Left main bifurcation stenting: a 2023 appraisal

Abstract

For several decades coronary bypass grafting has been considered the gold standard treatment for unprotected left main coronary artery lesions. However, the anatomic accessibility and the large caliber of the vessel render the percutaneous coronary intervention a very attractive treatment option for left main coronary artery lesions. The use of percutaneous coronary intervention in this subset of lesions has been further expanded as a result of the introduction of newer drug-eluting stents along with rapid advancements in techniques, devices, and adjunctive pharmacotherapies. The current evidence has demonstrated that patients with low or intermediate coronary complexity treated with percutaneous coronary intervention or coronary bypass grafting have comparable outcomes, for up to 10 years. Treatment of left main bifurcation lesions remains technically demanding despite recent developments. The provisional approach is the default strategy in most types of left main bifurcation lesions. However, a few complex left main bifurcation lesions would warrant an elective two-stent technique. An integrated approach incorporating custom- tailored techniques, adjunctive physiological and morphologic evaluation, and pharmacologic agents is critical to tackle this unique challenge and improve clinical outcomes.