Comparative Efficacy of Bifurcation Stenting Techniques for Left Main Disease: A Network Meta-analysis With Reconstructed Time-to-Event Data.

BACKGROUND

Percutaneous coronary intervention for distal left main bifurcation disease remains technically challenging owing to complex anatomy and high ischemic risk. Although multiple stenting techniques exist, the optimal approach is uncertain.

METHODS

Eligible strategies comprised provisional stenting, double-kissing (DK) crush, classic crush, minicrush, culotte, T-stenting, TAP, and nanocrush. The primary outcome was all-cause mortality. Secondary outcomes included cardiac death, myocardial infarction, stent thrombosis, target lesion revascularization, target vessel revascularization, and major adverse cardiovascular events (MACE). A frequentist random-effects network meta-analysis estimated hazard ratios (HRs) with 95% CIs, ranking treatments by P scores. Coherence was evaluated using node-splitting analyses. Individual-patient data were reconstructed from Kaplan-Meier curves for time-to-event outcomes.

RESULTS

Fifteen studies (3794 patients) were included. DK crush consistently ranked highest for most efficacy and safety outcomes. Compared with classic crush, DK crush was associated with lower risks of myocardial infarction (HR, 0.40; 95% CI, 0.17-0.91), target lesion revascularization (HR, 0.35; 95% CI, 0.15-0.84), target vessel revascularization (HR, 0.30; 95% CI, 0.16-0.57), and MACE (HR, 0.46; 95% CI, 0.32-0.66). Culotte stenting was associated with a higher risk of stent thrombosis (HR, 3.30; 95% CI, 1.07-10.13). No significant differences were observed among strategies for all-cause or cardiac mortality (P > .05). Node-splitting analyses demonstrated no evidence of important local inconsistency.

CONCLUSIONS

DK crush appears to provide the most effective and durable bifurcation strategy for distal left main percutaneous coronary intervention, reducing ischemia-driven revascularization and MACE. Findings support its preferential use in anatomically complex lesions, provided operator expertise and long-term follow-up are ensured.