Approach to Distal Left Main Coronary Artery Bifurcation Lesions

Distal left main coronary artery (LMCA) bifurcation lesions are associated with a worse prognosis than other coronary bifurcation lesions. Although coronary artery bypass grafting remains a safe and effective treatment option in this patient population, percutaneous coronary intervention (PCI) has been increasingly adopted in patients with low-to-intermediate anatomical complexity due to its less invasive nature and the favorable long-term outcomes demonstrated in major randomized clinical trials. Given the substantial impact of LMCA revascularization on patient prognosis, meticulous procedural planning and optimization are of paramount importance. The use of intravascular imaging has proven to be of significant value both in making revascularization decisions and in optimizing PCI outcomes. Since the side branch in distal LMCA bifurcation lesions is the left circumflex artery, which supplies a significant portion of the myocardium, accurately predicting and preventing damage to this side branch is of vital importance. Intravascular imaging plays a key role in predicting side branch compromise and in determining the most appropriate stenting strategy, including provisional stenting or an upfront 2-stent approach. Regardless of the stenting strategy employed, achieving optimal minimal stent area targets is essential for improving long-term clinical outcomes. Adverse events following distal LMCA PCI most frequently occur at the left circumflex ostium, highlighting the importance of maintaining long-term side branch patency. Drug-coated balloons, which have demonstrated favorable results in bifurcation interventions, may represent a promising adjunctive therapy for side branch treatment during provisional stenting. However, further large-scale randomized studies are required to establish their role in distal LMCA bifurcation.