Journal of Invasive Cardiology

The percutaneous treatment of bifurcation lesions remains suboptimal. A frequent problem, accounting for 10–20% of coronary lesions undergoing percutaneous coronary intervention (PCI), the bifurcation is plagued by acute technical challenges, long-term restenosis, and more recently, early and late stent thrombosis.^1–4 Generally defined as a lesion which involves a side branch of 2.0 mm or greater, the bifurcation is in part so complex due to its variability. This variability results from inconsistent plaque distribution, unpredictable side branch angulation and large differences in main branch and side branch diameters. Furthermore, these lesions are often noncompliant at the carina due to calcification and/or negative remodeling. A recent analysis of over 11,000 patients in whom 1,412 had bifurcation lesions suggested that PCI of the bifurcation was associated with an increased rate of death/MI/target vessel revascularization.⁵ Historically, bare metal stent restenosis rates of over 50% have been reported with no consistent favorable impact of systematic debulking.^6,7 A significant reason for left main disease being unsuitable for PCI is involvement of the bifurcation.
Though this subset of lesions is challenging, progress has been made. The impact of drug-eluting stents appears favorable, though less dramatic than in noncomplex lesions. In this issue of the Journal, Lee and colleagues describe a single-center experience with drug-eluting stents in de novo bifurcation lesions, of which 39% were true bifurcations with plaque involving both the main and the side branches.⁸ In this report, 83 patients with 85 bifurcation lesions were treated with either CYPHER™ (Cordis Corp., Miami, Florida) or TAXUS® (Boston Scientific Corp., Natick, Massachusetts) stents. The type of stent was not randomly assigned. Procedural success was high, 93% and 96% for CYPHER and TAXUS stents, respectively. In the TAXUS group, 10 patients received side branch stenting (34%), while in the CYPHER group only 1 patient underwent side branch stenting (8%). Only 25% of the TAXUS patients received a final kissing balloon inflation. One patient in each group had a CK elevation postprocedure. At 30 days, there were 2 stent thromboses, both in the TAXUS group. The overall MACE rate was numerically higher in the TAXUS group (7 versus 4%), but not statistically different. Similar early positive results have been reported by others. Compared to historical controls, it appears that drug-eluting stents have lowered the rate of main branch restenosis and target lesion revascularization; however, the impact on the side branch has been less impressive. Yamachita and colleagues reported a restenosis rate of 33–39% for the main branch using bare metal stents. The event rates ranged from 38–51%, depending on the implantation strategy at 6-month follow up.⁶ With the use of drug-eluting stents, restenosis rates have been 10% or less in the main branch, particularly when the side branch is not stented.³