Why the study?
Two-stent techniques for complex de novo left main coronary bifurcation lesions increase metal burden, procedural complexity, and restenosis risk. A hybrid strategy using a main-vessel drug-eluting stent and side-branch drug-coated balloon has emerged as an alternative, but no prior systematic synthesis had evaluated this approach in left main bifurcations.
Does a hybrid drug-eluting stent plus drug-coated balloon strategy reduce target lesion revascularisation, target vessel myocardial infarction, and post-procedural luminal stenosis compared to two-stent techniques in patients with complex de novo left main coronary bifurcation lesions?
Does a hybrid drug-eluting stent plus drug-coated balloon strategy reduce target lesion revascularisation, target vessel myocardial infarction, and post-procedural luminal stenosis compared to two-stent techniques in patients with complex de novo left main coronary bifurcation lesions?
This first systematic review and meta-analysis suggests that a hybrid drug-eluting stent and drug-coated balloon strategy for complex de novo left main bifurcation lesions yields comparable clinical outcomes and better main branch patency than two-stent techniques, despite higher side branch residual stenosis.
Hybrid strategy may lower revascularisation in left main bifurcations; leaves open superiority over two-stent techniques pending randomized trials.
Background Complex de novo left main coronary bifurcation lesions are among the most challenging scenarios in contemporary percutaneous coronary intervention, involving a large myocardial territory and high procedural risk. Two stent techniques remain conventional but increase metal burden, complexity and restenosis risk. A hybrid strategy using a drug eluting stent in the main vessel and a drug coated balloon in the side branch has emerged as an alternative, yet no prior systematic synthesis has focused on this approach in left main bifurcation lesions. Purpose To provide the first systematic comparative evaluation of a hybrid drug eluting stent plus drug coated balloon strategy versus two stent techniques in complex de novo left main bifurcation intervention. Methods A systematic search through 1 January 2026 identified studies exclusively evaluating de novo left main coronary bifurcation lesions and reporting target lesion revascularisation, target vessel myocardial infarction or post procedural luminal stenosis. Comparative and single arm studies were analysed separately and not combined in pooled models. Comparative cohorts were synthesised using random effects models, while single arm hybrid studies were analysed independently to estimate pooled mid term event rates. Results Of 1 045 screened records, five cohort studies including 269 patients met inclusion criteria. Two propensity matched cohorts (n=160) showed numerically lower target lesion revascularisation with the hybrid strategy compared with two stent techniques (RR 0.45 [95% CI 0.14 to 1.40]; p=0.17) and a similar directional reduction in target vessel myocardial infarction (RR 0.63 [95% CI 0.08 to 4.97]; p=0.66). Main branch residual stenosis favoured the hybrid approach (−0.91% [95% CI −1.83 to −0.00]; p=0.05), whereas side branch residual stenosis was higher (8.38% [95% CI 6.99 to 9.77]; p<0.00001). Three additional hybrid cohorts (n=109), analysed separately, showed low mid term event rates, with pooled target lesion revascularisation of 1% (95% CI [0.00 to 0.05]) and target vessel myocardial infarction of 0% (95% CI [0.00 to 0.01]), consistent with the direction observed in comparative analyses. Conclusion(s) In complex de novo left main coronary bifurcation lesions, a hybrid drug eluting stent and drug coated balloon strategy was associated with numerically lower repeat revascularisation and myocardial infarction compared with two stent techniques and improved main branch angiographic results, with higher residual stenosis in the side branch. While evidence remains limited and predominantly observational, this synthesis provides a structured clinical framework for future prospective and randomised investigations.
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Leal et al. (2026) studied this question.
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