Percutaneous Coronary Intervention for Bifurcation: How Can We Outperform the Provisional Strategy?

Abstract

In the era of drug-eluting stents, the provisional stenting strategy has been established as the default strategy in percutaneous coronary intervention for bifurcation lesions. However, emerging evidence shows that, in selected situations, the complex strategy of stenting both vessels regardless could reduce side-branch restenosis without penalty. In particular, the double kissing crush technique has been proven to outperform the provisional strategy and other complex strategies in randomized trials. In this review, we present the evidence comparing the 2 strategies and individual stenting techniques and discuss the roles of other optimization techniques such as final kissing balloon inflation, proximal optimization technique, intravascular ultrasonography, and optical coherence tomography. Finally, we suggest a practical approach for choosing the optimal strategy for intervention with coronary bifurcation lesions.

Keywords: Coronary artery disease; Coronary bifurcation lesion; Percutaneous coronary intervention.

Figure 1

Schematic illustration of the DK crush technique. First, wire both vessels and perform predilation. (A) Deploy first stent to the SB with small protrusion into the MV. (B) Inflate a balloon in the MV to crush the SB stent. (C) Rewire the SB through the stent struts and perform balloon dilation. (D) Perform first KBI. (E) Deploy second stent to the MV. (F) Rewire the SB and dilate the stent struts. (G) Perform second (final) KBI. Finish with POT. Remarks: The main difference between crush and DK crush is the use of first KBI. Abbreviations: DK, double kissing; KBI, kissing balloon inflation; MV, main vessel; POT, proximal optimization technique; SB, side branch.

Figure 2

Schematic illustration of the crush technique. First, wire both vessels and perform predilation. (A) Deploy first stent to the SB with small protrusion into the MV. (B) Inflate a balloon in the MV to crush the SB stent. (C) Rewire the SB through the stent struts and perform balloon dilation. (D) Deploy second stent to the MV. (E) Rewire the SB and dilate the stent struts. (F) Perform FKBI. Finish with POT. Abbreviations: FKBI, final kissing balloon inflation; MV, main vessel; POT, proximal optimization technique; SB, side branch.

Figure 3

Schematic illustration of the culotte technique. First, wire both vessels and perform balloon predilation. (A) Deploy first stent from proximal MV to SB. (B) Rewire distal MV and dilate through the stent struts. (C) Deploy second stent from proximal to distal MV. (D) Rewire the SB and perform FKBI. Finish with POT. Abbreviations: FKBI, final kissing balloon inflation; MV, main vessel; POT, proximal optimization technique; SB, side branch.

Figure 4

Proposed algorithm according to current evidence. Abbreviations: DK, double kissing; IVUS, intravascular ultrasonography; LM, left main; OCT, optical coherence tomography; SB, side branch.