One- Versus Two-Stent Stenting Strategies in Coronary Bifurcation Lesions

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/25.00096. Epub September 5, 2025.

Objectives. Additional studies are needed on the follow-up outcomes of 1- vs 2-stent techniques in bifurcation percutaneous coronary interventions (PCI).

Methods. The authors examined the angiographic and procedural characteristics, and outcomes of 1306 bifurcation PCIs (1139 patients) performed at 6 centers between 2014 and 2024 from the PROGRESS-BIFURCATION registry.

Results. Upfront 1-stent PCI (96.2% provisional stenting, 2% mini crush with 1 stent, 1.7% side branch [SB] stent only) was used in 75.5% of lesions; upfront 2-stent PCI was used in 24.5% (48.1% double kissing crush, 16.9% culotte, 35% other). Patients treated with an upfront 2-stent strategy were older (68 ± 12 vs 66 ± 12 years; P = .011) and more likely to have dyslipidemia (82.7% vs 76.0%; P = .019) and a history of heart failure (27.6% vs 20.3%; P = .011). An upfront 2-stent strategy was more common in left main bifurcations and lesions with moderate/severe calcification or larger SB diameter. Upfront 2-stent strategies required longer procedure and fluoroscopy times and higher patient radiation dose but similar contrast volume. Two-stent strategies were associated with higher technical success (98.4% vs 94.4%; P = .003), but similar procedural success (93.5% vs 90.4%; P = .116) and in-hospital major adverse cardiac events (MACE) (5.2% vs 3.9%; P = .355) compared with 1-stent strategies. Follow-up data was available for 783 patients. During a median follow-up of 1095 days, patients treated with an upfront 2-stent strategy had similar incidence of MACE, target vessel revascularization, myocardial infarction, and all-cause mortality (hazard ratio, 0.99; 95% CI, 0.61-1.62; P = .98).

Conclusions. Upfront 1- vs 2-stent bifurcation PCI was associated with similar procedural success and follow-up outcomes during a median follow-up of 3 years.

Approximately 20% of percutaneous coronary interventions (PCI) involve a bifurcation.^1-3 Bifurcation PCI can be complex and has been associated with worse clinical outcomes compared with PCI of non-bifurcated lesions.^1-3 Whereas provisional stenting is accepted as the preferred PCI strategy for most bifurcations, 2-stent strategies are performed in a large patient subset.^4,5 We compared upfront single vs 2-stent strategies in a large, multicenter bifurcation PCI registry.

We examined the angiographic characteristics, procedural characteristics, and outcomes of 1306 bifurcation PCIs (1139 patients) performed at 6 centers between 2014 and 2024 that were included in the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION, ClinicalTrials.gov Identifier: NCT05100992). The Research Electronic Data Capture (REDCap) hosted at the Minneapolis Heart Institute Foundation was used to capture and manage anonymized data. The study was approved by the institutional review board of the participating centers.

The primary endpoint of the study was the incidence of follow-up outcomes: major adverse cardiac events (MACE), target vessel revascularization (TVR), myocardial infarction (MI), and all-cause mortality. Secondary endpoints were technical and procedural success. Follow-ups were conducted through medical record review.

Bifurcation lesions were defined as coronary artery stenoses adjacent to and/or involving the origin of a significant side branch (SB).⁶ When SB stenting was attempted, technical success was defined as achievement of Thrombolysis in Myocardial Infarction (TIMI)-3 flow and a residual stenosis of less than 30% in both the main vessel (MV) and the side branch (SB). If there was no attempt to stent the SB, technical success was defined as achievement of TIMI-3 flow in the MV and either an SB residual stenosis of less than or equal to the initial SB stenosis or a residual SB stenosis of less than 50% or normal SB physiology alongside TIMI-3 flow. Procedural success was defined as the achievement of technical success without in-hospital MACE. In-hospital MACE was defined as the composite of death, MI, stroke, urgent repeat of TVR via either PCI or coronary artery bypass graft (CABG) surgery because of recurring symptoms, and tamponade necessitating either surgical intervention or pericardiocentesis prior to discharge. MI was defined as type 4a MI using the Third Universal Definition of Myocardial Infarction. Acute kidney injury (AKI) was diagnosed as an increase in creatinine of greater than or equal to 0.3 mg/dL or more than 1.5 times the baseline creatinine within 48 hours post-procedure.

The Medina classification was used as described by Medina et al.⁷ Follow-up MACE was defined as the composite of death, MI, stroke, urgent repeat of TVR via either PCI or CABG because of recurring symptoms, and tamponade necessitating either surgical intervention or pericardiocentesis after discharge from the hospital. Follow-up TVR was defined as any repeat PCI or surgical bypass of the target vessel, and non-target vessel revascularization (NTVR) was defined as any repeat PCI or surgical bypass of a non-target vessel. Repeat PCI or surgical bypass of the target lesion for restenosis or other complications were defined as follow-up target lesion revascularization (TLR). Heart failure was defined as physician documentation or report of any of the following clinical symptoms of heart failure described as: unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention; or the description of rales, jugular venous distension, pulmonary edema on physical exam, or pulmonary edema on chest x-ray. A low ejection fraction alone, without clinical evidence of heart failure did not qualify as heart failure.⁸ A bifurcation lesion was considered complex using the DEFINITION criteria.⁹  

Statistical methods

Categorical variables were presented as percentages and compared using Pearson’s chi-square test. Continuous variables were described as mean ± SD for normally distributed data or median with IQR for non-normally distributed data. Normally distributed data were analyzed using the independent-sample t-test; non-parametric data were analyzed using the Mann-Whitney U-test. Univariable logistic regression analysis was initially used to evaluate the effect of different stenting strategies on bifurcation PCI for technical success and periprocedural or in-hospital MACE. Variables found to be associated with outcomes at a significance level of P less than 0.10 were included in the multivariable models. Kaplan-Meier survival analysis was used to calculate the incidence of follow-up events, which were compared using the log-rank test and mixed effects Cox proportional hazard ratios (HR). All statistical analyses were performed using R Statistical Software, version 4.4.0 (R Foundation for Statistical Computing). A P-value of less than 0.05 was considered statistically significant.

Patient characteristics

Between 2014 and 2024, upfront 1-stent strategies were used in 986 out of 1306 bifurcations (75.5%), and upfront 2-stent strategies were used in the remaining 24.5% (320). Provisional stenting was used in 96.2% (949) of upfront 1-stent strategies and SB-only stenting in the remaining 3.8% (37): 1.7% (17) SB stenting without crushing and 2% (20) side-branch stenting followed by main vessel balloon inflation crushing the protruding segment of the SB stent (mini crush). Double kissing (DK) crush was used in 48.1% (154) of upfront 2-stent strategies, culotte in 16.9% (54), and other techniques in 35% (112). Patients who underwent upfront 3-stent strategies were older, more likely to have dyslipidemia, and more likely to have heart failure (Table 1).

Angiographic characteristics

Table 2 displays the angiographic characteristics of the study lesions. Two-stent strategies were more often used in the left main coronary artery (LMCA) and the left anterior descending artery (LAD) as its proximal main vessel and less often in the right coronary artery (RCA) and circumflex artery. Patients treated with upfront 2-stent strategies had larger proximal and distal main vessel diameters along with longer main vessel lesion length. The same trend was observed for SB diameter and lesion length. Two stent-strategies were more common in cases with moderate to severe calcification and less common in cases with moderate to severe tortuosity.

In-hospital outcomes

Upfront 2-stent strategies had higher technical success (98.4% vs 94.4%; P = .003) without significant difference in procedural success (Table 3), longer procedure and fluoroscopy times, and higher air kerma radiation dose, but similar contrast volume.

Follow-up outcomes

Follow-up data was available for 783 (68.7%) of the 1139 patients for a median follow-up duration of 1095 days. Compared with an upfront single stent strategy, upfront 2-stent techniques had similar incidence of follow-up MACE (HR, 1.18; 95% CI, 0.89-1.57; P = .36), TVR (HR, 0.85; 95% CI, 0.49-1.48; P = .55), and MI (HR, 1.48; 95% CI, 0.80-2.74; P = .27), and a trend for higher all-cause mortality (HR, 1.39; 95% CI, 0.96-2.02; P = .079). After adjusting for confounders, all-cause mortality was similar for 1- and 2-stent strategies (HR, 0.99; 95% CI, 0.61-1.62; P = .98) (Figure).

Subgroup outcomes

There was higher follow-up MACE in acute MI patients and low left ventricular ejection fraction (LVEF) patients who underwent an upfront 2-stent strategy than those who underwent a 1-stent strategy. There was no significant difference in patients with multivessel disease (MVD) or unprotected left main (LM) disease (Supplemental Figure). Using the DEFINITION criteria,⁹ 298 patients had simple bifurcation lesions, of which provisional stenting was used in 215 (72.1%) patients and 2-stent techniques in 99 (33.2%) patients; 815 patients had complex bifurcation lesions, of which provisional stenting was used in 578 (70.9%) patients and 2-stent techniques in 259 (31.8%) patients.  

Patient characteristics

Between 2014 and 2024, upfront 1-stent strategies were used in 986 out of 1306 bifurcations (75.5%), and upfront 2-stent strategies were used in the remaining 24.5% (320). Provisional stenting was used in 96.2% (949) of upfront 1-stent strategies and SB-only stenting in the remaining 3.8% (37): 1.7% (17) SB stenting without crushing and 2% (20) side-branch stenting followed by main vessel balloon inflation crushing the protruding segment of the SB stent (mini crush). Double kissing (DK) crush was used in 48.1% (154) of upfront 2-stent strategies, culotte in 16.9% (54), and other techniques in 35% (112). Patients who underwent upfront 3-stent strategies were older, more likely to have dyslipidemia, and more likely to have heart failure (Table 1).

Angiographic characteristics

Table 2 displays the angiographic characteristics of the study lesions. Two-stent strategies were more often used in the left main coronary artery (LMCA) and the left anterior descending artery (LAD) as its proximal main vessel and less often in the right coronary artery (RCA) and circumflex artery. Patients treated with upfront 2-stent strategies had larger proximal and distal main vessel diameters along with longer main vessel lesion length. The same trend was observed for SB diameter and lesion length. Two stent-strategies were more common in cases with moderate to severe calcification and less common in cases with moderate to severe tortuosity.

In-hospital outcomes

Upfront 2-stent strategies had higher technical success (98.4% vs 94.4%; P = .003) without significant difference in procedural success (Table 3), longer procedure and fluoroscopy times, and higher air kerma radiation dose, but similar contrast volume.

Follow-up outcomes

Follow-up data was available for 783 (68.7%) of the 1139 patients for a median follow-up duration of 1095 days. Compared with an upfront single stent strategy, upfront 2-stent techniques had similar incidence of follow-up MACE (HR, 1.18; 95% CI, 0.89-1.57; P = .36), TVR (HR, 0.85; 95% CI, 0.49-1.48; P = .55), and MI (HR, 1.48; 95% CI, 0.80-2.74; P = .27), and a trend for higher all-cause mortality (HR, 1.39; 95% CI, 0.96-2.02; P = .079). After adjusting for confounders, all-cause mortality was similar for 1- and 2-stent strategies (HR, 0.99; 95% CI, 0.61-1.62; P = .98) (Figure).

Subgroup outcomes

There was higher follow-up MACE in acute MI patients and low left ventricular ejection fraction (LVEF) patients who underwent an upfront 2-stent strategy than those who underwent a 1-stent strategy. There was no significant difference in patients with multivessel disease (MVD) or unprotected left main (LM) disease (Supplemental Figure). Using the DEFINITION criteria,⁹ 298 patients had simple bifurcation lesions, of which provisional stenting was used in 215 (72.1%) patients and 2-stent techniques in 99 (33.2%) patients; 815 patients had complex bifurcation lesions, of which provisional stenting was used in 578 (70.9%) patients and 2-stent techniques in 259 (31.8%) patients.  

Upfront 1-stent bifurcation PCIs had lower technical success but were associated with similar procedural success and follow-up outcomes compared with upfront 2-stent strategies during a median period of 3 years.

Zachary Chan, BS^1,2; Michaella Alexandrou, MD²; Dimitrios Strepkos, MD²; Deniz Mutlu, MD²; Pedro E. P. Carvalho, MD²; Oleg Krestyaninov, MD³; Dimitri Khelimskii, MD³; Barkin Kultursay, MD⁴; Ali Karagoz, MD⁴; Ufuk Yildirim, MD⁵; Korhan Soylu, MD⁵; Mahmut Uluganyan, MD⁶; Ozgur Selim Ser, MD²; Olga Mastrodemos, BA²; Bavana V. Rangan, BDS, MPH²; Sandeep Jalli, DO²; Konstantinos Voudris, MD, PhD²; Yader Sandoval, MD²; M. Nicholas Burke, MD², Emmanouil S. Brilakis, MD, PhD²

From ¹Cornell University, Ithaca, New York, ²Minneapolis Heart Institute and Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, Minnesota, ³Meshalkin Novosibirsk Research Institute, Novosibirsk, Russia, ⁴Kartal Kosuyolu Postgraduate Training and Research Hospital, Istanbul, Turkey, ⁵Ondokuz Mayis University, Samsun, Turkey, ⁶Bezmialem Vakif University, Istanbul, Turkey.

The abstract has been previously published: Chan Z, Alexandrou M, Stepkos D, et al. One- vs two-stent stenting strategies in coronary bifurcation lesions. JACC. 85(12_Supplement), 857–857. doi:10.1016/S0735-1097(25)01341-5)

Acknowledgments: The authors are grateful for the philanthropic support of our generous anonymous donors (2), and the philanthropic support of Drs Mary Ann and Donald A. Sens; Mrs Diane and Dr Cline Hickok; Mrs Wilma and Mr Dale Johnson; the Mrs Charlotte and Mr Jerry Golinvaux Family Fund; the Roehl Family Foundation; the Joseph Durda Foundation; Ms Marilyn and Mr William Ryerse; and Mr Greg and Mrs Rhoda Olsen. The generous gifts of these donors to the Minneapolis Heart Institute Foundation’s Science Center for Coronary Artery Disease (CCAD) helped support this research project.

Disclosures: Dr Sandoval is a consultant for, and serves on the advisory board of Abbott and gE Healthcare; is a consultant for, serves on the advisory board of, and is a speaker for Roche Diagnostics and Philips; serves on the advisory board of Zoll; is a consultant for CathWorks; is a speaker for HeartFlow; is a speaker for, and receives research grants from Cleerly; is an associate editor for JACC Advances; and he and others hold patent 20210401347. Dr Brilakis receives consulting/speaker honoraria from Abbott Vascular, the American Heart Association (associate editor, Circulation), Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), Cordis, CSI, Elsevier, GE Healthcare, Haemonetics, IMDS, Medtronic, SIS Medical, Teleflex, and Orbus Neich; receives research support from Boston Scientific and GE Healthcare; is the owner of Hippocrates, LLC; and is a shareholder in LifeLens Technologies, Inc, MHI Ventures, Cleerly Health, Stallion Medical, and TrueVue, Inc. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Emmanouil S. Brilakis, MD, PhD, Minneapolis Heart Institute, 920 E 28th Street #300, Minneapolis, MN 55407, USA. Email: esbrilakis@gmail.com; X: @esbrilakis