Clinical and procedural outcomes of ostial left anterior descending artery intervention with or without crossover to left-main

BACKGROUND: It remains debated whether just ostial stenting (JOS) or crossover stenting (COS) is optimal for isolated ostial lesions of the left anterior descending (LAD) artery, and available comparative data on intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) remains limited. We aim to compare clinical outcomes between the strategies and identify determinants of strategy selection. METHODS AND RESULTS: This retrospective study included 172 patients with isolated ostial LAD lesions who underwent IVI-guided PCI with either JOS (n = 112) or COS (n = 60) between 2018 and 2025. The primary endpoint was two-year major adverse cardiac events (MACEs), defined as all-cause mortality, myocardial infarction, and any revascularization. MACE rates did not differ significantly in both strategies (23% vs.17%; adjusted hazard ratio: 0.74; 95% confidence interval [CI]: 0.37-1.49; P = 0.40). LAD diameter on angiography (odds ratio [OR] 2.04, 95% CI 1.03-4.05, P = 0.040) and LAD proximal reference area measured by IVI (OR 1.26, 95% CI 1.02-1.55, P = 0.033) were independently associated with selecting JOS over COS. Optimal minimum stent areas (MSA) were achieved in most cases in both groups (89% vs. 98%, P = 0.032). CONCLUSIONS: Under IVI-guided PCI, clinical outcomes showed no significant difference between JOS and COS, and LAD anatomy determined the strategy. These findings support individualized, anatomy-driven technique selection and IVI-guided procedural optimization for ostial LAD lesions.