Stenting techniques for coronary bifurcation lesions: Evidence from a network meta-analysis of randomized clinical trials

Objectives: We conducted a systematic review and network meta-analysis of available randomized clinical trials (RCTs) to compare cardiovascular outcomes involving stenting techniques in coronary bifurcation lesions. Background: Although provisional stenting of the main branch and balloon angioplasty of the side branch is considered the standard approach, the use of two stents is often pursued with a wide variety of bifurcation stenting techniques available. Methods: We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and Clinicaltrials.gov from inception to December 2018. We performed a frequentist network meta-analysis to estimate relative risks (RR) of death, major adverse cardiovascular events (MACE), target vessel revascularization (TVR), target lesion revascularization (TLR), and stent thrombosis (ST) among different two stent bifurcation techniques. Results: We identified 14 studies, yielding data on 4,285 patients. Double Kissing (DK) Crush and Mini-crush were associated with significant reductions in MACE, TVR, and TLR when compared with the Provisional stenting (RR 0.31–0.55 [all p <.01] and RR 0.42–0.45 [all p <.02], respectively) and with the remaining bifurcation techniques (RR 0.44–0.55 [all p <.05] for DK Crush and RR 0.37–0.45 [all p <.05] for Mini-crush). In addition, Culotte and Crush were associated with an increased risk for ST compared to Provisional stenting (RR 3.25–4.27 [both p <.05]) and to DK crush (RR 3.02–3.99 [both p <.05]). Conclusions: DK crush and mini-crush were found to be associated with fewer events and complications compared to the other techniques reviewed, including the Provisional approach. Further, Culotte and Crush were associated with an increased risk of stent thrombosis when compared to the Provisional approach.