BMC cardiovascular disorders · 2026
Long-term outcomes of stepwise provisional versus upfront two-stent strategies for true distal left main bifurcation lesions: a single-center registry study.
СтатьяСравнительное исследованиеНаблюдательное исследованиеНазвание и аннотация: Перевод в очереди
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Kumar Prathap, Toukami Youness, Rajendran Manu, Katragadda Abhiram, Hussein Thaha Mohamed, Ghimire Roshan, Jino Blessvin
Аннотация
BACKGROUND: Randomized trials in true distal left main (LM) bifurcation PCI have shown broadly comparable outcomes between stepwise provisional and planned two-stent strategies. We evaluated long-term clinical outcomes and procedural patterns in a contemporary real-world cohort.
METHODS: We analyzed a single-center registry of patients with true distal LM bifurcation lesions (Medina 1,1,1; 1,0,1; or 0,1,1) treated with either a stepwise provisional or an upfront two-stent strategy. The primary endpoint was major adverse cardiovascular events (MACE), defined as all-cause death, myocardial infarction, or target lesion revascularization (TLR). Stabilized inverse probability of treatment weighting (IPTW) was used as a sensitivity analysis for the primary strategy comparison. To address the nonrandomized use of intravascular imaging, we also performed a post hoc propensity score-weighted analysis for imaging guidance including age, sex, diabetes, chronic kidney disease, left ventricular ejection fraction, SYNTAX score, ACS presentation, and initial stent strategy.
RESULTS: Among 214 patients (provisional n = 106; two-stent n = 108) with a median follow-up of 25 months (IQR 8-50), upfront two-stent cases more frequently used intravascular imaging and kissing balloon inflation (both p < 0.001). MACE occurred in 17.9% versus 16.7% of patients in the provisional and two-stent groups, respectively (RR 1.08, 95% CI 0.60-1.93; p = 0.86). All-cause mortality was similar (13.2% vs. 12.0%; p = 0.79). Findings were consistent after IPTW adjustment (adjusted RR 1.19, 95% CI 0.58-2.44; p = 0.63). In crude exploratory analyses, imaging-guided PCI was associated with lower MACE and TLR than angiography-guided PCI alone; however, this association was attenuated after propensity score weighting (weighted RR for MACE 0.74, 95% CI 0.39-1.42; weighted RR for TLR 0.23, 95% CI 0.04-1.48).
CONCLUSIONS: In this real-world cohort of true distal LM bifurcation PCI, stepwise provisional and upfront two-stent strategies were associated with similar long-term outcomes. These data support anatomy-driven strategy selection and meticulous procedural optimization. The crude association between imaging guidance and lower adverse events was attenuated after adjustment and should be interpreted as hypothesis-generating.
METHODS: We analyzed a single-center registry of patients with true distal LM bifurcation lesions (Medina 1,1,1; 1,0,1; or 0,1,1) treated with either a stepwise provisional or an upfront two-stent strategy. The primary endpoint was major adverse cardiovascular events (MACE), defined as all-cause death, myocardial infarction, or target lesion revascularization (TLR). Stabilized inverse probability of treatment weighting (IPTW) was used as a sensitivity analysis for the primary strategy comparison. To address the nonrandomized use of intravascular imaging, we also performed a post hoc propensity score-weighted analysis for imaging guidance including age, sex, diabetes, chronic kidney disease, left ventricular ejection fraction, SYNTAX score, ACS presentation, and initial stent strategy.
RESULTS: Among 214 patients (provisional n = 106; two-stent n = 108) with a median follow-up of 25 months (IQR 8-50), upfront two-stent cases more frequently used intravascular imaging and kissing balloon inflation (both p < 0.001). MACE occurred in 17.9% versus 16.7% of patients in the provisional and two-stent groups, respectively (RR 1.08, 95% CI 0.60-1.93; p = 0.86). All-cause mortality was similar (13.2% vs. 12.0%; p = 0.79). Findings were consistent after IPTW adjustment (adjusted RR 1.19, 95% CI 0.58-2.44; p = 0.63). In crude exploratory analyses, imaging-guided PCI was associated with lower MACE and TLR than angiography-guided PCI alone; however, this association was attenuated after propensity score weighting (weighted RR for MACE 0.74, 95% CI 0.39-1.42; weighted RR for TLR 0.23, 95% CI 0.04-1.48).
CONCLUSIONS: In this real-world cohort of true distal LM bifurcation PCI, stepwise provisional and upfront two-stent strategies were associated with similar long-term outcomes. These data support anatomy-driven strategy selection and meticulous procedural optimization. The crude association between imaging guidance and lower adverse events was attenuated after adjustment and should be interpreted as hypothesis-generating.