Percutaneous coronary intervention for true bifurcation lesions: a single-center experience including the setting of acute coronary syndromes
Authors: Brandao M , Ribeiro Silva M , Rodrigues A , Guerreiro C , Melica B , Santos L , Braga P , Oliveira M , Fontes-Carvalho R 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Percutaneous coronary intervention (PCI) for true coronary bifurcation lesions is challenging.

Purpose
To describe procedural and clinical outcomes of true bifurcation PCI.

Methods
Single-center retrospective study of consecutive patients (pts) submitted to PCI for true bifurcation lesions (06/2018-06/2020). MACE comprised death, myocardial infarction (MI), stroke, restenosis and reintervention.

Results
During the study period, 1678 PCI were performed, of which 7% were for true bifurcation lesions (Medina x,x,1). 118 pts (mean age 66.4 ± 11.0 years; 74.6% male; 32.2% diabetic; mean left ventricular ejection fraction 49.8 ± 8.4%) were included.
Most pts (64.7%) were treated in the setting of an acute coronary syndrome (ACS): 26.7% ST-elevation MI, 31.9% non-ST-elevation MI, 6.0% unstable angina. 35.3% were treated for a chronic coronary syndrome. 24.8% of pts presented with 3-vessel disease and 11.1% had a left main (LM) lesion.
The most frequently diseased main branch was the left anterior descending artery: 21.2% (68), followed by the left circumflex: 17.8% (21), right coronary artery: 12.7% (15) and LM: 11.9% (14). In terms of bifurcation classification, lesions were mainly Medina 1,1,1 (71.2%), followed by 0,1,1 (13.6%); 1,0,1 (9.2%) and 0,0,1 (5.9%).
PCI was mainly performed via radial artery (73.7%). Mean number of stents: 1.4 ± 0.6. Lesions were predominantly treated with single stenting technique (80.3%). Double-stenting was used in 23 (19.7%) pts: TAP was the most used technique (10), followed by culotte (3), crush (2), double kissing crush (2) and T-stent (1). Proximal optimization technique and kissing balloon inflation were performed in 38.1% and 44.9% of cases, respectively. Rotational atherectomy was used in 10.4%. Ventricular support devices were used in 3 pts (1 Impella, 2 intra-aortic balloon pump).
Intracoronary imaging was used in 13 pts: intravascular ultrasound (IVUS) and optical coherence tomography (OCT) in 8 and 5 pts, respectively; its use was more frequent in cases of LM PCI (p=.002). OCT was associated with higher contrast doses (350 vs 224 ml, p&lt;.001), with no increase in acute kidney injury incidence (p=.413). Fluoroscopic time (p=.684) and radiation dose (p=.916) did not differ.
Side branch occlusion occurred in 5 pts and iatrogenic coronary dissection in 7 pts. At a mean follow-up time of 17.3 ± 8.1 months, MACE and mortality rates were 13.3% and 6.9%. MACE occurred more frequently in pts with LM lesion (p&lt;.001) and less often in cases where complete revascularization was achieved (p=.006).

Conclusions
True bifurcations represented a relatively small percentage of PCI lesions and were mainly performed in ACS setting. In line with literature, single stenting was the most used technique. MACE rate was globally low and was decreased by complete revascularization. Still, LM bifurcation PCI was associated with increased MACE.