Indian Experience of Bifurcation PCI: Provisional or Two-Stent—Does Strategy Matter?

Introduction:
Coronary bifurcation lesions, encountered in roughly one-fifth of PCI cases, remain among the most technically demanding scenarios in interventional cardiology. While provisional stenting has become the global default, complex anatomy or large diseased side branches often demand a planned two-stent approach. Most evidence guiding these decisions comes from Western populations, with limited data available on Indian cohorts reflecting our unique patient profiles and disease patterns. This study evaluates the clinical profile, angiographic patterns, and mid-term outcomes of bifurcation PCI using second-generation drug-eluting stents (DESs) in an Indian tertiary care setting, and to compare provisional and two-stent strategies in real-world practice.

Methods:
In this prospective observational study (April 2022–April 2023), 100 consecutive patients with major epicardial bifurcation lesions (main vessel >2.5 mm, side branch >2.3 mm) underwent PCI at a high-volume centre in Western India. Procedural details, risk factors, and lesion morphology (Medina classification) were documented. Follow-up at 8–12 months included clinical review and quantitative coronary angiography (QCA). The primary endpoint was major adverse cardiac events (MACE: death, MI, TVR, TLR, stent thrombosis); the secondary endpoint was binary in-stent restenosis (ISR).

Results:
The mean age was 60.5 ± 12.1 years; 76% were male. True bifurcation lesions (Medina 1,1,1) dominated (58%), followed by 0,1,1 (21%). Hypertension (66%) and family history (57%) were common, with significant clustering in complex patterns (1,1,1 and 1,0,1; p<0.02). Provisional stenting was used in 73%, two-stent techniques in 27% (T-stenting most frequent). ISR occurred in 16.9% overall, with no difference between strategies. The MACE rate was 16%, again comparable across groups.

Conclusion:
In this detailed Indian dataset, provisional and two-stent bifurcation PCI with second-generation DESs achieved similar mid-term safety and efficacy. Our findings reinforce an anatomy-driven approach—provisional for simpler lesions, dedicated two-stent techniques for complex bifurcations—while underscoring the need for larger multicentre Indian registries.