Abdelfattah Omar M, Radwan Ahmed, Sayed Ahmed, Elbadawi Ayman, Derbas Laith A, Saleh Yehia, Ahmad Yousif, ElJack Ammar, Masoumi Amirali, Karmpaliotis Dimitri, Elgendy Islam Y, Alfonso Fernando
Department of Medicine, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA.
Faculty of Medicine, Ain Shams University, Cairo, Egypt.
Cardiovasc Revasc Med. 2022 Dec;45:53-62. doi: 10.1016/j.carrev.2022.07.017. Epub 2022 Jul 27.
We sought to compare the clinical outcomes with provisional versus double-stenting strategy for left main (LM) bifurcation percutaneous coronary intervention (PCI).
Despite two recent randomized controlled trials (RCTs) and several observational reports, the optimal LM bifurcation PCI technique remains controversial.
PubMed, Cochrane Central Register of Controlled-Trials (CENTRAL), Clinicaltrials.gov, International Clinical Trial Registry Platform were leveraged for studies comparing PCI bifurcation techniques for LM coronary lesions using second-generation drug eluting stents (DES). The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes of interest were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), target vessel or lesion revascularization, and stent thrombosis.
Two RCTs and 10 observational studies with 7105 patients were included. Median follow-up duration was 42 months (IQR: 25.7). Double stenting was associated with a trend towards higher incidence of MACE (odds ratio [OR] 1.20; 95 % confidence interval [CI] 0.94 to 1.53) compared with provisional stenting. This was mainly driven by higher rates of target lesion revascularization (TLR) (OR 1.50; 95 % CI 1.07 to 2.11). There were no statistically significant differences in the incidence of all-cause mortality, cardiovascular mortality, MI, or stent thrombosis. On subgroup analysis according to the study type, provisional stenting was associated with lower MACE and TLR in observational studies, but not in RCTs.
For LM bifurcation PCI using second-generation DES, a provisional stenting strategy was associated with a trend towards lower incidence of MACE driven by statistically significant lower rates of TLR, compared with systematic double stenting. These differences were primarily driven by observational studies. Further RCTs are warranted to confirm these findings.
我们试图比较左主干（LM）分叉病变经皮冠状动脉介入治疗（PCI）中临时支架置入术与双支架置入术策略的临床结局。
尽管最近有两项随机对照试验（RCT）和几份观察性报告，但最佳的LM分叉病变PCI技术仍存在争议。
利用PubMed、Cochrane对照试验中心注册库（CENTRAL）、Clinicaltrials.gov、国际临床试验注册平台检索比较使用第二代药物洗脱支架（DES）治疗LM冠状动脉病变的PCI分叉技术的研究。主要结局是主要不良心血管事件（MACE）。感兴趣的次要结局是全因死亡率、心血管死亡率、心肌梗死（MI）、靶血管或病变血运重建以及支架血栓形成。
纳入两项RCT和10项观察性研究，共7105例患者。中位随访时间为42个月（四分位间距：25.7）。与临时支架置入术相比，双支架置入术的MACE发生率有升高趋势（优势比[OR]1.20；95%置信区间[CI]0.94至1.53）。这主要是由较高的靶病变血运重建（TLR）率驱动的（OR 1.50；95%CI 1.07至2.11）。全因死亡率、心血管死亡率、MI或支架血栓形成的发生率无统计学显著差异。根据研究类型进行亚组分析，在观察性研究中，临时支架置入术与较低的MACE和TLR相关，但在RCT中并非如此。
对于使用第二代DES的LM分叉病变PCI，与系统性双支架置入术相比，临时支架置入术的MACE发生率有降低趋势，主要是由于TLR率显著降低。这些差异主要由观察性研究驱动。需要进一步的RCT来证实这些发现。
