Navigating the Left Main Bifurcation: Which Stenting Strategy Best Minimises Major Adverse Cardiac Events and Target Lesion Revascularisation? A Network Meta-analysis

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' 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 - population, intervention, comparison, outcome. Key techniques evaluated included provisional single-stenting, doublestenting (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 [0.38-0.88]) and MACE (RR 0.51; 95% CI [0.36-0.72]) compared with single-stenting. Pooled double-stenting techniques increased TLR risk (RR 1.29; 95% CI [1.06-1.58]). 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.