coronary bifurcation lesions. J Am Coll Cardiol, 2015, 17, 65(6): 533-543.
29.	成万钧, 周玉杰, 赵迎新, 等. TAP 技术与必要性支架术处理冠状动脉分叉病变的疗效对比. 中华心血管病杂志, 2010, 38(2): 131-134.
30.	陈新军, 郑若龙, 钱惠东, 等. 单支架及双支架植入治疗冠状动脉分叉病变的临床疗效比较. 中华临床医师杂志电子版, 2011, 5(5): 1277-1282.
31.	王光公, 王丽霞, 李永强, 等. 单支架与双支架置入治疗冠状动脉真性分叉病变临床分析. 中华实用诊断与治疗杂志, 2014, 28(9): 881-883.
32.	曾令伟, 杨晶. 对吻支架与单支架治疗冠状动脉分叉病变疗效的临床分析. 中国医药科学, 2016, 6(4): 21-23.
33.	王天松, 冯旭霞, 李新明, 等. 对吻支架与单支架治疗冠状动脉分叉病变疗效的临床研究. 中国综合临床, 2012, 28(12): 1287-1290.
34.	Rigatelli G, Dell AF, Zuin M, et al. Complex coronary bifurcation revascularization by means of very minimal crushing and ultrathin biodegradable polymer DES: feasibility and 1-year outcomes of the "nano-crush" technique. Cardiovasc Revasc Med, 2017, 18 (1): 22-27.
35.	Bennett J, Vanhaverbeke M, Vanden DN, et al. Absorb bioresorbable vascular scaffold in complex coronary bifurcation interventions: insights from an in vivo multimodality imaging study. Circ Cardiovasc Interv, 2016, 9(8): e003849.
36.	Jang WJ, Park YH, Hahn JY, et al. Differential effect of side branch intervention on long-term clinical outcomes according to side branch stenosis after main vessel stenting: results from the COBIS (Coronary Bifurcation Stenting) Registry II. Int J Cardiol, 2016, 221(15): 471-477.
37.	Katritsis DG, Siontis GC, Ioannidis JP, et al. Double versus single stenting for coronary bifurcation lesions: a meta-analysis. Circ Cardiovasc Interv, 2009, 2(5): 409-415.
38.	Zimarino M, Corazzini A, Ricci F, et al. Late thrombosis after double versus single drug-eluting stent in the treatment of coronary bifurcations: meta-analysis of randomized and observational studies. JACC Cardiovasc Interv, 2013, 6(7): 687-695.

1. Lopez AD, Mathers CD, Ezzati M, et al. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. Lancet, 2006, 367(9524): 1747-1757.
2. Louvard Y, Lefèvre T, Morice MC, et al. Percutaneous coronary intervention for bifurcation coronary disease. Heart, 2004, 90(6): 713-722.
3. Colombo A, Moses JW, Morice MC, et al. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation, 2004, 109(10): 1244-1249.
4. Zhang F, Dong L, Ge J, et al. Simple versus complex stenting strategy for coronary artery bifurcation lesions in the drug-eluting stent era: a meta-analysis of randomised trials. Heart, 2009, 95(20): 1676-1681.
5. Hakeem A, Fmbhatti K. Provisional vs. complex stenting strategy for coronary bifurcation lesions: meta-analysis of randomized trials. J Inv Cardiol, 2009, 21(11): 589-595.
6. Niccoli G, Ferrante G, Porto I, et al. Coronary bifurcation lesions: to stent one branch or both? A meta-analysis of patients treated with drug eluting stents. Int J Cardiol, 2010, 139(1): 80-91.
7. Gao XF, Zhang YJ, Tian NL, et al. Stenting strategy for coronary artery bifurcation with drug-eluting stents: a meta-analysis of nine randomised trials and systematic review. Eurointervention, 2014, 10(5): 561-569.
8. Koh YS, Kim PJ, Chang K, et al. Long-term clinical outcomes of the one-stent technique versus the two- stent technique for non-left main true coronary bifurcation disease in the era of drug-eluting stents. J Interv Cardiol, 2013, 26(3): 245-253.
9. Chen SL, Santoso T, Zhang JJ, et al. A randomized clinical study comparing double kissing crush with provisional stenting for treatment of coronary bifurcation lesions: results from the DKCRUSH –II (Double Kissing Crush versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions) trial. J Am Coll Cardiol, 2011, 57(8): 914-920.
10. Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0). Available at: http://www. cochrane-handbook.org.
11. Pan M, de Lezo JS, Medina A, et al. Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy. Am Heart J, 2004, 148(5): 857-864.
12. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation, 2006, 114(18): 1955-1961.
13. Ferenc M, Gick M, Kienzle RP, et al. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J, 2008, 29(23): 2859-2867.
14. Jensen JS, Galløe A, Lassen JF, et al. Safety in simple versus complex stenting of coronary artery bifurcation lesions. The nordic bifurcation study 14-month follow-up results. EuroIntervention, 2008, 4(2): 229-233.
15. Behan MW, Holm NR, de Belder AJ, et al. Coronary bifurcation lesions treated with simple or complex stenting: 5-year survival from patient-level pooled analysis of the Nordic bifurcation study and the British bifurcation coronary study. Eur Heart J, 2016, 37(24): 1923-1928.
16. Korn HV, Yu J, Ohlow MA, et al. Interventional therapy of bifurcation lesions a TIMI flow-guided concept to treat side branches in bifurcation lesions-a prospective randomized clinical study (thueringer bifurcation study, THUEBIS study as pilot trial). Circ Cardiovasc Interv, 2009, 2(6): 535-542.
17. Hildick-Smith D, Miles WB, Jens FL, et al. The EBC Two study (European Bifurcation Coronary Two) a randomized comparison of provisional t-stenting versus a systematic 2 stent culotte strategy in large caliber true bifurcations. Circ Cardiovasc Interv, 2016, 9(9): e003643.
18. Zhang L, Zhong W, Luo Y, et al. A pilot study on culottes versus crossover single stenting for true coronary bifurcation lesions. Acta Cardiol Sin, 2016, 32(4): 450-459.
19. Lin QF, Luo YC, Peng YF, et al. Choice of stenting strategy in true coronary artery bifurcation lesions. Coronary Artery Disease, 2010, 21(6): 345-351.
20. Hildick-Smith D, de Belder AJ, Cooter N, et al. Randomized trial of simple versus complex drug-eluting stenting for bifurcation lesions: the British Bifurcation Coronary Study: old, new, and evolving strategies. Circulation, 2010, 121(10): 1235-1243.
21. Behan MW, Holm NR, Curzen NP, et al. Simple or complex stenting for bifurcation coronary lesions: a patient-level pooled-analysis of the Nordic Bifurcation Study and the British Bifurcation Coronary Study. Circ Cardiovasc Interv, 2011, 4(1): 57-64.
22. Fei Y, Chen SL, Zhang JJ, et al. Hemodynamic changes of fractional flow reserve after double kissing crush and provisional stenting technique for true bifurcation lesions. Chin Med J (Engl), 2012, 125(15): 2658-2662.
23. vander Heijden LC, Kok MM, Lam MK, et al. Bifurcation treatment with novel, highly flexible drug-eluting coronary stents in all-comers: 2-year outcome in patients of the DUTCH PEERS trial. Clin Res Cardiol, 2016, 105(3): 206-215.
24. Diletti R, Garciagarcia HM, Bourantas CV, et al. Clinical outcomes after zotarolimus and everolimus drug eluting stent implantation in coronary artery bifurcation lesions: insights from the RESOLUTE All Comers Trial. Heart, 2013, 99(99): 1267-1274.
25. Maeng M, Holm NR, Erglis A, et al. Long-term results after simple versus complex stenting of coronary artery bifurcation lesions: Nordic Bifurcation Study 5-year follow-up results. J Am Coll Cardiol, 2013, 62(1): 30-34.
26. Kim YH, Lee JH, Roh JH, et al. Randomized comparisons between different stenting approaches for bifurcation coronary lesions with or without side branch stenosis. JACC Cardiovasc Interv, 2015, 20, 8(4): 550-560.
27. Ferenc M, Ayoub M, Büttner HJ, et al. Long-term outcomes of routine versus provisional T-stenting for de novo coronary bifurcation lesions: five-year results of the Bifurcations Bad Krozingen I study. EuroIntervention, 2015, 11(8): 856-859.
28. Généreux P, Kumsars I, Lesiak M, et al. A randomized trial of a dedicated bifurcation stent versus provisional stenting in the treatment of coronary bifurcation lesions. J Am Coll Cardiol, 2015, 17, 65(6): 533-543.
29. 成万钧, 周玉杰, 赵迎新, 等. TAP 技术与必要性支架术处理冠状动脉分叉病变的疗效对比. 中华心血管病杂志, 2010, 38(2): 131-134.
30. 陈新军, 郑若龙, 钱惠东, 等. 单支架及双支架植入治疗冠状动脉分叉病变的临床疗效比较. 中华临床医师杂志电子版, 2011, 5(5): 1277-1282.
31. 王光公, 王丽霞, 李永强, 等. 单支架与双支架置入治疗冠状动脉真性分叉病变临床分析. 中华实用诊断与治疗杂志, 2014, 28(9): 881-883.
32. 曾令伟, 杨晶. 对吻支架与单支架治疗冠状动脉分叉病变疗效的临床分析. 中国医药科学, 2016, 6(4): 21-23.
33. 王天松, 冯旭霞, 李新明, 等. 对吻支架与单支架治疗冠状动脉分叉病变疗效的临床研究. 中国综合临床, 2012, 28(12): 1287-1290.
34. Rigatelli G, Dell AF, Zuin M, et al. Complex coronary bifurcation revascularization by means of very minimal crushing and ultrathin biodegradable polymer DES: feasibility and 1-year outcomes of the "nano-crush" technique. Cardiovasc Revasc Med, 2017, 18 (1): 22-27.
35. Bennett J, Vanhaverbeke M, Vanden DN, et al. Absorb bioresorbable vascular scaffold in complex coronary bifurcation interventions: insights from an in vivo multimodality imaging study. Circ Cardiovasc Interv, 2016, 9(8): e003849.
36. Jang WJ, Park YH, Hahn JY, et al. Differential effect of side branch intervention on long-term clinical outcomes according to side branch stenosis after main vessel stenting: results from the COBIS (Coronary Bifurcation Stenting) Registry II. Int J Cardiol, 2016, 221(15): 471-477.
37. Katritsis DG, Siontis GC, Ioannidis JP, et al. Double versus single stenting for coronary bifurcation lesions: a meta-analysis. Circ Cardiovasc Interv, 2009, 2(5): 409-415.
38. Zimarino M, Corazzini A, Ricci F, et al. Late thrombosis after double versus single drug-eluting stent in the treatment of coronary bifurcations: meta-analysis of randomized and observational studies. JACC Cardiovasc Interv, 2013, 6(7): 687-695.

Chinese Journal of Evidence-Based Medicine

The influence of single-stent versus double-stent strategy for coronary bifurcation lesions prognosis: a meta-analysis

Abstract Full text Figures/Tables Video References Cited by

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