Treating the left main coronary artery with provisional stenting was non-inferior to systematic dual stenting in the EBC MAIN trial, presented at EuroPCR 2021 and simultaneously published in the European Heart Journal.
The composite primary endpoint of death, infarction, and target-lesion revascularization was 14.7% for provisional stenting vs. 17.7% for systematic dual stenting (hazard ratio: 0.78; 95% confidence interval: 0.5-1.3).
This discussion of strategies for treating the left coronary artery has been going on for several years and there seems to be no end in sight.
Some studies, such as NORDIC, suggest a higher mortality with dual stenting, while others, like randomized trial DKCRUSH-V, show the opposite.
DKCRUSH-V was the study on which the 2018 European guidelines based their recommendation of the double kissing crush technique over provisional stenting to treat left main artery bifurcation.
According to the authors, the results of the EBC MAIN suggest starting in the simplest way (provisional stenting); if the results are not as expected, converting to dual stenting is still possible. About 22% of patients randomized to provisional stenting required a second stent after kissing balloon, with no predictive factor detected.
In EBC MAIN, 467 patients —from 11 European countries—with left main coronary artery bifurcation lesion were randomized to provisional stenting (n = 230) vs. systematic dual stenting (n = 237).
Read also: EuroPCR 2021 | TVT Registry: Outcomes of TAVR in Low Surgical Risk Bicuspids.
The double stenting technique was left to operator discretion (culotte, DK crush, minicrush, T/Tap), but proximal optimization and kissing end-balloon were mandatory in both strategies.
Surprisingly enough, the use of intravascular imaging was not mandatory—something that many investigators criticized after the presentation. Another questionable aspect is that there was no experience or volume requirements for centers or operators (despite the fact that their impact has been proven on clinical outcomes and other studies, such as DKCRUSH, factored them in).
EBC-MAINOriginal Title: The European Bifurcation Club Left Main coronary stent study: a randomized comparison of stepwise provisional vs. systematic dual stenting strategies (EBC MAIN).
Reference: Hildick-Smith D et al. Eur Heart Journal. 2021; Epub ahead of print. doi:10.1093/eurheartj/ehab283.
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