Percutaneous treatment of left main and non-left main bifurcation coronary lesions using drug-eluting stents

ABSTRACT

Current evidence and guidelines support the use of the single-stent technique as the default treatment strategy for the treatment of coronary bifurcations. For the single-stent technique, routine final kissing balloon inflation is not recommended, unless side branch ostial stenosis is assumed to be functionally significant. The double-stent technique is still a viable option for bifurcations with large and severely diseased side branches. Due to the unique features of bifurcation anatomy and bifurcation stenting techniques, all deployed stents should be optimized by postdilation, kissing balloon inflation and/or the proximal optimization technique, regardless of the stenting technique used. Intravascular ultrasound can guide preimplantation decision-making and postimplantation optimization by providing information on reference diameter, plaque burden and distribution, and stent underexpansion and malapposition.

KEYWORDS:

• Coronary bifurcation lesion
• percutaneous coronary intervention
• bifurcation stenting technique
• stent optimization
• single-stent technique
• double-stent technique

Key issues

• Current evidence and guidelines support the single-stent technique as the default treatment strategy for coronary bifurcations.

• Previous studies comparing the single- and double-stent techniques included considerable numbers of bifurcations with small and mildly diseased side branches (SBs). Therefore, the efficacy of the double-stent technique in bifurcations with large and severely diseased SBs remains to be investigated.

• The double-stent technique is still a viable option for coronary bifurcations with large and severely diseased SBs.

• The benefit of routine use of the jailed wire technique outweighs its potential harmful effects.

• A considerable number of angiographically jailed SBs have no hemodynamic significance.

• For the single-stent technique, routine final kissing balloon inflation is not recommended.

• The functional significance of SB jailing should be taken into account, before bail-out stenting is determined.

• Main branch (MB) first double-stent techniques should be reserved for provisional SB stenting.

• There are a number of double-stent techniques with their own strengths and weaknesses.

• The MB stent should be sized according to the distal MB reference diameter, bearing in mind its maximally achievable diameter and subsequently induced deformations.

• IVUS imaging can guide pre-implantation decision-making and post-implantation optimization.

• For the double-stent technique, high-pressure dilation of both ostia (preferably the SB first) followed by a lower pressure kissing inflation are mandatory to achieve full stent expansion.

• The proximal optimization technique has been reported to have several beneficial effects.

• Because of different anatomical characteristics and amount of feeding myocardium, some considerations must be given to PCI of unprotected distal left main bifurcations.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.