When and how to perform the provisional approach for distal LM stenting

Despite the tremendous developments that have been made in the field of interventional cardiology over the past few decades, the percutaneous treatment of left main (LM) bifurcation still remains challenging. The provisional one-stent approach for LM bifurcation showed more favourable outcomes compared to the double-stenting technique. Consequently, it has been the preferred strategy in the majority of LM bifurcation stenosis. However, due to the large myocardial burden of the side branch, the risk of haemodynamic collapse after main vessel stenting has always existed. To reduce the risk of side branch occlusion and for proper selection of this strategy, it is acknowledged that meticulously performed IVUS evaluation of the side branch ostium is helpful. A fractional flow reserve measurement of the angiographically jailed side branch could also lead to the avoidance of an unnecessary complex intervention. However, as the overall data were derived from observational studies, further larger randomised trials would be necessary to assess the optimal provisional one-stent strategy for LM bifurcation.