Bifurcation intervention with a two-stent strategy: can one size fit all?

This editorial refers to `Culotte stenting vs. TAP stenting for treatment of de-novo coronary bifurcation lesions with the need for side-branch stenting: the Bifurcations Bad Krozingen (BBK) II angiographic trial'†, by M. Ferenc et al., on page 3399. Bifurcation lesions account for 15–20% of lesions treated by contemporary percutaneous intervention (PCI). Due to greater technical complexity, successful treatment remains challenging and the rate of subsequent adverse events is high in comparison with non-bifurcation lesions. Moreover, the optimal management strategy is a matter of considerable debate and randomized trial design is difficult for a number of reasons. First, there is a broad range of contemporary bifurcation PCI techniques from which to choose. Second, thanks to the high performance of current stent technology and the refinement of interventional techniques, clinical event rates are low, meaning that trials powered for clinical endpoints require large sample sizes to show a difference in such rates. Third, the wide variation in anatomical lesion characteristics—including location of the bifurcation (left main vs. non-left main); location of disease within the bifurcation (true vs. non-true); size of the side branch (SB) and its dependent myocardium; and degree of the angle between the main vessel (MV) and SB—makes it difficult to find a ‘one size fits all’ solution.