Background:
Coronary CT angiography (CCTA) provides high-resolution noninvasive assessment of coronary anatomy and plaque morphology and may therefore be an optimal tool to support procedural planning for percutaneous coronary intervention (PCI). While CCTA-guided planning has been investigated for fluoroscopic view selection and chronic total occlusion PCI, its value for predicting stenting strategy in coronary bifurcation lesions remains insufficiently defined.
Objective:
To identify CCTA-derived predictors of a one- versus two-stent strategy in PCI of bifurcation lesions involving the left anterior descending coronary artery and a diagonal branch.
Methods:
We retrospectively included 65 patients who underwent CCTA within 3 months before PCI of an LAD/diagonal branch bifurcation lesion at two German cardiac care units. CCTA datasets were analyzed using dedicated CT-guided PCI software. Candidate predictors from CCTA included bifurcation angle, Medina classification, carina plaque, plaque composition, lesion length, plaque volume, side-branch diameter, stenosis severity, minimal luminal area, and CT-derived fractional flow reserve. The primary endpoint was the use of a two-stent strategy. Predictors were assessed using univariate and multivariable logistic regression. Discriminatory performance was determined by receiver-operating characteristic analysis.
Results:
Of 65 patients, 44 underwent a one-stent strategy and 21 underwent a two-stent strategy. Baseline clinical characteristics were comparable between groups. CCTA markers of lesion complexity were significantly associated with two-stent PCI. Carina plaque was more frequent in the two-stent group and was associated with markedly increased odds of a two-stent strategy (odds ratio [OR] 6.57, 95% confidence interval [CI] 1.69–25.55; p=0.007). Side-branch stenosis severity was also strongly associated with two-stent PCI, both by area stenosis (median 80% vs. 47%; OR per 10% increase 1.53, 95% CI 1.17–1.99; p=0.002) and diameter stenosis (median 58% vs. 31%; OR per 10% increase 1.61, 95% CI 1.20–2.16; p=0.002). Smaller minimal side-branch area was associated with two-stent treatment (0.6 vs. 1.3 mm²; OR 0.33, 95% CI 0.14–0.79; p=0.013). Aggregated plaque volume was higher in patients treated with a two-stent strategy (433.0 vs. 270.5 mm³; OR per 100 mm³ 1.43, 95% CI 1.06–1.91; p=0.018). In parsimonious multivariable models, carina plaque and side-branch stenosis remained independently associated with two-stent PCI, whereas aggregated plaque volume lost statistical significance. A model incorporating carina plaque, side-branch stenosis, and aggregated plaque volume yielded good discrimination for two-stent strategy selection, with an area under the curve of 0.85. Procedural duration was longer in the two-stent group (110 vs. 86 minutes; p=0.003), while contrast volume and radiation dose were numerically but not significantly higher.
Conclusion:
In patients undergoing PCI of LAD/diagonal branch bifurcation lesions, CCTA-derived carina plaque and side-branch stenosis severity are strong predictors of a two-stent strategy. These findings support the potential role of CCTA for preprocedural bifurcation PCI planning and warrant prospective validation in larger cohorts.
