Bifurcation PCI With a Hybrid Strategy With Drug Eluting Balloons Versus a Stepwise Provisional Two-stent Strategy

Study Overview
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Brief Summary
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The optimal treatment of coronary bifurcation lesions is complex and remains subject of current research. There is ongoing debate about the optimal strategy for bifurcations with upfront two-stent strategy or provisional one-stent strategy. Current European Society of Cardiology (ESC) guidelines advise a provisional approach with optional stepwise two-stent strategy in case of suboptimal result of the side branch (SB). However, a two-stent strategy (either upfront and stepwise) caries technical difficulties and is associated with increased procedure duration and costs and higher exposure of the patient to radiation and contrast. Therefore there is upcoming interest in the use of a drug-eluting balloon (DEB) in the side branch of bifurcation lesions after provisional approach. Drug-eluting balloons are conventional semi-compliant angioplasty balloons covered with an anti-proliferating drug, which is released into the vessel wall during inflation. Several small pilot studies have successfully investigated a hybrid approach with use of DEB in addition to the provisional strategy. This hybrid approach has shown to be safe and feasible, however no large trials have been performed comparing this with current two-stent bifurcation strategies. The aim of this randomized controlled, single blinded, multicenter trial is to investigate whether a hybrid DEB approach is non-inferior to a stepwise provisional two-stent strategy in patients with de novo bifurcation lesions and a suboptimal result of the SB after provisional approach. Patients included in this study will receive PCI using provisional approach (implantation of drug-eluting stent (DES) in the main branch). Patients with an unsatisfactory result of the SB after provisional PCI (≥ 70% residual stenosis and/or diminished flow < Thrombolysis in Myocardial Infarction (TIMI) III) will be randomized in a 1:1 ratio to receive the Hybrid DEB approach or the two-stent strategy. Patients with a satisfactory result of the side branch after provisional PCI will be included in a registry. Follow-up will be performed at 12 months and at the anticipated median 2 year follow-up with a minimum follow-up of 1 year in each subject by either a phone call or outpatient clinic visit. During follow-up information regarding cardiovascular drug use, hospitalizations, invasive and non-invasive diagnostic tests, angina status and SAE's is obtained.

Official Title
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Bifurcation PCI With a Hybrid Strategy With Drug Eluting Balloons Versus a Stepwise Provisional Two-stent Strategy. A Randomized Controlled Trial and Registry

Conditions
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Coronary Artery Disease, Coronary Bifurcation Lesion

Intervention / Treatment
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* Other: Hybrid DEB approach with drug-eluting balloon
* Other: Two-stent strategy


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Significant de novo bifurcation lesion (main vessel and side branch diameter ≥ 2.5mm, diameter stenosis of the main vessel ≥ 70% and of the side branch ≥ 50% or in intermediate stenosis FFR ≤ 0.80 or iFR ≤ 0.89) Stable coronary artery disease or stabilized acute coronary syndrome Age ≥ 18 years Acceptable candidate for treatment with a drug eluting stent Exclusion Criteria: Unstable clinical condition Previous PCI with stent implantation in the target lesion(s) Known comorbidity with a life expectancy of <2 year Active bleeding requiring medical attentions (BARC >2 at index PCI) Pregnancy Unable to provide consent for any other reason Participation in another stent or drug trial Known hypersensitivity or allergy for asprin, clopidogrel, ticagrelor, prasugrel, cobalt chromium, sirolimus, to excipients with phospholipid or related origins.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Patients will be randomized in a 1:1 ratio to either hybrid DEB approach or two-stent strategy
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Hybrid DEB<br>Patients randomized to hybrid DEB group will receive application of DEB in the side branch. | Other: Hybrid DEB approach with drug-eluting balloon<br>* If a patient is randomized to the hybrid DEB approach, lesion preparation of the SB with non-compliant balloon (NC) is mandatory before DEB application. The application of DEB can be performed if acceptable result of the lesion preparation is obtained (at least TIMI III flow and no flow limiting dissection). The drug- eluting balloon used in this study is the CE- marked Magic Touch Sirolimus Coated Balloon Catheter (Concept Medical, Gujarat, India). The size of the DEB is measured on a ratio 1:1 on reference diameter of the SB. The DEB balloon is inflated for 60 seconds, or two times more than 30 seconds if long duration inflations are not possible. Finally low pressure kissing inflation with the same DEB in place, and Proximal Optimization Therapy (POT) are performed. In case of SB occlusion, or flow limiting dissections in non-Left Main (LM) bifurcations and < TIMI 3 flow or 70-99% residual stenosis in LM bifurcations, cross- over to two-stent technique is performed.<br>|
| Other: Two-stent strategy<br>Patients randomized to two-stent strategy will receive implantation of a second DES in the side branch, using Culotte or TAP/T technique. | Other: Two-stent strategy<br>* When randomized to the conventional two-stent strategy, TAP/T or Culotte stenting is performed. First lesion preparation of the SB is mandatory. The drug-eluting stent (Supraflex stent) can be placed in the SB if acceptable result of the lesion preparation is obtained and is measured on a 1:1 ratio on reference diameter of the SB. Finally, kissing inflation and POT are mandatory.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Composite of all-cause death, periprocedural or spontaneous myocardial infarction (MI) and/or target vessel revascularization (TVR) | Composite of all-cause death, periprocedural (according to the SCAI/ARC II definition and a secondary analysis according to the 4th universal definition) or spontaneous (according to the 4th universal definition) myocardial infarction (MI) and/or target vessel revascularization (TVR) at the anticipated median 2 year | Anticipated median 2 year follow-up after the date of randomization, with a minimum follow-up in all subjects of 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Procedural success | Procedural success defined as successful stent delivery with final core lab (defined as TIMI flow of III, angiographic in-stent MB and SB diameter stenosis ≤30%, or ≤50% after DEB in the side branch) and absence of in-hospital major adverse cardiac and cerebrovascular events (MACCE, defined as all cause death, spontaneous MI, TVR, stoke) at discharge, 12 months and the anticipated median 2 year | Discharge, 12 months and the anticipated median 2 year follow-up after the date of randomization | 
| Target vessel failure (TVF) | Target vessel failure (TVF), defined as cardiac death, target vessel spontaneous MI, TVR at discharge, 12 months and the anticipated median 2 year | Discharge, 12 months and the anticipated median 2 year follow-up after the date of randomization | 
| Major adverse cardiac events (MACE) | Major adverse cardiac events (MACE), defined as all-cause death, spontaneous MI, repeat revascularization at discharge, 12 months and the anticipated median 2 year | Discharge, 12 months and the anticipated median 2 year follow-up after the date of randomization | 
| Individual components of MACE and TVF | Individual components of MACE and TVF (All-cause death, cardiac death, periprocedural of spontaneous MI, target vessel revascularization, target vessel spontaneous MI) at discharge, 12 months and the anticipated median 2 year | Discharge, 12 months and the anticipated median 2 year follow-up after the date of randomization | 
| Periprocedural MI | Periprocedural MI within 48 hours after procedure, according to the SCAI/ARC II definition, secondary analysis according to the 4th universal definition | 48 hours after the Percutaneous Coronary Intervention (PCI) | 
| Major intraprocedural complications | Major intraprocedural complications, defined as type C-F dissections, perforations, slow flow or no reflow (< TIMI III), thrombus, major side branch occlusion (>2mm) during the index procedure | The end of the PCI | 
| Probable and definite stent thrombosis | Probable and definite stent thrombosis, defined as Angiographic confirmation of stent thrombosis, or any myocardial infarction that is related to documented acute ischemia in the territory of the implanted stent without angiographic confirmation of stent thrombosis and in the absence of any other obvious cause at discharge, 12 months and the anticipated median 2 year | Discharge, 12 months and the anticipated median 2 year follow-up after the date of randomization | 
| Major bleeding, defined as BARC type 2-5 | Major bleeding, defined as BARC type 2-5 at discharge | Discharge after the PCI | 
| Contrast volume used during the PCI procedure | Contrast volume used during the PCI procedure (in ml) | The end of the PCI | 
| Radiation exposure of the patient, measured in DAP and AirKerma | Radiation exposure of the patient, measured in DAP and AirKerma during the PCI procedure | The end of the PCI | 
| Procedural time, measured in minutes, defined as time from first to last procedural angiography image | Procedural time, measured in minutes, defined as time from first to last procedural angiography image | The end of the PCI | 
| Total procedural costs (in euro's) per patient stratified to treatment group | Total procedural costs (in euro's) per patient stratified to treatment group | The end of the PCI | 
| Percentage of stent expansion in proximal and distal main branch and side branch, measured with intracoronary imaging (OCT or IVUS) | Percentage of stent expansion in proximal and distal main branch and side branch, measured with intracoronary imaging (OCT or IVUS) | The end of the PCI | 
| Final minimal lumen and stent area post stenting in the proximal and distal main branch measured with intracoronary imaging (OCT or IVUS) | Final minimal lumen and stent area post stenting in the proximal and distal main branch measured with intracoronary imaging (OCT or IVUS) | The end of the PCI | 
| Dissections in the proximal and distal main branch and side branch, measured using intracoronary imaging (OCT or IVUS) | Dissections in the proximal and distal main branch and side branch, measured using intracoronary imaging (OCT or IVUS) | The end of the PCI | 
| Core Lab Assessed initial TIMI flow main branch and side branch | Core Lab Assessed initial TIMI flow main branch and side branch | During the Coronary Angiography (CAG), before the PCI | 
| Core Lab Assessed Lesion Length (in mm) | Core Lab Assessed Lesion Length (in mm) | During the CAG, before the PCI | 
| Core Lab Assessed percentage diameter stenosis main branch and side branch | Core Lab Assessed percentage diameter stenosis main branch and side branch | During the CAG, before the PCI | 
| Core Lab Assessed reference diameter (in mm) proximal main branch and side branch | Core Lab Assessed reference diameter (in mm) proximal main branch and side branch | During the CAG, before the PCI | 
| Core Lab Assessed minimal lumen diameter (in mm) main branch and side branch | Core Lab Assessed minimal lumen diameter (in mm) main branch and side branch | During the CAG, before the PCI | 
| The severity of calcification main branch and side branch, Core Lab Assessed | The severity of calcification main branch and side branch, Core Lab Assessed | During the CAG, before the PCI | 
| Core Lab Assessed Bifurcation angle | Core Lab Assessed Bifurcation angle | During the CAG, before the PCI | 
| Core Lab Assessed syntax I score as absolute value | Core Lab Assessed syntax I score as absolute value | During the CAG, before the PCI | 
| Bifurcation medina score | Bifurcation medina score | During the CAG, before the PCI | 
| Core Lab Assessed final TIMI flow main branch and side branch | Core Lab Assessed final TIMI flow main branch and side branch | The end of the PCI | 
| Core Lab Assessed residual dissection (type A-F) after PCI in the main branch and/or side branch | Core Lab Assessed residual dissection (type A-F) after PCI in the main branch and/or side branch | The end of the PCI | 
| Core Lab Assessed residual in-stent and in-segment stenosis (in %) after PCI | Core Lab Assessed residual in-stent and in-segment stenosis (in %) after PCI | The end of the PCI | 
| Core Lab Assessed minimal lumen diameter (in mm) main branch and side branch post PCI | Core Lab Assessed minimal lumen diameter (in mm) main branch and side branch post PCI | The end of the PCI | 
| Core Lab Assessed percentage diameter stenosis main branch and side branch post PCI | Core Lab Assessed percentage diameter stenosis main branch and side branch post PCI | The end of the PCI | 
| Core Lab Assessed acute lumen gain (in mm) main of the branch and side branch after PCI | Core Lab Assessed acute lumen gain (in mm) main of the branch and side branch after PCI | The end of the PCI | 
| Core Lab Assessed Procedural coronary thrombus | Core Lab Assessed Procedural coronary thrombus, defined as yes or no | The end of the PCI | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Coronary bifurcation lesion, Coronary artery disease, Drug-eluting balloon, Percutaneous coronary intervention