Questioning ‘Keep it Simple’ in Treatment of Coronary Bifurcation Disease

The favoured approach for coronary bifurcation disease is provisional stenting, which involves stenting the main vessel (MV) and ignoring the side branch unless clinical circumstances warrant placement of a second stent. This approach is based on a number of studies showing that provisional stenting is superior to conventional two-stent approaches. There is reason to suspect, however, that the conventional wisdom regarding provisional stenting does not accurately reflect the risks and benefits of a traditional two-stent approach. Analysis of studies (e.g. Nordic I; Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus-Eluting Stents [CACTUS]; and the British Bifurcation Coronary Study: Old, New and Evolving Strategies [BBC ONE]) shows that provisional stenting frequently has similar long-term outcomes to a conventional two-stent approach in some patient populations. The long-term superiority of provisional stenting in coronary bifurcation disease depends on measuring a periprocedural or post-procedural rise in cardiac enzymes; removing this measure results in similar long-term outcomes between provisional and conventional two-stent approaches. New technologies or techniques will hopefully yield clear, unambiguous improvement in coronary bifurcation stenting.