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Recent Perspectives on Left Main Bifurcation Interventions

Debabrata Dash

For several decades, coronary bypass grafting has been considered as the gold standard treatment of unprotected left main (LM) disease. However, because of large vessel caliber and anatomic accessibility, percutaneous coronary intervention (PCI) for LM has been attractive option for interventional cardiologists. PCI of LM bifurcation can be technically demanding that warrants reinforcement of integrated approach combining advanced devices, tailored techniques, adjunctive support of physiologic evaluation, and adjunctive pharmacologic agents. The provisional one -stent approach has shown more favourable outcome than two-stent technique, making the former the preferred strategy in most types of LM bifurcation lesions. In complex lesions, two-stent technique may be required and may yield superior results. Selecting the proper strategy using intravascular ultrasound for ostium of the side branch (SB) is critical for reducing the risk for SB occlusion and for improving patient's outcome. Even unnecessary complex interventions can be deferred by measuring fractional flow reserve in angiographic isolated SB. Importantly, final successful procedure is more important than the type of stenting technique., emphasizing the greater importance of optimizing the selected technique rather than choice of method. Alongside the evolution of bifurcation techniques, there has been development of several dedicated bifurcation stents which are safe and effective in LM bifurcation PCI both at short and mid-term follow up.