Stepwise Provisional Versus Systematic Dual-Stent Strategies for Treatment of True Left Main Coronary Bifurcation Lesions.

Summary

In this multicenter RCT of 467 patients with true unprotected left main bifurcation lesions, stepwise provisional stenting achieved similar 3-year major adverse cardiovascular events compared with systematic upfront dual stenting but significantly reduced target lesion revascularization. Findings support stepwise provisional as the default strategy for noncomplex left main bifurcation PCI.

Key Findings

• No significant difference in 3-year MACE between stepwise provisional and systematic dual-stent strategies.
• Target lesion revascularization was significantly lower with stepwise provisional strategy.
• Events were independently adjudicated; analyses followed intention-to-treat.

Clinical Implications

Adopt stepwise provisional stenting as the default for noncomplex true left main bifurcations, reserving dual-stent techniques for bailout or clearly complex side branch disease.

Limitations

• Open-label design may introduce procedural or operator bias
• European-only enrollment may limit generalizability to other healthcare settings

Future Directions

Head-to-head evaluations stratified by bifurcation complexity and physiological assessment, cost-effectiveness analyses, and operator learning curve effects.