Stenting strategy for coronary artery bifurcation with drug-eluting stents: a meta-analysis of nine randomised trials and systematic review

Aims: The present study sought to compare angiographic and clinical outcomes of a simple strategy versus a complex strategy in patients with coronary bifurcation lesions undergoing drug-eluting stent implantation. Methods and results: Medline, the Cochrane Library, and other internet sources were searched for randomised trials comparing simple strategy versus complex strategy for treating patients with bifurcation lesions. Nine eligible randomised trials including 2,569 patients were identified. The meta-analysis showed that cardiac death (odds ratio [OR]: 0.99, 95% confidence interval [CI]: 0.40-2.41, p=0.98) and stent thrombosis (OR: 0.64, 95% CI: 0.31-1.34, p=0.24) were similar in the simple and the complex strategy. Compared with the complex strategy, the simple strategy was associated with a reduced risk of either early or follow-up myocardial infarction (OR: 0.53, 95% CI: 0.36-0.79, p=0.002; OR: 0.60, 95% CI: 0.43-0.86, p=0.01, respectively). The overall risks of side branch restenosis (OR: 1.44, 95% CI: 0.73-2.87, p=0.30), target lesion (OR: 1.72, 95% CI: 0.95-3.12, p=0.07) and target vessel revascularisation (OR: 1.59, 95% CI: 0.94-2.69, p=0.09) were comparable between the two groups. In the true bifurcation, with large side branches, and DK-crush subgroups, there were higher rates of reintervention seen in the simple strategy than in the complex strategy. Conclusions: A complex strategy remains an optional treatment for patients with coronary bifurcation lesions without severe safety concerns. A complex strategy may be an optimal treatment for true bifurcation lesions with large side branches.