Redefining PCI for complex de novo left main coronary bifurcation lesions: first systematic review and meta-analysis of a hybrid drug-eluting stent and drug-coated balloon strategy
D Leal, M Guillen, N Aguirre, W Cueva, S Manzur, J Gasca, G La Mota, J GermanAbstract
Background
Complex de novo left main coronary bifurcation lesions are among the most challenging scenarios in contemporary percutaneous coronary intervention, involving a large myocardial territory and high procedural risk. Two stent techniques remain conventional but increase metal burden, complexity and restenosis risk. A hybrid strategy using a drug eluting stent in the main vessel and a drug coated balloon in the side branch has emerged as an alternative, yet no prior systematic synthesis has focused on this approach in left main bifurcation lesions.
Purpose
To provide the first systematic comparative evaluation of a hybrid drug eluting stent plus drug coated balloon strategy versus two stent techniques in complex de novo left main bifurcation intervention.
Methods
A systematic search through 1 January 2026 identified studies exclusively evaluating de novo left main coronary bifurcation lesions and reporting target lesion revascularisation, target vessel myocardial infarction or post procedural luminal stenosis. Comparative and single arm studies were analysed separately and not combined in pooled models. Comparative cohorts were synthesised using random effects models, while single arm hybrid studies were analysed independently to estimate pooled mid term event rates.
Results
Of 1 045 screened records, five cohort studies including 269 patients met inclusion criteria. Two propensity matched cohorts (n=160) showed numerically lower target lesion revascularisation with the hybrid strategy compared with two stent techniques (RR 0.45 [95% CI 0.14 to 1.40]; p=0.17) and a similar directional reduction in target vessel myocardial infarction (RR 0.63 [95% CI 0.08 to 4.97]; p=0.66). Main branch residual stenosis favoured the hybrid approach (−0.91% [95% CI −1.83 to −0.00]; p=0.05), whereas side branch residual stenosis was higher (8.38% [95% CI 6.99 to 9.77]; p<0.00001). Three additional hybrid cohorts (n=109), analysed separately, showed low mid term event rates, with pooled target lesion revascularisation of 1% (95% CI [0.00 to 0.05]) and target vessel myocardial infarction of 0% (95% CI [0.00 to 0.01]), consistent with the direction observed in comparative analyses.
Conclusion(s)
In complex de novo left main coronary bifurcation lesions, a hybrid drug eluting stent and drug coated balloon strategy was associated with numerically lower repeat revascularisation and myocardial infarction compared with two stent techniques and improved main branch angiographic results, with higher residual stenosis in the side branch. While evidence remains limited and predominantly observational, this synthesis provides a structured clinical framework for future prospective and randomised investigations.Post-PCI side branch stenosis (%)For image description, please refer to the figure legend and surrounding text.TLR: hybrid vs two-stentFor image description, please refer to the figure legend and surrounding text.