title: Five-year clinical follow-up of unprotected left main bifurcation lesion stenting: one-stent versus two-stent techniques versus double-kissing crush technique.
abstract: OBJECTIVE
  The present study aimed to compare the long-term (five-year) safety and efficacy between the one-stent, two-stent and double-kissing (DK) crush strategies, utilising drug-eluting stents, for unprotected left main coronary artery (ULMCA) bifurcation lesions.
  
  
  RESULTS
  Between March 2004 and April 2007, 633 consecutive patients with ULMCA bifurcation lesions (232 in the one-stent group and 401 in the two-stent group) were prospectively enrolled. The primary endpoint was the occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction (MI), and target vessel revascularisation (TVR), at five-year follow-up. Patients in the the two-stent group were classified as DK crush (n=155) and other two-stent techniques (culotte, T-stenting, kissing stenting and classical crush, n=246). Forty-seven (16.8%) patients in the one-stent group crossed over to the two-stent group. The one-stent group was associated with an increased incidence of MI compared to the two-stent approach (10.5% vs. 5.5%, p=0.025). The crude rate of MACE at five years was 28.0% in the one-stent group and 28.4% in the two-stent group (p=0.927). DK crush was associated with a significantly decreased five-year MACE compared to the other two-stent approaches or the one-stent approach (DK crush: 14.8% vs. other two-stent approaches: 37.0%, one-stent approach: 28.0%, p<0.001). The main benefit of DK crush primarily appeared to be secondary to a reduction in TVR (7.7% vs. 30.5% vs. 18.1%, p<0.001). By Cox regression analyses, the non-DK crush two-stent technique, a high SYNTAX Score (≥33) or New Risk Stratification (NERS) score (>20), and incomplete revascularisation were shown to be independent predictors of MACE at five-year follow-up.
  
  
  CONCLUSIONS
  With distal left main true bifurcations, the two-stent technique (excluding DK crush) is an independent predictor of long-term MACE. DK crush is associated with more favourable long-term clinical outcomes. Confirmation of these findings is required from randomised controlled trials.
authors.affiliation: Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China. chmengx@126.com
authors.forename: Shao-Liang
authors.initials: SL
authors.lastname: Chen
authors.forename: Yaojun
authors.initials: Y
authors.lastname: Zhang
authors.forename: Bo
authors.initials: B
authors.lastname: Xu
authors.forename: Fei
authors.initials: F
authors.lastname: Ye
authors.forename: Junjie
authors.initials: J
authors.lastname: Zhang
authors.forename: Nailiang
authors.initials: N
authors.lastname: Tian
authors.forename: Zhizhong
authors.initials: Z
authors.lastname: Liu
authors.forename: XueSong
authors.initials: X
authors.lastname: Qian
authors.forename: Shiqing
authors.initials: S
authors.lastname: Ding
authors.forename: Feng
authors.initials: F
authors.lastname: Li
authors.forename: Aiping
authors.initials: A
authors.lastname: Zhang
authors.forename: Yueqiang
authors.initials: Y
authors.lastname: Liu
authors.forename: Song
authors.initials: S
authors.lastname: Lin
mesh_terms: D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods* / Q000401:mortality; D016009:Chi-Square Distribution; D002681:China / Q000453:epidemiology; D017023:Coronary Angiography; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D018572:Disease-Free Survival; D054855:Drug-Eluting Stents; D005260:Female; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011474:Prosthesis Design; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome