Double kissing inflation outside the stent secures the patency of small side branch without rewiring

Abstract

Background: The jailed balloon technique is widely used for coronary bifurcation lesions, but a residual risk of SB occlusion remains, necessitating SB rewiring and further interventions, including balloon inflation or stenting, which may result in failure and SB loss. This study introduced a novel modified technique of small side branch (SB) protection, namely, double kissing inflation outside the stent (DKo) technique, for coronary bifurcations without the need for SB rewiring.

Methods: We performed the DKo technique in consecutive patients in our center from 1/2019 to 12/2019. The procedure was as follows. We inserted a guide wire into both branches followed by proper preparation. The SB balloon was simultaneously inflated with main vessel (MV) stenting. The SB balloon remained in situ until it was kissing inflated with postdilation of the bifurcation core, which is different from traditional strategies. The proximal optimization technique was performed with a short noncompliant balloon strictly not exceeding the bifurcation. Rates of SB loss and in-hospital outcomes were evaluated.

Results: The technique was successfully performed in all 117 enrolled patients without any rewiring or SB loss. The mean lesion lengths of the MV and SB were 38.3 ± 19.9 mm and 11.7 ± 7.1 mm, respectively. On average, 1.5 ± 0.6 stents were used per patient, while the mean pressure of the SB balloon was 7.4 ± 3.1 atm. DKo achieved excellent procedural success in the proximal and distal MVs: increased minimal lumen diameter (0.64 ± 0.58 mm to 3.05 ± 0.38 mm, p < 0.001; 0.57 ± 0.63 mm to 2.67 ± 0.35 mm, p < 0.001) and low residual stenosis (11.4 ± 3.4%; 7.2 ± 4.6%). DKo secured the patency of the SB without any rewiring and improved the SB stenosis with minimal lumen diameter (0.59 ± 0.48 mm to 1.20 ± 0.42 mm, p < 0.001) and stenosis (71.9 ± 19.4% to 42.2 ± 14.0%, p < 0.001). No MACE was noted in the hospital.

Conclusions: DKo for bifurcation lesions was shown to be acceptable with high procedural success and excellent SB protection.

Keywords: Coronary bifurcation lesion; Kissing balloon inflation; Percutaneous coronary intervention; Side branch protection.

Fig. 1

Schematic image depicting the key steps of traditional JBT and DKo techniques. a Coronry bifurcation lesion. b Stent deployment with jailed balloon protection. c Postdilation of bifurcation in traditional JBT caused carina shift. d POT, e compromise of side branch, c′ Kissing inflation of bifurcation core. d′ POT. e′ Patency of side branch. JBT, jailed balloon technique; DKo, double kissing inflation outside the stent; POT, proximal optimization technique

Fig. 2

Step-by-step procedures of double kissing inflation outside the stent technique in one representative patient. a Bifurcation lesion of left anterior descending artery (LAD) and first diagonal branch (D1). b Wiring both branches and management of LAD with a semicompliant balloon; c A 3.5 * 38 mm stent was used to cover the LAD lesion, and a 2.0 * 20 mm balloon was delivered into the D1 covering its ostium; d First kissing inflation of the stent balloon (12 atm) and balloon (6 atm); e Second kissing inflation of D1 balloon (6 atm) and a noncompliant 3.5 * 15 mm balloon at the bifurcation core (20 atm); f TIMI 3 flow in D1 and LAD; g Proximal optimization technique was performed with a noncompliant 4.0 * 10 mm balloon; h Final results

Fig. 3

Distribution of main vessel stent and side branch balloon diameters. This is distribution of main vessel stent and side branch balloon diameters

Fig. 4

Representative images of one patient. a Bifurcation lesion of left anterior descending artery (LAD) and first diagonal branch (D1). b First kissing inflation of the stent balloon (12 atm) and balloon (6 atm); c Second kissing inflation of D1 balloon (6 atm) and a noncompliant 3.5 * 15 mm balloon at the bifurcation core (20 atm); d Proximal optimization technique; e Final coronary angiogram and its complete stent apposition and good stent symmetry in both distal (g) and proximal (h) stent segments