Abordaje de las lesiones en bifurcación con aterectomía rotacional: estudio piloto aleatorizado

Introduction and objectives: Coronary bifurcation lesions are a common scenario in our interventional practice and can be challenging for our routine clinical practice. Yet despite the existence of well-defined techniques, side-branch compromise is still the most important problem. Currently, the standard strategy recommended is a 1-stent technique: balloon angioplasty and provisional stenting. Published non-randomized data reveal that in up to 26% of the cases the indication for rotational atherectomy was to preserve the side-branch. A randomized comparison between rotational atherectomy and provisional stenting (RAPS) and standard strategy (SS) for the management of bifurcation lesions is needed at this point. Methods: We conducted a single center, prospective, randomized pilot study of consecutive patients from our center with bifurcation lesions. We compared the RAPS strategy to the SS. Lesions had to be located in the main vessel only. The bifurcation lesion angle was recorded. The primary endpoint was the need for side-branch therapy. Results: 148 patients were included: 74 patients (95 rotational atherectomy) were enrolled in the RAPS group and 74 patients in the SS group. The bifurcation lesion most frequently treated was that of the proximal left anterior descending coronary artery. The primary endpoint was lower in the RAPS group compared to the SS group (1.1 vs 31.2%; P < .001). Target vessel failure (TVF) was 13.1% and 24.8% (P = .04) in RAPS and SS, respectively. Both the primary endpoint and TVF were higher with bifurcation lesion angles < 70º compared to bifurcation lesion angles ≥ 70º (P = .03 and P = .02) in both groups. Conclusions: The need for side-branch therapy and TVF was lower when the RAPS strategy was used compared to the SS. Bifurcation lesion angles < 70º are associated with higher side-branch compromise and TVF rates. The SS was associated with a 4.92-fold higher risk of side-branch compromise compared to the RAPS strategy with bifurcation lesion angles < 70º. These data reinforce the idea of the overall clinical relevance of the RAPS strategy regarding the patency of the side-branch. Introducción y objetivos: Durante el intervencionismo coronario percutáneo es frecuente observar lesiones coronarias que afectan a las bifurcaciones. El compromiso de la rama lateral es la principal complicación observada con las diversas técnicas descritas para su tratamiento. La estrategia convencional (EC) recomendada en la actualidad es la col