Preprocedural clinical and angiographic predictors of improved cardiovascular outcomes with final two-stent implantation in coronary bifurcation lesions; the Bifurcation Two-Stent (BTS) score

초록

Background Provisional stenting has become the default treatment strategy for most coronary bifurcation lesions However, in some clinical and anatomical settings, final two-stent implantation may yield better cardiovascular outcomes. This study aimed to identify preprocedural clinical and angiographic predictors associated with greater benefit from final two-stent implantation in coronary artery bifurcation lesions and to guide patient selection for this strategy. Methods We analyzed 5333 patients with coronary bifurcation lesions (mean age 66.2 years; 76% male) from the BIFURCAT registry, an international merged dataset combining the COBIS III and RAIN registries. All patients received second-generation drug-eluting stents; 82% underwent final single-stent and 18% final two-stent implantation. The primary endpoint was major adverse cardiac events (MACE)—a composite of all-cause death, myocardial infarction, and target lesion revascularization—at 2 years. Multivariable Cox regression with interaction testing was used to identify preprocedural clinical and angiographic predictors of differential benefit from two-stent implantation. Results Six predictors demonstrated a statistically significant interaction with final one stent and two stent implantation groups: diabetes mellitus, main vessel reference diameter > 3.0 mm, main vessel lesion length < 20 mm, side branch lesion length ≥ 20 mm, non-left main lesion, and severe coronary artery calcification. Each variable was assigned one point to construct the Bifurcation Two-Stent (BTS) score. In patients with a BTS score < 4 (80% of the cohort), final two-stent implantation was associated with significantly higher MACE rates compared with single-stent implantation (HR: 2.04; 95% CI: 1.64–2.56; P < 0.001). Conversely, patients with a BTS score ≥ 4 (approximately 20% of the cohort) demonstrated significantly lower MACE with two-stent implantation (HR: 0.56; 95% CI: 0.35–0.89; P = 0.014), driven primarily by a reduction in hard endpoints including death and myocardial infarction. These findings remained consistent after adjustment for procedural variables and antiplatelet therapy. Conclusion The BTS score may help identify patients with coronary bifurcation lesions who are most likely to benefit from final two-stent implantation. In patients with BTS score ≥ 4, final two-stent implantation was associated with lower MACE and hard clinical endpoints, supporting a selective rather than routine two-stent strategy in bifurcation PCI. © 2026 Elsevier Inc.

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