Principles and Practical Strategies for Left Main Bifurcation & Trifurcation PCI: A Comprehensive Review
Principles and Practical Strategies for Left Main Bifurcation & Trifurcation PCI: A Comprehensive Review
Updated 2025 – Educational & Clinical Insights
Published in JACC: Cardiovascular Interventions (June 2025; reported in medical news on September 17, 2025).
Meta-analysis on left main bifurcation stenting strategies.
1. Basic Definitions
1. Bifurcation: LM divides into two branches (LAD + LCX).
2. Trifurcation: LM divides into three branches (LAD + LCX + Ramus/Intermediate).
2. Clinical Importance
1. LM disease supplies a large myocardial territory → very high risk.
2. Bifurcation lesions are common; trifurcation lesions are rarer and more complex.
3. More branches = higher risk of restenosis, side branch closure, and stent overlap.
3. Treatment Options for LM Disease
1. PCI (stenting): preferred if anatomy is suitable; always IVUS/OCT-guided.
2. CABG: gold standard for very complex or high SYNTAX score lesions.
3. CABG in acute STEMI:
• Primary PCI is the standard of care.
• CABG is considered only if:
* PCI fails.
* Mechanical complications occur (e.g., rupture, severe valve dysfunction).
* LM occlusion unsuitable for PCI (diffuse/calcified lesions, poor distal vessels).
4. LM Occlusion with Heavy Thrombus Burden
1. First step: aspiration thrombectomy.
2. If residual severe stenosis → cautious small-balloon predilatation (1.5–2 mm, low pressure).
3. Stent implantation only after thrombus minimized.
4. If no-reflow or hemodynamic collapse:
• Stop device maneuvers.
• Give intracoronary adenosine, verapamil/diltiazem, or nitroprusside.
• Provide hemodynamic support (fluids, pressors, IABP/Impella if available).
5. Antithrombotics:
• Cangrelor preferred if CABG possible (bridging substitute for ticagrelor/prasugrel/clopidogrel; rapid onset and offset; temporary replacement for oral P2Y12 while aspirin continued).
• Aspirin always continued.
• GP IIb/IIIa inhibitors (e.g., tirofiban/Aggrastat): avoided if CABG possible because their effect lasts hours, increasing surgical bleeding risk.
6. If PCI fails → CABG rescue
