Bifurkasyon Stentlemede Antitrombotik Tedavi
Özet
Bifurkasyon lezyonlarında perkütan koroner girişim (PKG), bifurkasyon olmayan lezyonlara kıyasla daha düşük prosedür başarısı ve yüksek komplikasyon riskleri taşımaktadır. Mevcut kılavuzlar provizyonel stentlemeyi ön planda önerse de olguların %5-25'inde yan dal için ikinci bir stent gerekebilmekte ve bu durum stent trombozu riskini yaklaşık iki kat artırmaktadır. Stentleme sonrası aspirin ve bir P2Y12 inhibitörünü (klopidogrel, tikagrelor, prasugrel) içeren ikili antiplatelet tedavi (İAPT) standart yaklaşımı oluştururken, özellikle akut koroner sendromlu hastalarda klopidogrele kıyasla prasugrel ve tikagrelor gibi potent oral ajanlar ön plana çıkmaktadır. İAPT süresinin belirlenmesinde hastanın iskemik ve kanama risklerinin bireyselleştirilmiş bir algoritma ile değerlendirilmesi kritik öneme sahiptir. DAPT ve PRECISE-DAPT skorlamalarının yanı sıra, ARC kriterleri yüksek kanama riskini öngörmede etkin şekilde kullanılmaktadır. Son dönemde, kanama riskini azaltmak amacıyla kısa süreli İAPT kullanımının ardından tikagrelor gibi antiplatelet monoterapilerine geçiş veya oral antikoagülan ihtiyacı olan hastalarda üçlü yerine ikili antitrombotik tedaviler tercih edilmektedir. Ayrıca, optik koherens tomografi (OCT) ve intravasküler ultrason (IVUS) gibi intrakoroner görüntüleme yöntemleri, stent apozisyonunu optimize ederek daha kısa süreli İAPT stratejilerine güvenle olanak tanımaktadır. Sonuç olarak, bifurkasyon PKG sonrası antitrombotik tedavi yönetimi, hasta bazlı risk-yarar dengesi gözetilerek tamamen kişiselleştirilmelidir.
Percutaneous coronary intervention (PCI) for bifurcation lesions is associated with lower procedural success and higher complication rates compared to non-bifurcation lesions. Although current guidelines recommend the provisional stenting technique as the primary approach, a second stent is required in 5-25% of cases, which significantly increases the risk of stent thrombosis. Dual antiplatelet therapy (DAPT), combining aspirin and a P2Y12 inhibitor, represents the standard treatment after drug-eluting stent implantation, with potent agents like prasugrel and tikagrelor preferred over clopidogrel in acute coronary syndrome patients. Determining the optimal DAPT duration requires an individualized risk assessment balancing ischemic and bleeding risks. While scoring systems like DAPT and PRECISE-DAPT assist in this evaluation, the ARC criteria provide a well-correlated framework for identifying high bleeding risk. Recently, dropping aspirin after a short course of DAPT to continue with P2Y12 inhibitor monotherapy, or utilizing dual antithrombotic regimens in patients requiring oral anticoagulants, has emerged to reduce bleeding without increasing ischemic events. Additionally, intracoronary imaging modalities, including intravascular ultrasound (IVUS) and optical coherence tomography (OCT), optimize stent deployment and may guide safer, shorter DAPT durations. Ultimately, antithrombotic management after bifurcation PCI must be tailored to the patient's specific clinical and anatomical characteristics.
Referanslar
Burzotta F, Lassen J, Lefèvre T, et al. Percutaneous coronary intervention for bifurcation coronary lesions: the 15th consensus document from the European Bifurcation Club [online]. https://eurointervention.pcronline.com/article/percutaneouscoronaryinterventionforbifurcationcoronary-lesionsthe15thconsensus-document-from-the-european-bifurcation-club EuroIntervention. [accessed 20th May 2022].
Grundeken MJ, Wykrzykowska JJ, Ishibashi Y, et al. First generation versus second generation drug-eluting stents for the treatment of bifurcations: 5-year follow-up of the LEADERS all-comers randomized trial. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2016; 87(7): E248-260.
Gao XF, Zhang YJ, Tian NL, et al. Stenting strategy for coronary artery bifurcation with drug-eluting stents: a meta-analysis of nine randomised trials and systematic review. EuroIntervention J Eur Collab Work Group Interv Cardiol Eur Soc Cardiol. 2014; 10(5): 561-9.
Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019; 40(2): 87-165.
Zimarino M, Renda G, De Caterina R. Optimal duration of antiplatelet therapy in recipients of coronary drug-eluting stents. Drugs. 2005; 65(6): 725-32.
Zimarino M, Angiolillo DJ, Dangas G, et al. Antithrombotic therapy after percutaneous coronary intervention of bifurcation lesions. EuroIntervention J Eur Collab Work Group Interv Cardiol Eur Soc Cardiol. 2021; 17(1): 59-66.
Zimarino M, Barbato E, Nakamura S, et al. The impact of the extent of side branch disease on outcomes following bifurcation stenting. Catheter Cardiovasc Interv. 2020; 96(1): E84-92.
Giustino G, Chieffo A, Palmerini T, et al. Efficacy and Safety of Dual Antiplatelet Therapy After Complex PCI. J Am Coll Cardiol. 2016; 68(17): 1851-64.
Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2018; 39(3): 213-60.
Cannon CP, Harrington RA, James S, et al. Comparison of ticagrelor with clopidogrel in patients with a planned invasive strategy for acute coronary syndromes (PLATO): a randomised double-blind study. Lancet Lond Engl. 2010; 375(9711): 283-93.
Wiviott SD, Braunwald E, McCabe CH, et al. Intensive oral antiplatelet therapy for reduction of ischaemic events including stent thrombosis in patients with acute coronary syndromes treated with percutaneous coronary intervention and stenting in the TRITON-TIMI 38 trial: a subanalysis of a randomised trial. Lancet Lond Engl. 2008; 371(9621): 1353-63.
Schüpke S, Neumann FJ, Menichelli M, et al. Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. N Engl J Med. 2019; 381(16): 1524-34.
Collet JP, Thiele H, Barbato E, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42(14): 1289-367.
Stone GW, Généreux P, Harrington RA, et al. Impact of lesion complexity on peri-procedural adverse events and the benefit of potent intravenous platelet adenosine diphosphate receptor inhibition after percutaneous coronary intervention: core laboratory analysis from 10 854 patients from the CHAMPION PHOENIX trial. Eur Heart J. 2018; 39(46): 4112-21.
Song PS, Song YB, Yang JH, et al. Triple versus dual antiplatelet therapy after percutaneous coronary intervention for coronary bifurcation lesions: results from the COBIS (COronary BIfurcation Stent) II Registry. Heart Vessels. 2015; 30(4): 458-68.
Kang J, Han JK, Yang HM, et al. Comparison of 2-Stenting Strategies Depending on Sequence or Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era - Analysis From the COBIS (Coronary Bifurcation Stenting) III Registry. Circ J Off J Jpn Circ Soc. 2021; 85(11): 1944-55.
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation. 2016; 134(10): e123-155.
De Filippo O, Kang J, Bruno F, et al. Benefit of Extended Dual Antiplatelet Therapy Duration in Acute Coronary Syndrome Patients Treated with Drug Eluting Stents for Coronary Bifurcation Lesions (from the BIFURCAT Registry). Am J Cardiol. 2021; 156: 16-23.
Cirillo P, DI Serafino L, Gamra H, et al. Impact of dual antiplatelet therapy duration on clinical outcome after coronary bifurcation stenting: results from the Euro Bifurcation Club registry. Panminerva Med [online]. [accessed 31th July 2022] https://europepmc.org/article/med/35546730
Rhee TM, Park KW, Kim CH, et al. Dual Antiplatelet Therapy Duration Determines Outcome After 2- But Not 1-Stent Strategy in Left Main Bifurcation Percutaneous Coronary Intervention. JACC Cardiovasc Interv. 2018; 11(24): 2453-63.
Yeh RW, Kereiakes DJ, Steg PG, et al. Lesion Complexity and Outcomes of Extended Dual Antiplatelet Therapy After Percutaneous Coronary Intervention. J Am Coll Cardiol. 2017; 70(18): 2213-23.
Vranckx P, Valgimigli M, Jüni P, et al. Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial. The Lancet. 2018; 392(10151): 940-9.
Kogame N, Chichareon P, De Wilder K, et al. Clinical relevance of ticagrelor monotherapy following 1-month dual antiplatelet therapy after bifurcation percutaneous coronary intervention: Insight from GLOBAL LEADERS trial. Catheter Cardiovasc Interv. 2020; 96(1): 100-11.
Dangas G, Baber U, Sharma S, et al. Ticagrelor With or Without Aspirin After Complex PCI. J Am Coll Cardiol. 2020; 75(19): 2414-24.
Kerneis M, Gibson CM, Chi G, et al. Effect of Procedure and Coronary Lesion Characteristics on Clinical Outcomes Among Atrial Fibrillation Patients Undergoing Percutaneous Coronary Intervention: Insights From the PIONEER AF-PCI Trial. JACC Cardiovasc Interv. 2018; 11(7): 626-34.
Berry NC, Mauri L, Steg PG, et al. Effect of Lesion Complexity and Clinical Risk Factors on the Efficacy and Safety of Dabigatran Dual Therapy Versus Warfarin Triple Therapy in Atrial Fibrillation After Percutaneous Coronary Intervention: A Subgroup Analysis From the REDUAL PCI Trial. Circ Cardiovasc Interv. 2020; 13(4): e008349.
Horie K, Matsumoto T, Mizutani Y, et al. A prospective interventional registry of short-term dual-antiplatelet treatment after implantation of drug-eluting stents in patients with atrial fibrillation requiring oral anticoagulation therapy. Cardiovasc Interv Ther. 2020; 35(2): 150-61.
Nakamura M, Yaku H, Ako J, et al. JCS/JSCVS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J Off J Jpn Circ Soc. 2022; 86(3): 477-588.
Lee SY, Kim JS, Yoon HJ, et al. Early Strut Coverage in Patients Receiving Drug-Eluting Stents and its Implications for Dual Antiplatelet Therapy: A Randomized Trial. JACC Cardiovasc Imaging. 2018; 11(12): 1810-9.
Worthley SG, Abizaid A, Kirtane AJ, et al. First-in-Human Evaluation of a Novel Polymer-Free Drug-Filled Stent: Angiographic, IVUS, OCT, and Clinical Outcomes From the RevElution Study. JACC Cardiovasc Interv. 2017;10(2): 147-56.
