No Disadvantage for 2-Stent Strategy in Bifurcation Lesions With Second-Generation DES

While a 2-stent approach to treating bifurcation lesions has been shown repeatedly to produce worse outcomes than a single-stent strategy, second-generation DES seem to attenuate this disparity, according to a pooled analysis of Korean registry patients published in the August 24, 2015, issue of JACC: Cardiovascular Interventions.

Take Home:  No Disadvantage for 2-Stent Strategy in Bifurcation Lesions With Second-Generation DES

Previous studies “do not reflect the current real-world practice, because first-generation DES are no longer used,” write Hyo-Soo Kim, MD, PhD, of Seoul National University Hospital (Seoul, South Korea), and colleagues. “Therefore, we need more evidence regarding the performance of second-generation DES in the treatment of bifurcation lesions, especially the results of the 2-stenting technique.”

Investigators assessed 3,162 patients who underwent PCI for bifurcation lesions with first-generation DES (n = 2,475) or second-generation DES (n = 687) and were enrolled in the COBIS II, EXCELLENT, or RESOLUTE-Korea registries. The 2-stent strategy was used in 27.2% of patients receiving first-generation stents and 40.5% of those with second-generation devices. 

By 3 years, the primary endpoint of target lesion failure (TLF; composite of cardiac death, MI, and clinically indicated TLR) had occurred more frequently when patients receiving first-generation DES were treated with 2 stents compared with 1 stent (8.6% vs 17.5%; P < .001), a difference driven by higher rates of MI and TLR. However, TLF rates were comparable irrespective of stent number in those treated with second-generation DES (5.4% vs 5.8%; P = .659). Additionally, the patient-oriented composite outcome (all-cause mortality, MI, any revascularization, and cerebrovascular accident) showed a similar pattern for those treated with first- vs second-generation DES (table 1).

Table 1. Three-Year Outcomes With 2 Stents vs 1 Stent: HR (95% CI)

The findings were maintained after inverse probability-weighted adjustment. Rates of Academic Research Consortium-defined definite or probable stent thrombosis were almost 4 times higher among those treated with 2 vs 1 first-generation DES even after adjustment (HR 3.77; 95% CI 1.95-7.28). Again, this pattern was not observed in the second-generation DES group (HR 1.60; 95% CI 0.47-5.48).

There were no differences in outcomes among various 2-stent techniques including T-stenting, crush, culotte, kissing, or V-stenting regardless of DES type.

Overall, among patients treated for LM bifurcation (n = 903), rates of TLR were similar between those who received first- and second-generation DES (P = .025). However, in patients with first-generation DES, the 2-stent technique showed higher rates of TLR than single stenting (17.8% vs 5.5%; P < .001), whereas there was no difference in TLR rates between the techniques in those who received second-generation DES (3.8% vs 6.7%; P =.361).

No Long-Term Penalty to a 2-Stent Strategy

According to an accompanying editorial by Aaron V. Kaplan, MD, of Dartmouth-Hitchcock Medical Center (Lebanon, NH), the study shows “how interventional technique is continuing to evolve and suggest[s] that our ability to treat bifurcation lesions is improving.”

Dr. Kaplan stresses the importance of an individualized approach to bifurcation lesions “focused on anatomic variables that make a lesion appropriate for 1 of a number of 1- or 2-stent strategies.” The study gives “further comfort that utilization of a 2-stent strategy with current technology and technique does not carry long-term penalties,” he adds.

Likewise, John A. Bittl, MD, of the Ocala Heart and Vascular Institute (Ocala, FL), told TCTMD in a telephone interview that the study, by virtue of being observational, cannot “really prove that 2 second-generation DES for a bifurcation lesion are better than one. But it suggests that 2 stents are probably not any worse than one.” This kind of research, he added, provides reassurance to interventionalists, especially those dealing with complex cases and suboptimal anatomy.

While a randomized trial might be used to study stenting techniques for bifurcation lesions, that prospect is “very challenging because the lesion types are so protean,” Dr. Bittl observed. “On the other hand, I think it’s exciting to consider the possibility of a randomized trial using only second-generation DES for bifurcation lesions. I think the results might confirm what has been seen here.”

Dr. Bittl said the evolution of dedicated stents for bifurcation lesions might change practice going forward. “What potentially could be very exciting is individualized stent design using something like a 3D printer to ultimately match a device to a particular patient’s anatomy,” he said.


1. Lee JM, Hahn J-Y, Kang J, et al. Differential prognostic effect between first- and second-generation drug-eluting stents in coronary bifurcation lesions: patient-level analysis of the Korean Bifurcation Pooled Cohorts. J Am Coll Cardiol Intv. 2015;8:1318-1331.
2. Kaplan AV. Current treatment of bifurcation lesions: re-examining the 1- versus 2-stent argument [editorial]. J Am Coll Cardiol Intv. 2015;8:1332-1334

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  • The study was supported by grants from the Korea Healthcare Technology R&amp;D Project and the Innovative Research Institute for Cell Therapy, Seoul National University Hospital, both sponsored by the Ministry of Health, Welfare &amp; Family, Republic of Korea.
  • Drs. Kim and Bittle report no relevant conflicts of interest.
  • Dr. Kaplan reports being the founder and director of Tryton Medical, a venture-backed start-up company developing a dedicated bifurcation stent.