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

ct Objectives. The purpose of this study was to compare the immediate angiographic and long-term results of debulking versus balloon angioplasty for treatment of true bifurcation lesions. Background. Previous studies have shown true bifurcation lesions to be high risk morphological subset for percutaneous transluminal coronary angioplasty (PTCA). Although atherectomy devices have been used to treat bifurcation lesions, no studies have compared the outcomes of these alternative treatment modalities. Methods. Between January 1992 and May 1997, we treated 70 consecutive patients with true bifurcation lesions (defined as greater than 50% stenosis in both the parent vessel and contiguous side branch) with conventional PTC (n = 30) or debulking (with rotational or directional atherectomy) plus adjunctive PTC (n = 40). Paired angiograms were analyzed by quantitative angiography, and clinical follow-up was obtained in all patients. Results. Acute procedural success was 73% in the PTC group and 97% in the debulking group (p = 0.01). Major in-hospital complications occurred in two patients in the PTC group and one in the debulking group. Treatment with atherectomy plus PTC resulted in lower postprocedure residual stenoses than PTC 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 year follow-up, the incidence of target vessel revascularization (TVR) was 53% in the PTC group as compared with 28% in the debulking group (p = 0.05). Independent predictors of the need for repeat TVR were side branch diameter >2.3 mm, longer lesion lengths, and treatment with PTC alone. Conclusions. For the treatment of true bifurcation lesions, atherectomy with adjunctive PTC is safe, improves acute angiographic results, and decreases target vessel revascularization compared to PTC alone. The benefits of debulking for bifurcation lesions were especially seen in lesions involving large side branches.