Bifurcation Treatment Strategies in Acute Coronary Syndrome: Balancing Procedural Success and Clinical Outcomes.

Bifurcation lesions in the coronary arteries present a unique and challenging subset of coronary artery disease, involving the branching points where 2 vessels emerge from a single trunk. These coronary artery bifurcation lesions involve 3 vessel segments—proximal main vessel (MV), distal MV, and side branch (SB). These lesions occur in approximately 20% of patients who underwent percutaneous coronary intervention (PCI).1Lassen JF Holm NR Banning A Burzotta F Lefèvre T Chieffo A Hildick-Smith D Louvard Y Stankovic G. Percutaneous coronary intervention for coronary bifurcation disease: 11th consensus document from the European Bifurcation Club.EuroIntervention. 2016; 12: 38-46Crossref PubMed Google Scholar They are especially challenging in patients with acute coronary syndrome (ACS) because of a higher risk of acute stent thrombosis and SB occlusion. Treating bifurcation lesions can be complex because of the intricate anatomy, varied physiological characteristics, and potential for adverse outcomes. Although the provisional stenting is the most preferred,2Sawaya FJ Lefèvre T Chevalier B Garot P Hovasse T Morice MC Rab T Louvard Y Contemporary approach to coronary bifurcation lesion treatment.JACC Cardiovasc Interv. 2016; 9: 1861-1878Crossref PubMed Scopus (114) Google Scholar the optimal strategy for managing bifurcation lesions in ACS is still a matter of ongoing research and debate. In this issue of The American Journal of Cardiology, Tigen et al3Tigen K Dogan Z Sunbul M Gurel E Cincin A Kanar B Sayar N Ozben B. “Main vessel-oriented” treatment strategy versus “open side branch” treatment strategy in acute coronary syndrome patients with culprit bifurcation lesions.Am J Cardiol. 2023; 204: 339-344Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar present the results of a retrospective analysis of ACS patients with a culprit bifurcation lesion. This study examines and compares the procedural success and in-hospital outcomes of 2 treatment strategies—the MV Only (MVO) and the Open SB (OSB) approaches, thereby offering significant insights into the implications of these methodologies in the management of patients with ACS. They recruited 575 ACS patients with a culprit bifurcation lesion, with 384 patients treated with an MVO strategy and 191 with an OSB strategy. Baseline characteristics in the groups were similar, though the MVO strategy had more radial access and the OSB group had longer procedures and used more contrast agent. No significant differences were observed in lesion locations. The OSB group had more SBs originating from the bifurcation core and larger SB diameters. Although the overall procedural success rate was higher in the OSB group (91.1% vs 84.1%) in all-comers, there were no differences in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction and unstable angina patients subgroups. No significant differences were seen in left ventricular ejection fraction, peak troponin T level, duration of stay, or major adverse cardiovascular and cerebrovascular events (MACCEs) rates, except for slightly higher contrast-induced nephropathy in the OSB group. Procedural success rates were higher in the OSB group when the SB originated from the bifurcation core or had a diameter of ≥2 mm. Postprocedural MACCE rates did not show significant differences between the 2 strategies. It is important to acknowledge that the study had specific exclusions, including patients with left main bifurcations, multivessel disease requiring staged PCI, previous coronary artery bypass grafts, cardiogenic shock, and those necessitating cardiopulmonary resuscitation, in other criteria. Notably, the bifurcation PCI strategy was influenced by operator discretion, potentially introducing a source of bias. Additionally, the study is constrained by the absence of intravascular imaging guidance data. Despite these limitations, the findings of this retrospective analysis mirror the underlying themes found in most contemporary consensus documents and studies focused on bifurcation PCI.4Pan M Lassen JF Burzotta F Ojeda S Albiero R Lefèvre T Hildick-Smith D Johnson TW Chieffo A Banning AP Ferenc M Darremont O Chatzizisis YS Louvard Y Stankovic G. The 17th expert consensus document of the European Bifurcation Club – techniques to preserve access to the side branch during stepwise provisional stenting.EuroIntervention. 2023; 19: 26-36Crossref PubMed Scopus (0) Google Scholar In particular, provisional stenting has evolved into the default technique for addressing most coronary bifurcation lesions. As emphasized by the sixteenth expert consensus document of the European Bifurcation Club,5Albiero R Burzotta F Lassen JF Lefèvre T Banning AP Chatzizisis YS Johnson TW Ferenc M Pan M Daremont O Hildick-Smith D Chieffo A Louvard Y Stankovic G. Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club.EuroIntervention. 2022; 18: e362-e376Crossref PubMed Scopus (22) Google Scholar a more refined stepwise layered provisional stenting approach is commonly employed in treating coronary bifurcation lesions. Although the MVO strategy represents a provisional approach without specific measures for SB occlusion, the OSB strategy involves a stepwise layered provisional stenting, and also employs an upfront 2-stent strategy intending to preserve the SB. Consequently, the OSB strategy exhibited superior procedural success in terms of thrombolysis in myocardial infarction 3 flow in both the MV and SB. This success, however, was offset by increased procedural time, contrast, and radiation usage, and greater reliance on femoral access. Given that MACCE rates exhibited no significant differences between the 2 strategies, the question arises as to which stenting approach is preferable in ACS. Although the simplistic MVO strategy might present a potential advantage, this hypothesis warrants further exploration through dedicated randomized controlled trials. In conclusion, the study conducted by Tigen et al3Tigen K Dogan Z Sunbul M Gurel E Cincin A Kanar B Sayar N Ozben B. “Main vessel-oriented” treatment strategy versus “open side branch” treatment strategy in acute coronary syndrome patients with culprit bifurcation lesions.Am J Cardiol. 2023; 204: 339-344Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar serves as a valuable addition to the existing body of evidence, further reinforcing the merits of the stepwise layered provisional stenting strategy within the realm of coronary bifurcation PCIs, particularly when addressing larger SBs. The authors have no competing interests to declare.