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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.

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