Keep it simple

Many years after the release of the first large randomized trial, there is still wide discussion regarding the best treatment of coronary bifurcations in both left main and nonleft main settings. Studies of coronary bifurcation lesions have shown no advantage of systematic two‐stent strategies over one‐stent strategies. Non‐randomized data suggest worse outcomes with a two‐stent strategy, while randomized data support the double kissing crush technique for left main disease over culotte technique. The European Bifurcation Club Left Main Coronary Stent Study (EBC MAIN) compared the clinical outcomes of the two strategies, one‐ and two‐stent, in patients with distal left main lesions. Although with non‐statistically significant differences, patients with left main stenosis in a true bifurcation lesion treated with a stepwise layered provisional stenting (PS) experienced fewer major adverse cardiac events than a more complex planned dual stenting, with the PS approach requiring the use of a second stent in only 20% patients. PS is therefore recommended by the European Bifurcation Club (EBC) as the upfront strategy of choice in the treatment of coronary bifurcation lesions, whether using a one‐ or a two‐stent approach, with the goal of keeping the procedure as simple as possible and minimizing the number of stents needed in a bifurcation lesion. The multicenter, randomized Two‐stent versus Provisional Stenting Techniques for Patients with Complex Coronary Bifurcation Lesions (DEFINITION‐II) trial documented an advantage of the two‐stent strategy in complex bifurcations where it was associated with a significant benefit in clinical outcomes compared with the PS approach. In this issue of Catheterization and Cardiovascular Interventions, Arunothayaraj and colleagues, analyzed the procedural and outcome data of 438 patients with left main bifurcation lesion randomized to a PS or two‐stent strategy (T, T‐and‐protrude, or culotte) with the aim of identifying technical variables influencing procedural outcomes and periprocedural myocardial infarction. EBC recommends the systematic use of the “jailing wire” technique. This technique, in this sub‐study, was associated with an independently increased chance of successful side vessel (SV) rewiring. Failure to rewire the jailed SV occurred in 3.9% of cases and was strongly associated with the absence of jailed wire use (9.5% vs. 2.5%, odds ratio 6.4, 95% confidence interval 2.0–20.7). The absence of both jailed wire use and SV preparation led to very high rates of rewiring failure (16.1%). Furthermore, jailed wires have been reported to aid recovery of SV flow and act as an ostial marker with a potential bifurcation optimization effect for re‐accessing. The proximal optimization technique is another crucial step in the treatment of coronary bifurcations, a protective factor in terms of target lesion failure that reduced the need for further SV intervention without influence SV re‐access rates in this study. Although currently available data do not support the routine use of kissing balloon inflation (KBI), this technique can reduce target lesion revascularizations, as already demonstrated in other studies. Authors demonstrated that KBI with noncompliant balloons improved stent expansion, reduced SV stenting and avoided balloon overexpansion at high pressures with a significant reduction in periprocedural myocardial infarction.