Side Branch Dilatation Helpful Before T-Stenting of Bifurcation Lesions

PARIS, France—In treating patients with true bifurcation lesions, predilatation of the side branch before provisional T-stenting improves coronary blood flow and has no adverse consequences, according to findings of a randomized trial presented Thursday, May 23 at EuroPCR 2013.

Manuel Pan, MD, of Reina Sofia Hospital (Cordoba, Spain), said that currently the preferred strategy for bifurcation PCI is the so-called simple approach: stenting of the main vessel with optional stenting of the side branch.

“However, the procedure could be [described as] not so simple,” Dr. Pan noted, citing the possible compromise or complete occlusion of the side branch that can occur after main vessel stenting. While predilatation of the side branch could be helpful, some experts have cautioned against the approach based on observational studies, he reported.

The researchers randomized 372 patients with bifurcation lesions treated between February 2009 and November 2012 to provisional stenting with (n = 187) or without side branch predilatation (n = 185). Baseline patient and procedural characteristics were well-balanced apart from the need for side branch balloon postdilation; only 68% of patients in the predilatation group required further intervention after obtaining poor results (stenosis > 50% or TIMI flow < 3) compared with 100% of those in in the non-predilatation group (P = 0.001).

Method Improves Coronary Flow

After main vessel stenting, the prevalence of TIMI flow 0-1 was lower with predilatation than without (1% vs. 10%; P < 0.001). TIMI flow less than 3 also was reduced after side branch predilatation (P < 0.001). Final percent stenosis of the side branch and postprocedural troponin levels were similar between the 2 groups.

In addition, there were no ill effects from predilatation in the event that further intervention was required. Patients who needed postdilation, irrespective of whether they were in the predilatation or non-predilatation group, had similar levels of inability to cross the lesion (1.5% vs. 1%; P = 0.62) and rewiring time (2.2 ± 6 minutes vs. 3.2 ± 7 minutes; P = 0.20). Rewiring procedures in patients who received predilatation involved slightly fewer wires (1.1 ± 0.4 vs. 1.3 ± 0.6; P = 0.023).

At 1 month, the rate of NSTEMI was numerically lower after predilatation (1.6% vs. 3.7%; P = 0.23). There also was 1 death in the predilatation group.

Between 1 and 6 months, there was 1 acute MI (0.5%) in the non-predilatation group and 5 TLRs (2.7%) in each of the 2 groups. One additional death (0.5%) occurred with predilatation and 3 deaths (1.6%) without (P = 0.37).

Study Speaks to Daily Practice 

“Predilatation of the side branch in patients with true bifurcation lesions during provisional T-stenting is a useful maneuver,” Dr. Pan concluded. Not only does the method improve TIMI flow, it “does not penalize the rewiring of the side branch through the metallic structure of the main vessel stent.” 

Following the presentation, session co-chair Rodney H. Stables, MD, of Imperial College London (London, United Kingdom), commented, “I really appreciate this study because anyone who performs angioplasty on a daily basis faces difficult questions of technique like this.”

However, Dr. Stables questioned the choice of primary outcome (TIMI flow in the side branch). In this case, he said, it “describes something that is an intermediate stage toward the final desired outcome. It’s like reporting the score in a football match at 60 minutes. Because really, I don’t care what happens in the conduct of the procedure. I care what the final result is at the end.”

Panel member Antonio Serra, MD, PhD, of Hospital del Mar (Barcelona, Spain), noted that the risk of dissection always accompanies predilatation. Clinical practice must involve “common sense,” he said, asking Dr. Pan whether he truly recommended predilatation across the board.

“In our daily practice, we [only] predilate severe lesions that are difficult to wire,” Dr. Pan said.


Pan M. Predilatation of the side branch in patients with true bifurcation lesions during provisional T stenting. Presented at: EuroPCR. May 23, 2013. Paris, France.



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