Inverted provisional in the left main: A therapeutic alternative in ostial circumflex lesions

Percutaneous revascularization of ostial lesions in the circumflex without involvement of the left anterior descending (LAD) (Medina 1,0,1-0,0,1) presents a clinical challenge due to higher event rates and complex anatomy. The inverted provisional has shown good outcomes in bifurcation lesions, although evidence in this specific setting remains scarce. Our aim was to assess the safety, immediate outcomes, and long-term follow-up of this technique in such lesions.

This is a retrospective study of patients treated with inverted provisional for left main lesions Medina 1,0,1-0,0,1 between 2017 and 2024. The primary endpoint was a composite of cardiac mortality, target lesion revascularisation (TLR), myocardial infarction and stent thrombosis.

A total of 29 patients were included, with a mean age of 71.7 ± 10.9 years and 75.9 % were male; 18 patients had a 0,0,1 lesion(62.1 %) and 11 patients had a 1,0,1 lesion(37.9 %). Left or balanced dominance was present in 48.2 %, and 86.2 % had moderate-severe angiographic calcification. The circumflex was larger than the LAD (3.55 mm vs 3.11 mm; p < 0.01). The immediate success rate was 96.6 %, one case required a second stent with TAP technique(3.4 %) due to dissection of the ostial LAD. After 3 years, the primary endpoint rate was 20.5 %, with a low rate of cardiac mortality(6.9 %) and TLR(13.8 %).

The inverted provisional was safe and effective for treating left main lesions Medina 0,0,1-1,0,1. This approach may be reasonable in patients with left or balanced dominance and a large circumflex, showing low event rates during follow, but it requires confirmation in larger prospective studies.