Treatment of coronary bifurcations with third generation drug‐eluting stent: Making major headway or just baby steps?

Percutaneous coronary artery interventions (PCI) for bifurcation lesions comprise 15–20% of all PCIs. These lesions represent a puzzling subset to PCI operators due to their diverse morphology, the inability to predict coronary plaque shift following crossover stenting, and the scarcity of large randomized data to guide clinical decisions. Besides, the operators have to choose through a wide array of stenting techniques [1], making the design of a standardized approach for the treatment of bifurcation lesions particularly difficult. Several studies demonstrated that the rates of stent thrombosis and target-lesion revascularization after bare-metal stent and/or first-generation drug-eluting stent (DES) implantation are all higher in bifurcation lesions when compared with nonbifurcation lesions. The advent of dependable, newer-generation DES such as the everolimus-eluting Platinum Chromium Coronary Stent System stent (EES, Promus Element or Premier, Boston Scientific Corporation, Natick, Massachusetts) and the zotarolimus-eluting stent [(ZES), Resolute Integrity, Medtronic Vascular, Santa Rosa, California] has clearly led to significant improvements in safety over firstgeneration DES, representing the contemporary DES workhorses. Several meta-analyses evaluating the safety and efficacy of EES compared to firstgeneration DES (sirolimus and paclitaxel-eluting stent) have consistently showed superior results with EES [2,3]. Particularly in bifurcation lesions, a recent subanalyzis of two pooled Spanish randomized PCI studies (N1⁄4 443) compared EES with sirolimus-eluting stent. In that analysis, both stents performed particularly well at 3-year follow-up (major adverse cardiac events: 10.6% with sirolimus vs. 6.7% with EES, P1⁄4 0.159), but EES showed significantly better safety profile beyond 1 year. Another study evaluating two consecutive bifurcation cohorts [first-generation DES from the year 2002 to 2005 and newer generation DES (EES and ZES) from 2006 to 2011] also exhibited superior results with newer generation DES. Lately, the use of biolimus-eluting stents (BES) with biodegradable polymer and abluminal drug release has emerged as a novel DES alternative. Several studies have demonstrated BES superiority over firstgeneration DES, while only preliminary data indicate that it has comparable performance to current DES workhorses [4]. Hitherto, it is unknown whether BES will live up to expectations and match EES and ZES performance in the setting of coronary bifurcation lesions. In this issue of Catheterization and Cardiovascular Interventions, Costopoulos and colleagues performed a comparison between EES (n1⁄4 154) and BES (n1⁄4 69) implantation for the treatment of bifurcation lesions [5]. In this study, both groups had similarly low reintervention rates (6.9 6 3.5% vs. 8.0 6 2.7%, P1⁄4 0.889) and no episodes of stent thrombosis at 3year follow-up. These encouraging results highlight the safety and efficacy of current DES technology even in difficult conditions such as coronary bifurcation lesions. Although BES seemed to mimic EES outcome, this study has limited sample size and it is nonrandomized. Nowadays, DES workhorses are particularly appealing owing to their optimal deliverability and conformability to the vessel curvature along with an adequate radial force. In addition, they have consistently showed a superb safety and efficacy profile that far surpass first-generation DES, substantially raising the bar. Certainly, it is going to be a major task to BES or any another novel DES to replicate EES and ZES results. At this point, owing to the lack of robust