Is two better than one?

In this issue of CCI, Murasato et al. [1] present a complex patient in cardiogenic shock with left main, left anterior descending (LAD), and left circumflex (LCX) disease in addition to an occluded right coronary artery (RCA). Because of the hemodynamic instability, the operators chose to proceed with urgent percutaneous coronary intervention (PCI) supported by intra-aortic balloon pump. As there was disease in both the LAD and the LCX, the operators predilated both vessels, noting significant dissections. PCI of the left main and LAD was performed without protecting the circumflex, which occluded, requiring resuscitation and the use of cardiopulmonary support. Fortunately, PCI of the RCA and then the LCX was successfully accomplished. Although the necessity for PCI of the RCA first could be questioned, one cannot argue with their outcome, which resulted ultimately in stability and only the need for reintervention using Culotte stenting of the ramus and circumflex in a staged procedure. In our experience and theirs, reliance on a provisional bifurcation strategy for left main disease has become the default option. This has been encouraged by less predictable outcomes with two-stent results, likely related to operators not optimizing the final results, negative experiences associated with more challenging current two-stent strategies including crush, ‘‘T,’’ Culotte, and kissing stents, and the lack of a dedicated user friendly bifurcation stent design. However, as was identified in this situation, the loss of the side branch resulted in a catastrophic hemodynamic collapse. So, when the interventionalist approaches these types of patients, the challenge is to determine when two stents are indeed better than one. The basic premise is that if the side branch is significantly diseased at its ostium or nearby, and it is large enough to be stented, PCI with stents supporting both the main and the side branches needs to be strongly considered. The anatomy can even change during the PCI, which may change the planned initial strategy. Although the authors did appreciate significant LCX ostial dissection after predilation, they did not pursue a more proactive management to protect the LCX with a stent. Current bifurcation stenting techniques are often challenged when there are shallow angles, bulky lesions, culprit acute myocardial infarction lesions, and trifurcations with large branches, but in a critically ill patient an aggressive stenting approach is reasonable to ensure stability. Additional measures, such as the use of percutaneous left ventricular assist device support, should also be considered if available. An algorithm describing this approach is outlined in Fig. 1.