British Bifurcation Coronary Study Compares Stenting Strategies

March 1, 2010—David Hildick-Smith, MD, et al have published findings from BBC ONE (British Bifurcation Coronary Study) online ahead of print in Circulation.

The BBC study was conducted because the optimal strategy for treating coronary bifurcation lesions remains a subject of debate. With bare-metal stents, single-stent approaches appear to be superior to systematic two-stent strategies; however, drug-eluting stents have low rates of restenosis and might offer improved outcomes with complex stenting techniques, the investigators stated.

As detailed in Circulation, patients with significant coronary bifurcation lesions were randomized to either a simple or complex stenting strategy with drug-eluting stents. In the simple strategy, the main vessel was stented followed by optional kissing-balloon dilatation/T-stenting. In the complex strategy, both vessels were systematically stented (culotte or crush techniques) with mandatory kissing-balloon dilatation. The study randomized 500 patients aged 64 ± 10 years; 77% were men. Eighty-two percent of lesions were true bifurcations (> 50% narrowing in both vessels). In the simple group (n = 250), 66 patients (26%) had kissing balloons in addition to main vessel stenting, and seven (3%) had T-stenting. In the complex group (n = 250), 89% of culotte (n = 75) and 72% of crush (n = 169) cases were completed successfully with final kissing-balloon inflations. The primary endpoint (a composite at 9 months of death, myocardial infarction, and target vessel failure) occurred in 8% of the simple group versus 15.2% of the complex group (hazard ratio, 2.02; 95% confidence interval, 1.17–3.47; P = .009). Myocardial infarction occurred in 3.6% of the simple group versus 11.2% of the complex group (P = .001), and in-hospital major adverse cardiovascular events occurred in 2% versus 8% (P = .002), respectively. Procedure duration and x-ray dose favored the simple approach, the investigators reported.

The investigators concluded that when coronary bifurcation lesions are treated, a systematic two-stent technique results in higher rates of in-hospital and 9-month major adverse cardiovascular events. This difference is largely driven by periprocedural myocardial infarction. Procedure duration is longer and x-ray dose is higher. The provisional technique should remain the preferred strategy in the majority of cases.