{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T16:55:05Z","timestamp":1785430505182,"version":"3.56.0"},"reference-count":26,"publisher":"Radcliffe Medical Media Ltd","license":[{"start":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T00:00:00Z","timestamp":1770854400000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/legalcode"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Interv Cardiol"],"abstract":"<jats:p>Background: Left main bifurcation lesions (LMBL) present considerable challenges in percutaneous coronary intervention due to the increased risk of restenosis, thrombosis and major adverse cardiac events (MACE). Determining the optimal stenting technique remains crucial to improving patient outcomes. Methods: This network meta-analysis systematically reviewed 19 eligible studies assessing diverse stenting strategies\u2019 effects on MACE and target lesion revascularisation (TLR) at 12-month follow-up. Random effects models were used and studies were selected using the PICO framework \u2013 population, intervention, comparison, outcome. Key techniques evaluated included provisional single-stenting, double-stenting (culotte, T-stenting and small protrusion (T\/TAP), V-stenting and standard crush) and double kissing (DK) crush. Quality and risk of bias were appraised using appropriate validated instruments. Results: DK crush demonstrated significantly lower TLR (RR 0.58; 95% CI [0.38\u20130.88]) and MACE (RR 0.51; 95% CI [0.36\u20130.72]) compared with single-stenting. Pooled double-stenting techniques increased TLR risk (RR 1.29; 95% CI [1.06\u20131.58]). Detailed ranking models consistently placed DK crush as the most effective, with p-values up to 0.95. Heterogeneity and reporting bias were minimal, supporting the robustness of these findings. Provisional stenting remains suitable for less complex bifurcations, while culotte and T\/TAP were associated with higher risks. Conclusion: DK crush is the preferred strategy for complex LMBL as it minimises MACE and TLR. Provisional stenting is reasonable in simpler anatomical scenarios. Clinical decision-making should incorporate lesion complexity, patient characteristics and operator expertise. Further large-scale randomised trials are warranted to validate these results.<\/jats:p>","DOI":"10.15420\/icr.2025.47","type":"journal-article","created":{"date-parts":[[2026,2,11]],"date-time":"2026-02-11T15:28:36Z","timestamp":1770823716000},"source":"Crossref","is-referenced-by-count":0,"title":["Navigating the Left Main Bifurcation: Which Stenting Strategy Best Minimises Major Adverse Cardiac Events and Target Lesion Revascularisation? A Network Meta-analysis"],"prefix":"10.15420","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9022-9674","authenticated-orcid":false,"given":"Suryono","family":"Suryono","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-7711-8644","authenticated-orcid":false,"given":"Muhammad Farhan","family":"Hibatulloh","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-1708-8115","authenticated-orcid":false,"given":"Alfiyah","family":"Ramadhani","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-1414-8339","authenticated-orcid":false,"given":"Candra Agung","family":"Wibisana","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4465-2011","authenticated-orcid":false,"given":"Achmad Ilham","family":"Tohari","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5956-6805","authenticated-orcid":false,"given":"Muhammad Rijal Fachrudin","family":"Hidayat","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5672-6957","authenticated-orcid":false,"given":"Muhammad Irsyad","family":"Amien","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-5526-1992","authenticated-orcid":false,"given":"Muhammad Naufal","family":"Hibatullah","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/049f0ha78","id-type":"ROR","asserted-by":"publisher"}],"name":"Universitas Jember"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3562-3887","authenticated-orcid":false,"given":"Hazbina Fauqi","family":"Ramadhan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"6096","published-online":{"date-parts":[[2026,2,12]]},"reference":[{"key":"ref0","doi-asserted-by":"crossref","unstructured":"Mohammad MA, Persson J, Buccheri S, et al. Trends in clinical practice and outcomes after percutaneous coronary intervention of unprotected left main coronary artery. J Am Heart Assoc 2022;11:e024040. https:\/\/doi.org\/10.1161\/JAHA.121.024040; PMID:\u00a035350870.","DOI":"10.1161\/JAHA.121.024040"},{"key":"ref1","doi-asserted-by":"crossref","unstructured":"M\u00fcller PP, Heim C, Weyand M, Harig F. Intraoperative visualization of a deformed left main stent during surgical aortic valve replacement. J Cardiothorac Surg 2023;18:49. https:\/\/doi.org\/10.1186\/s13019-023-02120-9; PMID:\u00a036721161.","DOI":"10.1186\/s13019-023-02120-9"},{"key":"ref2","doi-asserted-by":"crossref","unstructured":"Armstrong EJ, Graham LA, Waldo SW, et al. Patient and lesion-specific characteristics predict risk of major adverse cardiovascular events among patients with previous percutaneous coronary intervention undergoing noncardiac surgery. Catheter Cardiovasc Interv 2016;89:617\u201327. https:\/\/doi.org\/10.1002\/ccd.26624; PMID:\u00a027315550.","DOI":"10.1002\/ccd.26624"},{"key":"ref3","unstructured":"Ahn JM, Roh JH, Kim YH, et al. Randomized trial of stents versus bypass surgery for left main coronary artery disease: 5-year outcomes of the PRECOMBAT study. J Am Coll Cardiol 2015;65:2198\u2013206. https:\/\/doi.org\/10.1016\/j.jacc.2015.03.033; PMID:\u00a025787197."},{"key":"ref4","doi-asserted-by":"crossref","unstructured":"Nishida K, Toyofuku M, Morimoto T, et al. Prognostic impact of final kissing balloon technique after crossover stenting for the left main coronary artery: from the AOI-LMCA registry. Cardiovasc Interv Ther 2018;34:197\u2013206. https:\/\/doi.org\/10.1007\/s12928-018-0522-0; PMID:\u00a029691767.","DOI":"10.1007\/s12928-018-0522-0"},{"key":"ref5","doi-asserted-by":"crossref","unstructured":"Giacoppo D, Colleran R, Cassese S, et al. Percutaneous coronary intervention vs coronary artery bypass grafting in patients with left main coronary artery stenosis: a systematic review and meta-analysis. JAMA Cardiol 2017;2:1079\u201388. https:\/\/doi.org\/10.1001\/jamacardio.2017.2895; PMID:\u00a028903139.","DOI":"10.1001\/jamacardio.2017.2895"},{"key":"ref6","unstructured":"Kang SJ, Ahn JM, Song H, et al. Comprehensive intravascular ultrasound assessment of stent area and its impact on restenosis and adverse cardiac events in 403 patients with unprotected left main disease. Circ Cardiovasc Interv 2011;4:562\u20139. https:\/\/doi.org\/10.1161\/CIRCINTERVENTIONS.111.964643; PMID:\u00a022045969."},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Holvoet W, van den Buijs D, Bogaerts E, et al. Giant coronary artery aneurysm of the left main treated with a covered stent: a case report. Eur Heart J Case Rep 2022;7:ytac463. https:\/\/doi.org\/10.1093\/ehjcr\/ytac463; PMID:\u00a036865654.","DOI":"10.1093\/ehjcr\/ytac463"},{"key":"ref8","doi-asserted-by":"crossref","unstructured":"Rathore K, Wilke MM, Khialani B. Intimal windsock following type A aortic dissection: an intussusception of severe implications. J Card Surg 2021;36:4766\u20139. https:\/\/doi.org\/10.1111\/jocs.16000; PMID:\u00a034541706.","DOI":"10.1111\/jocs.16000"},{"key":"ref9","doi-asserted-by":"crossref","unstructured":"Fang HY, Wu CJ. Left main perforation and acute stent thrombosis \u2013 a cath lab nightmare. Catheter Cardiovasc Interv 2011;78:237\u201343. https:\/\/doi.org\/10.1002\/ccd.23033; PMID:\u00a021766426.","DOI":"10.1002\/ccd.23033"},{"key":"ref10","doi-asserted-by":"crossref","unstructured":"M\u00fcller P, Heim C, Weyand M, Harig F. Intraoperative visualization of a deformed left main stent. 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Comparative computed flow dynamic analysis of different optimization techniques in left main either provisional or culotte stenting. J Transl Int Med 2017;5:205\u201312. https:\/\/doi.org\/10.1515\/jtim-2017-0035; PMID:\u00a029340277.","DOI":"10.1515\/jtim-2017-0035"},{"key":"ref14","doi-asserted-by":"crossref","unstructured":"Park DY, An S, Jolly N, et al. Systematic review and network meta-analysis comparing bifurcation techniques for percutaneous coronary intervention. J Am Heart Assoc 2022;11:e025394. https:\/\/doi.org\/10.1161\/JAHA.122.025394; PMID:\u00a035723005.","DOI":"10.1161\/JAHA.122.025394"},{"key":"ref15","doi-asserted-by":"crossref","unstructured":"Rigatelli G, Zuin M, Nguyen T. Left main bifurcation stenting assessed by computational fluid dynamic: the impact on wall shear stress forces depends on both specific techniques and bifurcation angles. J Integr Cardiol 2018;4. https:\/\/doi.org\/10.15761\/JIC.1000259.","DOI":"10.15761\/JIC.1000259"},{"key":"ref16","doi-asserted-by":"crossref","unstructured":"Dan K, Bhogal S, Kuku KO, et al. Optical coherence tomography assessment of acute thrombogenicity at bifurcation sites using different stenting techniques: a porcine arteriovenous shunt study. Catheter Cardiovasc Interv 2022;99:1998\u20132005. https:\/\/doi.org\/10.1002\/ccd.30187; PMID:\u00a035485729.","DOI":"10.1002\/ccd.30187"},{"key":"ref17","doi-asserted-by":"crossref","unstructured":"Kahraman S, \u00c7izgici AY, G\u00fcner A, et al. Clinical outcomes of double-kissing crush or double-kissing culotte in non-left main bifurcation lesions: the ROUTE trial. Circ Cardiovasc Interv 2024;17:e014616. https:\/\/doi.org\/10.1161\/CIRCINTERVENTIONS.124.014616; PMID:\u00a039445416.","DOI":"10.1161\/CIRCINTERVENTIONS.124.014616"},{"key":"ref18","doi-asserted-by":"crossref","unstructured":"Burzotta F, D\u017eav\u00edk V, Ferenc M, et al. Technical aspects of the T and small protrusion (TAP) technique. EuroIntervention 2015;11(Suppl V):V91\u20135. https:\/\/doi.org\/10.4244\/EIJV11SVA20; PMID:\u00a025983182.","DOI":"10.4244\/EIJV11SVA20"},{"key":"ref19","doi-asserted-by":"crossref","unstructured":"Ng JCK, Ang HY, Zhong L, et al. Multimodality imaging results of TAP versus novel modified TAP stenting in coronary bifurcation: from bench testing to first-in-man investigation. Catheter Cardiovasc Interv 2022;101:44\u201357. https:\/\/doi.org\/10.1002\/ccd.30496; PMID:\u00a036403271.","DOI":"10.1002\/ccd.30496"},{"key":"ref20","doi-asserted-by":"crossref","unstructured":"Paradies V, Ng J, Lu S, et al. T and small protrusion (TAP) vs double-kissing crush technique: insights from in vitro models. Cardiovasc Revasc Med 2021;24:11\u20137. https:\/\/doi.org\/10.1016\/j.carrev.2020.09.013.","DOI":"10.1016\/j.carrev.2020.09.013"},{"key":"ref21","doi-asserted-by":"crossref","unstructured":"Rus M, Filimon GC, Ardelean AI. T and small protrusion (TAP) technique in bifurcations: coronary artery disease in acute myocardial infarction patients after COVID-19 pneumonia. Biomedicines 2023;11:2255. https:\/\/doi.org\/10.3390\/biomedicines11082255; PMID:\u00a037626751.","DOI":"10.3390\/biomedicines11082255"},{"key":"ref22","doi-asserted-by":"crossref","unstructured":"Saleem D, Chen W, Abu Daya H, Orozco-Hernandez E. Ostial right coronary artery stent loss, stent-in-stent entrapment, and subsequent surgical extraction. J Cardiothorac Surg 2026;21:70.  https:\/\/doi.org\/10.1186\/s13019-025-03798-9; PMID: 41491599.","DOI":"10.1186\/s13019-025-03798-9"},{"key":"ref23","doi-asserted-by":"crossref","unstructured":"G\u00fcner A, Uzun F, \u00c7izgici AY, et al. Long-term cardiovascular outcomes after mini-crush or T and minimal protrusion techniques in complex bifurcation lesions: the EVOLUTE-CRUSH III study. Coron Artery Dis 2024;35:641\u20139. https:\/\/doi.org\/10.1097\/MCA.0000000000001392; PMID:\u00a038809138.","DOI":"10.1097\/MCA.0000000000001392"},{"key":"ref24","doi-asserted-by":"crossref","unstructured":"Maznyczka A, Arunothayaraj S, Egred M, et al. Bifurcation left main stenting with or without intracoronary imaging: outcomes from the EBC MAIN trial. Catheter Cardiovasc Interv 2023;102:415\u201329. https:\/\/doi.org\/10.1002\/ccd.30785; PMID:\u00a037473405.","DOI":"10.1002\/ccd.30785"},{"key":"ref25","doi-asserted-by":"crossref","unstructured":"Solangi AA, Nasrullah, Jalaludin, et al. Provisional vs dual stenting of left main coronary artery bifurcation lesions. 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