Treatment of Coronary Bifurcation Lesions with "T"
and "Y" Stenting: Acute Results and Long Term Clinical Follow-Up. M.R.
Adams, T. Fukutomi, G. J. Blake, M.V. Wainstein, R. Prpic, J. J. Popma. Department
of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, U.S.A. Interventional
treatment of true bifurcation lesions is controversial, and is associated with
a high procedural complication rate. We examined the immediate and long-term
results in 33 consecutive bifurcation lesions treated with a "T" or "Y"
stenting approach. Over a 12-month period 1505 patients were
treated with intracoronary stent placement. Stenting of true bifurcation
lesions was attempted in 72 cases. In 33 cases planned "Y" stenting (11) or "T"
stenting (22) was attempted. Platelet glycoprotein IIb/IIIa inhibitors were
used in 85% of cases and all patients received aspirin and either ticlopidine
or clopidogrel, 24% received 2 weeks of enoxaparin post procedure. The initial
procedural results and the long-term clinical outcomes were assessed in these
patients. Procedures were performed in the setting of
myocardial infarction in 3 patients, unstable angina in 20 and stable angina in
10. The vessels involved were left main bifurcation in 1, LAD/diagonal in 13,
Circumflex/Marginal in 14, and distal RCA bifurcation in 5. Procedural success
was obtained in 100% of cases, with an average of 2.85±0.9 stents per lesion. There were two episodes of transient vessel
closure, but no other procedural complications. No patients had electrocardiographic
evidence of infarction, although 5 patients (16.7%) had a procedure-related
increase in CK post-procedure (mean total CK rise 544±310iU/L). The mean clinical follow-up was 7.2±3.4 months. There were no deaths, and 22 (67%) patients were event free
at follow-up. There were 3 episodes of in-stent thrombosis occurring within the
first month (time to event 8±9 days), and there were 6 cases of restenosis
requiring repeat revascularization (2 requiring coronary artery bypass grafts),
occurring a mean of 36±39 days post-procedure. There was a
significant relationship between diabetes and recurrent cardiovascular events
(event rate 80% in diabetics versus 25% in non-diabetics, p=0.01). Bifurcation stenting with a "T" or "Y"
technique is associated with a high rate of procedural and early complications,
although the late complication rate is acceptable in non-diabetics. The high
rate of late events in diabetic patients suggests that alternative therapies
should be considered.
