Provisional stenting is the standard treatment forpatients with coronary artery bifurcation lesions. This pooled individualpatient-level meta-analysis aims to summarize long-term (over six years) evidencecomparing provisional stenting with upfront two-stent techniques in patientswith true coronary bifurcation lesions after coronary drug-eluting stentimplantation.

A systematic review and individual patient data(IPD)-level meta-analysis of randomized trials with centrally adjudicatedendpoints was conducted to assess the efficacy and safety of provisionalstenting versus upfront two-stent approaches in patients with true coronarybifurcation lesions undergoing percutaneous coronary intervention withdrug-eluting stents. We searched randomized trials comparing provisionalstenting with systematic two-stent techniques in Ovid MEDLINE,Embase, and two websites (www.tctmd.com and www.escardio.org) from databaseinception up to September 28, 2024. The risk of bias was evaluated using the revisedCochrane risk-of-bias tool. All patients were prospectively followed, and thelast case was completed for at least 6 years. The primary endpoint, re-evaluatedby an independent clinical event committee, was target lesion failure (TLF)—acomposite of cardiac death, target vessel myocardial infarction, or clinicallydriven target lesion revascularization—at the end of follow-up by November 8,2024. 

A total of 6225 citations were screened. Of these, fourtrials that randomized patients to provisional stenting or upfront two-stenttechniques were included. Among 1573 patients in the intention-to-treatpopulation, TLFat 6 years occurred in 144 (Kaplan–Meier estimate 18.2%) in the upfronttwo-stent group and 193 (Kaplan–Meierestimate 24.7%) in the provisional stenting group (HR 0.71 [95% CI 0.57–0.89];p=0.0022, τ²=0.00, I²=0%), which was consistentwith unadjusted and per-protocol analyses. In patients with complex coronarybifurcation lesions, TLF occurred in 88 (Kaplan–Meier estimate 19.6%) in the two-stentgroup and 115 (Kaplan–Meier estimate 27.6%) in the provisional stenting group(HR 0.68 [95% CI 0.52–0.90]; p=0.0066). 

This study provides robust evidence that upfronttwo-stent techniques, particularly double kissing crush stenting, areassociated with a significant reduction in TLF over a 6-year follow-upperiod compared with provisional stenting.