In patients with true bifurcation lesions, clinical indication, left main coronary artery (LMCA) bifurcation and side branch (SB) disease severity were the strongest predictors of two-stent PCI, while optical coherence tomographic (OCT)-guided one-stent PCI was associated with the lowest risk for major adverse cardiovascular events (MACE), according to results from a post hoc analysis of the OCTOBER trial published Sept. 28 in JACC: Advances.

The OCTOBER trial enrolled 1,201 patients undergoing PCI for true coronary bifurcation lesions at 38 European centers from July 2017 to March 2022. Cox and logistic regression assessed clinical outcomes and predictors of a 2-stent technique, respectively. Overall, 36% received 1 stent and 64% received 2 stents. Mean age was 66 years and women comprised about a quarter of each group.

Results showed that the adjusted odds ratios (aORs) for clinical indication and LMCA bifurcation were 1.73 and 2.04, respectively, while the aORs for SB lesion length and lesion diameter were 1.06 per mm and 1.04 per 1%, respectively, for predicting two-stent PCI.

For the primary composite MACE endpoint, comprising cardiac death, target-lesion myocardial infarction or ischemia-driven target-lesion revascularization, the as-treated analysis revealed that one-stent PCI was associated with a lower rate at two years compared with two-stent PCI (9% vs. 14%; aOR, 1.53). No interaction with OCT was observed.

Planned-strategy analyses showed no significant differences in MACE, and in patients treated with a double kissing (DK)-crush technique, angiography-guided DK-crush was associated with higher MACE rates vs. OCT-guided DK-crush.

In what they believe is the largest study of its kind, Lene Dohn Andreasen, MD, PhD, et al. write that "...the comparisons between 1-stent and 2-stent techniques in the present analysis should be interpreted as observational, as patients were randomized to OCT-guided vs. angiography-guided PCI, not to stent technique," emphasizing that "further studies are needed to clarify how OCT-guided lesion assessment can optimize stent strategy selection..."

"As [drug-coated balloons] make further inroads into coronary bifurcation PCI, the balance between DCB use and [drug-eluting stents] will have to be determined," writes H. V. 'Skip' Anderson, MD, in an accompanying editorial. "...coronary bifurcations are not simple matters, and there are numerous possibilities to be compared."