Long-term outcomes of stepwise provisional versus upfront two-stent pci for true distal left main bifurcation lesions: a single-center registry study

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. 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. 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). 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.