Cardiovasc Revasc Med. 2026 Jul 22:S1553-8389(26)00300-3. doi: 10.1016/j.carrev.2026.07.012. Online ahead of print.
ABSTRACT
BACKGROUND: Provisional stenting has become the default treatment strategy for most coronary bifurcation lesions However, in some clinical and anatomical settings, final two-stent implantation may yield better cardiovascular outcomes. This study aimed to identify preprocedural clinical and angiographic predictors associated with greater benefit from final two-stent implantation in coronary artery bifurcation lesions and to guide patient selection for this strategy.
METHODS: We analyzed 5333 patients with coronary bifurcation lesions (mean age 66.2 years; 76% male) from the BIFURCAT registry, an international merged dataset combining the COBIS III and RAIN registries. All patients received second-generation drug-eluting stents; 82% underwent final single-stent and 18% final two-stent implantation. The primary endpoint was major adverse cardiac events (MACE)-a composite of all-cause death, myocardial infarction, and target lesion revascularization-at 2 years. Multivariable Cox regression with interaction testing was used to identify preprocedural clinical and angiographic predictors of differential benefit from two-stent implantation.
RESULTS: Six predictors demonstrated a statistically significant interaction with final one stent and two stent implantation groups: diabetes mellitus, main vessel reference diameter > 3.0 mm, main vessel lesion length < 20 mm, side branch lesion length ≥ 20 mm, non-left main lesion, and severe coronary artery calcification. Each variable was assigned one point to construct the Bifurcation Two-Stent (BTS) score. In patients with a BTS score < 4 (80% of the cohort), final two-stent implantation was associated with significantly higher MACE rates compared with single-stent implantation (HR: 2.04; 95% CI: 1.64-2.56; P < 0.001). Conversely, patients with a BTS score ≥ 4 (approximately 20% of the cohort) demonstrated significantly lower MACE with two-stent implantation (HR: 0.56; 95% CI: 0.35-0.89; P = 0.014), driven primarily by a reduction in hard endpoints including death and myocardial infarction. These findings remained consistent after adjustment for procedural variables and antiplatelet therapy.
CONCLUSION: The BTS score may help identify patients with coronary bifurcation lesions who are most likely to benefit from final two-stent implantation. In patients with BTS score ≥ 4, final two-stent implantation was associated with lower MACE and hard clinical endpoints, supporting a selective rather than routine two-stent strategy in bifurcation PCI.
PMID:42538181 | DOI:10.1016/j.carrev.2026.07.012