Temporal changes in characteristics, treatment strategies, and outcomes of coronary bifurcation lesion interventions Se Hun Kang a, *, Jung-Min Ahn b, *, Jung-Bok Lee c , Cheol Hyun Lee b , Do-Yoon Kang b , Pil Hyung Lee b , Soo-Jin Kang b , Seung-Whan Lee b , Young-Hak Kim b , Cheol Whan Lee b , Seong-Wook Park b , Duk-Woo Park b and Seung-Jung Park b Objectives Coronary bifurcations are common in daily practice of percutaneous coronary intervention and remain one of the most challenging lesions, but it is still unknown how characteristics, treatment strategy, and outcomes have changed over the last decade of drug-eluting stents (DES) era. We evaluated characteristics of treatment pattern and outcomes for patients with bifurcation disease over time in real-world clinical practice. Patients and methods A total of 7282 patients with coronary bifurcation lesions were pooled from the Interventional Cardiology Research Incorporation Society- Drug-Eluting Stents registry and the Interventional Research Incorporation Society-Left MAIN registry. Primary outcome was a target-vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or clinically indicated target-vessel revascularization. Results Among the total population, 2232 (30.7%) had left main bifurcation lesions. The use of one-stent strategy was more frequent in conjunction with second-generation DES (86.2 vs. 13.8%) than with first-generation DES (65.4 vs. 34.6%). Two-stent strategy was associated with a higher risk of TVF as compared with one-stent strategy [adjusted hazard ratio (HR): 1.28, 95% confidence interval (CI): 1.12–1.47, P < 0.001]. However, the risk of TVF with two-stent strategy relative to one-stent strategy has decreased from the first-generation DES (HR: 1.56, 95% CI: 1.22–1.99, P < 0.001) to the second-generation DES (HR: 1.12, 95% CI: 0.94–1.34, P = 0.19). Conclusion For patients with bifurcation disease, stenting strategy has become more simpler and percutaneous coronary intervention outcomes have more improved over time. One-stent strategy relative to two-stent strategy was associated with better clinical outcomes, but the advantage of one-stent strategy was less pronounced with the use of second-generation DES. Coron Artery Dis 30:33–43 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Coronary Artery Disease 2019, 30:33–43 Keywords: coronary artery disease, drug-eluting stents, percutaneous coronary intervention a Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, b Department of Cardiology and c Division of Biostatistics, Center for Medical Research and Information, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Correspondence to Duk-Woo Park, MD, PhD, Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: + 82 230 103 995; fax: + 82 24 756 898; e-mail: dwpark@amc.seoul.kr *Se Hun Kang and Jung-Min Ahn contributed equally to the writing of this article. Received 16 May 2018 Revised 10 September 2018 Accepted 28 September 2018 Introduction In the contemporary practice of percutaneous coronary interventions (PCIs), bifurcation lesions account for 15–20% of all coronary lesion subsets. Bifurcation PCI remains one of the most challenging procedures with respect to procedural complexity and a relatively higher rate of adverse clinical events, as compared with non- bifurcation PCI [1]. Nevertheless, during the past dec- ade, PCI outcomes for bifurcation lesions have steadily improved through advancements of device technology, procedural techniques, and background antithrombotic agents [2,3]. Especially, with the widespread adoption of drug-eluting stents (DES) with a lower risk of angio- graphic and clinical restenosis, PCI for complex bifurca- tion lesions has become more technically feasible and shows favorable short-term and long-term clinical out- comes. Moreover, newer-generation DES, as compared with first-generation devices, are associated with better efficacy and safety outcomes [4,5], and therefore the benefits associated with the use of newer-generation DES may be more pronounced for complex lesion sub- set such as coronary bifurcations. Although PCI procedures for bifurcation lesions have substantially improved in recent decade, limited data are available on the long-term trends of patient character- istics, stenting strategy, stent type, and associated clinical effects over time. Understanding such changes may be Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.coronary-artery.com. Original research 33 0954-6928 Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MCA.0000000000000672 Copyright r 2018 Wolters Kluwer Health, Inc. All rights reserved.