Comparison of Bifurcation and Trifurcation Anatomy in Distal Left Main Coronary Artery Stenting

Abstract

Aim: Although there is a lot of data comparing bifurcation and non-bifurcation lesions in left main coronary artery (LMCA) percuteneous coronary intervention (PCI), the specific influence of trifurcation anatomy on procedural outcomes and long-term prognosis is poorly understood. Given the technical complexities and probable disparities in clinical outcomes, a thorough research of these anatomical subgroups is required. This study aimed to compare procedural and clinical outcomes between bifurcation and trifurcation LMCA lesions. Material and Methods: This retrospective study analyzed patients who underwent distal LMCA stenting between January 2019 and June 2024. Patients with stable coronary artery disease (CAD) without prior coronary artery bypass grafting (CABG) and who underwent intravascular ultrasound (IVUS)-guided stenting and who have high surgical risk, as assessed by a heart team, or patient preference for PCI were included. Those with acute coronary syndrome at presentation, prior CABG, or PCI performed without IVUS guidance were excluded. A total of 43 eligible patients were identified from institutional records. Data were collected retrospectively, including procedural details, clinical outcomes, and follow-up findings. Results: There were no significant differences in baseline characteristics, including biochemical parameters and comorbidities, between the two groups (p>0.05). Trifurcation lesions required significantly longer stents (p=0.008). Ischemic events were more common in the trifurcation group (33.3% vs. 4.5%, p=0.015), and major adverse cardiac event (MACE) rates were significantly higher in the trifurcation group compared to the bifurcation group (57.1% vs. 9.1%, p=0.001). Bleeding events and mortality rates did not significantly differ between the groups (p>0.05). Conclusion: Patients with LMCA trifurcation lesions undergoing PCI exhibit higher ischemic event rates and MACE compared to those with bifurcation lesions, despite IVUS guidance. Further prospective studies are warranted to optimize treatment strategies for this high-risk population.

Keywords

• angiography
• bifurcation
• IVUS
• LMCA stenting; trifurcation

References

1. 1. Medina A, Suárez de Lezo J, Pan M. Una clasificación simple de las lesiones coronarias en bifurcación [A new classification of coronary bifurcation lesions]. Rev Esp Cardiol. 2006;59(2):183.
2. 2. Sawaya FJ, Lefèvre T, Chevalier B, Garot P, Hovasse T, Morice MC, et al. Contemporary Approach to Coronary Bifurcation Lesion Treatment. JACC Cardiovascular Interventions. 2016;1861–1878.
3. 3. Chen SL, Sheiban I, Xu B, Jepson N, Paiboon C, Zhang JJ, Ye F., et al. Impact of the complexity of bifurcation lesions treated with drug-eluting stents: the DEFINITION study (Definitions and impact of complEx biFurcation lesIons on clinical outcomes after percutaNeous coronary IntervenTIOn using drug-eluting steNts) . JACC Cardiovascular Interventions. 2014;1266–1276.
4. 4. Stone GW, Kappetein AP, Sabik JF, Pocock SJ, Morice MC, Puskas J, et al. Five-Year Outcomes after PCI or CABG for Left Main Coronary Disease. The New England Journal of Medicine. 2019;1820–1830.
5. 5. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. The New England Journal of Medicine. 2009;961–972.
6. 6. Karakayali M, Omar T, Artac I, Rencuzogullari I, Karabag Y, Hamideyin S, Altunova M. The white blood cell count to Mean Platelet Volume Ratio (WMR) is associated with syntax score in patients with ST-segment elevation myocardial infarction. Kafkas Journal of Medical Sciences. 2023;173–178.
7. 7. Kovacevic M, Burzotta F, Elharty S, Besis G, Aurigemma C, Romagnoli E, Trani C. Left Main Trifurcation and Its Percutaneous Treatment: What Is Known So Far?. Circulation Cardiovascular interventions. 2021;e009872.
8. 8. Kovacevic M, Burzotta F, Stankovic G, Chieffo A, Milasinovic D, Cankovic M, et al. Long-term clinical impact of angiographic complexity in left main trifurcation percutaneous coronary interventions. Minerva Cardiol Angiol. 2025;77–85.

9. 9. Lowe HC. Perspectives on Imaging the Left Main Coronary Artery Using Intravascular Ultrasound and Optical Coherence Tomography. Front Cardiovasc Med. 2015;1–16.
10. 10. Choi KH, Song YB, Lee JM, Lee SY, Park TK, Yang JH, et al. Impact of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention on Long-Term Clinical Outcomes in Patients Undergoing Complex Procedures. JACC Cardiovascular interventions. 2019;607–620.
11. 11. Kandzari DE, Gershlick AH, Serruys PW, Leon MB, Morice MC, Simonton CA, et al. Procedural characteristics and clinical outcomes in patients undergoing percutaneous coronary intervention for left main trifurcation disease: the EXCEL trial. EuroIntervention: Journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology. 2020;e982–e988.
12. 12. Chiarito M, Kini A, Roumeliotis A, Cao D, Power D, Sartori S, et al. Prevalence and Impact of High Bleeding Risk in Patients Undergoing Left Main Artery Disease PCI. JACC Cardiovascular Interventions. 2021;2447–2457.
13. 13. Zhang Q, Huan H, Han Y, Liu H, Sun S, Wang B, Wei S. Clinical Outcomes Following Simple or Complex Stenting for Coronary Bifurcation Lesions: A Meta-Analysis. Clinical Medicine Insights. Cardiology,. 2022;11795468221116842.
14. 14. Cho S, Kang TS, Kim JS, Hong SJ, Shin DH, Ahn CM, et al. Long-Term Clinical Outcomes and Optimal Stent Strategy in Left Main Coronary Bifurcation Stenting. JACC Cardiovascular Interventions. 2018;1247–1258.
15. 15. Phillips NR, Waters D, Havel RJ. Plasma lipoproteins and progression of coronary artery disease evaluated by angiography and clinical events. Circulation. 1993;2762–2770