Coronary artery bifurcation interventions: the disconnect between randomized clinical trials and patient centered decision-making.

The current evidence-base pertaining to PCI in coronary bifurcation lesions is not adequate to inform decision making in all patients, hence a gap still exists between the evidence-base and patient-centered decision-making. Although meta-analyses of the existing RCTs improve the statistical power of the data they do not remedy the problem of trial design. The reason for the gap between "evidence" and patient-centered decision-making is that the research methodology used in the RCTs does not simulate the questions asked in practice. The purpose of this review is to make the case for a counter perspective to the narrative that provisional stenting (PS) [stenting the main vessel (MV), with additional stenting of the side branch (SB) only in the case of an unsatisfactory result] is better than elective double stenting (EDS) of both branches in all patients. Namely, that neither approach should be the default strategy in all patients with bifurcation lesions and a decision as to which technique to use should be based on the patient's bifurcation anatomy. The majority of patients with bifurcation lesions will have anatomy that can be safely treated with PS; however, some patients have "at risk" bifurcation anatomy where PS may be associated with high risk of side branch occlusion.