Mechanical debulking versus balloon angioplasty for the treatment of true bifurcation lesions

Objectives. The purpose of this study was to compare the immediate angiogra phic and long-term results of debulking versus balloon angioplasty for trea tment of true bifurcation lesions. Background. Previous studies have shown true bifurcation lesions to be a hi gh risk morphological subset for percutaneous transluminal coronary angiopl asty (PTCA). Although atherectomy devices have been used to treat bifurcati on lesions, no studies have compared the outcomes of these alternative trea tment modalities. Methods. Between January 1992 and May 1997, we treated 70 consecutive patie nts viith true bifurcation lesions (defined as a greater than 50% stenosis in both the parent vessel and contiguous side branch) with conventional PTC A (n = 30) or debulking (with rotational or directional atherectomy) plus a djunctive PTCA (n = 40). Paired angiograms were analyzed by quantitative an giography, and clinical follow-up was obtained in all patients. Results. Acute procedural success was 73% in the PTCA group and 97% in the debulking group (p = 0.01). Major in-hospital complications occurred in two patients in the PTCA group and one in the debulking group. Treatment with atherectomy plus PTCA resulted in lower postprocedure residual stenoses tha n PTCA alone (16 +/- 15% vs. 33 +/- 17% in the parent vessel, and 6 +/- 15% vs. 39 +/- 22% in the side branch; p < 0.001 for both comparisons). At 1 y ear follow-up, the incidence of target vessel revascularization (TVR) was 5 3% in the PTCA group as compared with 28% in the debulking group (p = 0.05) , Independent predictors of the need for repeat TVR were side branch diamet er >2.3 mm, longer lesion lengths, and treatment with PTCA alone. Conclusions. For the treatment of true bifurcation lesions, atherectomy wit h adjunctive PTCA is safe, improves acute angiographic results, and decreas es target vessel revascularization compared to PTCA alone. The benefits of debulking for bifurcation lesions were especially seen in lesions involving large side branches. (J Am Coll Cardiol 1998;32:1845-52) (C)1998 by the Am erican College of Cardiology.