Six-months clinical and intracoronary imaging follow-up after reverse T and protrusion or double-kissing and crush stenting for the treatment of complex left main bifurcation lesions

Amr Ei Abouelnour; Maximilian Olschewski; Giulio Makmur; Helen Ullrich; Maike Knorr; Majid Ahoopai; Thomas Münzel; Tommaso Gori

doi:10.3389/fcvm.2023.1153652

Six-months clinical and intracoronary imaging follow-up after reverse T and protrusion or double-kissing and crush stenting for the treatment of complex left main bifurcation lesions

Front Cardiovasc Med. 2023 Apr 27:10:1153652. doi: 10.3389/fcvm.2023.1153652. eCollection 2023.

Authors

Amr Ei Abouelnour^{1

2}, Maximilian Olschewski¹, Giulio Makmur¹, Helen Ullrich¹, Maike Knorr¹, Majid Ahoopai¹, Thomas Münzel¹, Tommaso Gori¹

Affiliations

¹ University Medical Center Mainz, Department of Cardiology, Mainz, Germany and German Center for Cardiac and Vascular Research (DZHK), Standort Rhein-Main, Germany.
² Department of Cardiovascular Medicine, Assiut University Heart Hospital, Assiut, Egypt.

Abstract

Background: There is a debate regarding the best stent strategy for unprotected distal left main (LM) bifurcation disease. Among two-stent techniques, double-kissing and crush (DKC) is favored in current guidelines but is complex and requires expertise. Reverse T and Protrusion (rTAP) was shown to be a comparable strategy regarding short-term efficacy and safety, but with reduced procedural complexity.

Aim: To compare rTAP vs. DKC by optical coherence tomography (OCT) on the intermediate term.

Methods: 52 consecutive patients with complex unprotected LM stenoses (Medina 0,1,1 or 1,1,1) were randomized to either DKC or rTAP and followed-up for a median of 189[180-263] days for clinical and OCT outcomes.

Results: At follow-up OCT showed similar change in the side branch (SB) ostial area (primary endpoint). The confluence polygon showed a higher percentage of malapposed stent struts in the rTAP group that did not reach statistical significance (rTAP: 9.7[4.4-18.3] % vs. DKC: 3[0.07-10.9] %; p = 0.064). It also showed a trend towards larger neointimal area relative to the stent area (DKC: 8.8 [6.9 to 13.4] % vs. rTAP: 6.5 [3.9 to 8.9] %; p = 0.07), and smaller luminal area (DKC: 9.54[8.09-11.07] mm² vs. rTAP: 11.21[9.53-12.42] mm²; p = 0.09) in the DKC group. The minimum luminal area in the parent vessel distal to the bifurcation was significantly smaller in the DKC group (DKC: 4.64 [3.64 to 5.34] mm² vs. rTAP: 6.76 [5.20 to 7.29] mm²; p = 0.03). This segment also showed a trend for smaller stent areas (p = 0.05 to 0.09), and a bigger neointimal area relative to the stent area (DKC: 8.94 [5.43 to 10.5]% vs. rTAP: 4.75 [0.08 to 8.5]%; p = 0.06) in the DKC patients. The incidence of clinical events was comparably low in both groups.

Conclusion: At 6-months, OCT showed a similar change in the SB ostial area (primary endpoint) in rTAP compared to DKC. There was also a trend for smaller luminal areas in the confluence polygon and the distal parent vessel, and a larger neointimal area relative to the stent area, in DKC, along with a tendency for more malapposed stent struts in rTAP.

Clinical trial registration: https://clinicaltrials.gov/ct2/show/NCT03714750, identifier: NCT03714750.

Keywords: bifurcation; double kissing and crush; left main; optical coherence tomography (OCT); reverse t and protrusion.

Associated data

ClinicalTrials.gov/NCT03714750

Grants and funding

Open Access funding enabled and organized by Projekt DEAL. This study received funding from the Deutsches Zentrum für Herz und Kreislauf Forschung through the professorship of TG.