Key result
Stepwise provisional stenting matches dual-stent strategy for MACE at 3 years but reduces TLR.
Why the study?
The optimal coronary stenting technique for true left main bifurcation lesions was uncertain.
Does a stepwise provisional stenting strategy reduce major adverse cardiac events compared to a systematic dual-stent approach in patients undergoing PCI for true left main coronary bifurcation lesions?
RCT (n=467)
open-label
randomly assigned
Yes
Does a stepwise provisional stenting strategy reduce major adverse cardiac events compared to a systematic dual-stent approach in patients undergoing PCI for true left main coronary bifurcation lesions?
A stepwise provisional stenting strategy yields similar 3-year MACE rates but significantly less target lesion revascularization compared to a systematic dual-stent approach for true left main bifurcation lesions, supporting it as the default strategy.
Supports stepwise provisional stenting as default for true left main bifurcations; extends randomized bifurcation evidence to this high-risk anatomy.
BACKGROUND: The optimal coronary stenting technique for true left main bifurcation lesions is uncertain. EBC MAIN (European Bifurcation Club Left Main Trial) aimed to evaluate clinical outcomes of a stepwise provisional strategy compared with a systematic dual-stent approach. METHODS: EBC MAIN was a randomized, investigator-initiated, open-label, multicenter, parallel-group trial conducted across 35 hospitals in 11 European countries. A total of 467 participants undergoing percutaneous coronary intervention for unprotected true left main bifurcation lesions were randomly assigned to the stepwise provisional strategy (n=230) or an upfront dual-stent approach (n=237). The mean (SD) age was 71 (10) years and 23% of participants were women. The primary end point was a composite of major adverse cardiac events, defined as all-cause mortality, all myocardial infarction, or clinically driven target lesion revascularization. Events were adjudicated by an independent clinical events committee and all analyses were by the intention-to-treat principle. RESULTS: =0.005, respectively), with smaller vessels (<3.25 mm diameter) and shorter lesions (<10 mm length) favoring the provisional approach. CONCLUSIONS: In a European population with true left main stem bifurcation coronary disease requiring intervention, there was no difference in major adverse cardiovascular events between stepwise provisional and systematic dual-stent strategies at 3 years. Target lesion revascularization was significantly less frequent with the stepwise provisional approach, which should be the default strategy for noncomplex left main bifurcation coronary intervention. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02497014.
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Arunothayaraj et al. (2025) conducted an RCT in unprotected true left main bifurcation lesions (n=467). Stepwise provisional strategy vs. Systematic dual-stent approach was evaluated on composite of major adverse cardiac events, defined as all-cause mortality, all myocardial infarction, or clinically driven target lesion revascularization. A stepwise provisional strategy showed no difference in major adverse cardiovascular events compared to a systematic dual-stent approach at 3 years, but reduced target lesion revascularization.
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