The IEC-online chapter on Bifurcation lesions

Dive into this chapter on Bifucations lesions, it aims to review current strategies in the treatment of coronary bifurcation disease. Enjoy free access up until 11 March!

Summary

Coronary bifurcations are by nature prone to the development of atherosclerosis. They pose technical difficulties for percutaneous interventional treatment and they are associated with higher stent thrombosis and restenosis rates. The optimal approach for true coronary bifurcations is still a subject of debate, especially when the side branch (SB) is large, not easily accessible and narrowed by a long lesion. The general philosophy is: keep it simple and safe, understand and respect the original bifurcation anatomy, optimize flow and function of a bifurcation following percutaneous coronary angioplasty and limit the number of stents which should be well apposed and expanded with limited overlap. The role of dedicated devices in this setting remains unclear. Complex techniques (using two or three stents) should be used only when necessary, because they are associated with a worse outcome. Final kissing balloon (FKB) inflation is strongly recommended when using a complex technique.

The consensus is that main branch (MB) stenting with provisional SB stenting should be the default approach in the majority of cases. This approach is associated with a low risk of failure and complications provided that the following guidelines are implemented: wiring of both branches when starting the procedure, stenting of the MB with a stent diameter adapted to the distal MB, immediate optimization of the proximal stent segment according to Finet’s law using the proximal optimization technique (POT). The procedure can then be stopped at this point, however, if the SB does need attention, then the POT/side/POT technique (Re-POT) or FKB can be used. If SB stenting is necessary T, TAP or Culotte stenting can be performed.