Provisional or 2-Stent Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era

Background: For bifurcating coronary lesions, a provisional stent technique is recommended compared with a routine 2-stent strategy. However, much of these data are from trials involving first-generation drug-eluting stents (DES) or bare-metal stents where the risk of restenosis with the 2-stent technique is higher. We investigated the efficacy of various 2-stent techniques versus a provisional stent technique for bifurcation lesions with newer-generation DES. Methods: PubMed and Embase were searched through May 2022 for randomized control trials investigating bifurcation percutaneous coronary intervention techniques using newer-generation DES, and a meta-analysis was conducted. The primary end point was major adverse cardiovascular events (MACE) at the longest reported follow-up time. Results: Our study identified 13 randomized control trials including 4041 patients. Compared with the provisional technique, 2-stent techniques significantly decreased MACE (hazard ratio [HR], 0.76; 95% CI, 0.59-0.97; P =.03), target vessel myocardial infarction (HR, 0.38; 95% CI, 0.20-0.71; P =.002), and target vessel revascularization (HR, 0.66; 95% CI, 0.47-0.93; P =.02). There were no significant differences in all-cause mortality (HR, 0.94; 95% CI, 0.62-1.45; P =.79), cardiovascular mortality (HR, 0.82; 95% CI, 0.49-1.38; P =.45), myocardial infarction (HR, 1.00; 95% CI, 0.73-1.37; P =.99), and stent thrombosis (HR, 0.86; 95% CI, 0.52-1.44; P =.58). Of the 2-stent techniques, the double kissing crush technique significantly decreased MACE and target lesion revascularization than other 2-stent techniques. Conclusions: In this era of newer-generation DES, a 2-stent approach, especially the double kissing crush technique, is superior to a provisional stenting technique for a bifurcation lesion, with a significant reduction in MACE, target vessel myocardial infarction, and revascularization.