Provisional vs dedicated bifurcation strategy in unprotected Left main disease: A Randomized study

Optimal treatment of coronary bifurcation anatomy remains a subject of debate. Trials of all-comer bifurcation lesions have shown no advantage of dedicated bifurcation strategies and indeed that long-term mortality may be worse with a more complex approach.

For the left main stem, non-randomized data uniformly suggests that outcomes are worse with a two-stent strategy, but randomized data support the double kissing (DK) crush technique for true bifurcation left main stem disease. The European Bifurcation Club Left Main Coronary Stent Study (EBC MAIN) was designed to examine clinical outcomes in patients with distal bifurcation left main stem lesions undergoing intervention, randomly allocated to either a provisional stent strategy, or a dedicated bifurcation stenting strategy.

Four hundred and sixty-seven patients with true left main stem bifurcation lesions requiring intervention were recruited to the EBC MAIN study in 11 European countries. Patients were randomly allocated to a stepwise layered provisional strategy or a systematic dual stent approach.

The primary endpoint of the study was a composite of all-cause death, myocardial infarction, and target lesion revascularization at 12months. Secondary endpoints were the individual components of the primary endpoint, angina status, angina medication, and adjudicated stent thrombosis.

Outcomes of the study are

1) There was no difference between groups at 1 year in terms of death, myocardial infarction, target lesion revascularization, or the composite of the three (the primary endpoint).

2) Periprocedural myocardial infarction outcomes were underscored by recording of CK, CK-MB, or troponin.

Authors concluded that among patients with true bifurcation left main stem stenosis requiring intervention, fewer major adverse cardiac events occurred with provisional approach than with planned dual stenting, although the difference was not statistically significant.

The main study of comparison is the DKCRUSH-V trial published in 2017 where outcomes were in favour of dedicated bifurcation strategy. Some of reasons for these conflicting results are

1) DKCRUSH-V study used cardiac death and target vessel-related myocardial infarction rather than death and myocardial infarction

2) Different Syntax score [31 in DK crush vs. 23 in EBC MAIN] and the side-vessel lesion lengths [16mm in DK crush vs. 7mm in EBC MAIN]

Source: European Heart Journal. doi:10.1093/eurheartj/ehab283