In true bifurcations, the second stent tracked with more events, not the plan for one

Design

Post hoc analysis of a randomised trial (OCTOBER)

Population

1,201 patients with true coronary bifurcation lesions undergoing PCI

Primary outcome

Major adverse cardiac events at two years

Effect

As treated: 13.9% v 9.0%, adjusted HR 1.53 (1.04–2.27) for two stents; planned strategy: no significant difference

A post hoc analysis of the OCTOBER trial, published 28 September, looked at 1,201 patients with true coronary bifurcation lesions treated with PCI. Two-stent strategies were more likely with an acute presentation (odds ratio 1.73), left main bifurcation (2.04), and longer or tighter side-branch disease.

As actually treated, a single stent was associated with fewer major adverse cardiac events at two years than two stents (9.0% v 13.9%; adjusted HR 1.53 for two stents, 95% CI 1.04 to 2.27). But when patients were analysed by the strategy the operator planned, there was no significant difference. That pattern suggests complexity — the lesions that end up needing a second stent — drives the excess risk, rather than the technique itself.

One finding is more directly actionable: among double-kissing crush procedures, angiography guidance was associated with about twice the event rate of OCT guidance (HR 2.42, 1.12 to 5.24). The lowest event rates overall were with OCT-guided single-stent PCI.

• Planned one-stent and planned two-stent strategies had similar outcomes; choose by anatomy.
• Left main, acute presentation and severe side-branch disease predicted a two-stent approach.
• If performing double-kissing crush, intracoronary imaging guidance is worth using.
• Bailout to a second stent marks a higher-risk patient for follow-up.

Why it matters

It suggests the harm linked to two stents reflects the lesions that need them, not a reason to avoid planned two-stent PCI.

Don't overread it

This is a post hoc analysis of a trial designed to test OCT guidance, not stenting strategy.

The statistics, in plain English

An as-treated analysis compares patients by what they actually got, which mixes in the reasons they got it — patients who needed an unplanned second stent had harder lesions. The planned-strategy comparison is fairer and showed no difference. The crush subgroup result has a wide interval (1.12 to 5.24) and comes from a post hoc analysis, so it is a signal, not proof.

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