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. 2022 Aug 5;18(5):e362-e376.
doi: 10.4244/EIJ-D-22-00165.

Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club

Remo Albiero  1 , Francesco Burzotta  2 , Jens Flensted Lassen  3 , Thierry Lefèvre  4 , Adrian P Banning  5 , Yiannis S Chatzizisis  6 , Thomas W Johnson  7 , Miroslaw Ferenc  8 , Manuel Pan  9 , Olivier Daremont  10 , David Hildick-Smith  11 , Alaide Chieffo  12 , Yves Louvard  4 , Goran Stankovic  13
Affiliations

Treatment of coronary bifurcation lesions, part I: implanting the first stent in the provisional pathway. The 16th expert consensus document of the European Bifurcation Club

Remo Albiero et al. EuroIntervention. .

Abstract

Stepwise layered provisional stenting (PS) is the most commonly used strategy to treat coronary bifurcation lesions (CBL). The term 'stepwise layered' emphasises the versatility of this approach that allows the adjustment of the procedure plan according to the CBL complexity, starting with stent implantation in one branch and implantation of a second stent in the other branch only when required. A series of refinements have been implemented over the years to facilitate the achievement of predictable procedural results using this approach. However, despite its simplicity and versatility, operators using this technique require full knowledge of the pitfalls of each procedural step. Part I of this 16th European Bifurcation Club consensus paper provides a detailed step-by-step overview of the pitfalls and technical troubleshooting during the implantation of the first stent using the PS strategy for the treatment of CBL.

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Conflict of interest statement

R. Albiero has received speaker fees from Medtronic, and Abbott. F. Burzotta has received speaker fees from Medtronic, Abiomed, Abbott, and Terumo. J.F. Lassen has received speaker fees from Medtronic, Boston Scientific, Biotronik, Abbott, and Biosensors. A.P. Banning declares institutional funding of a fellowship from Boston Scientific and has received speaker fees from Boston Scientific, Abbott, Medtronic, Philips/Volcano, and Miracor. T.W. Johnson has received speaker fees from Abbott, Boston Scientific, Medtronic, and Terumo and institutional funding for fellowships from Boston Scientific, and Terumo. D. Hildick-Smith has received ad board/consultancy/research funding from Terumo, Medtronic, Abbott, and Boston Scientific. M. Pan has received speaker fees from Abbott, Terumo, and Volcano. A. Chieffo has received speaker fees from Abiomed, and GADA. O. Darremont has received speaker fees from Edwards Lifesciences. Y.S. Chatzizisis has received speaker fees/consultancy/research funding from Boston Scientific, and Medtronic. G. Stankovic has received speaker fees from Medtronic, Abbott, Boston Scientific, and Terumo. T. Lefèvre has received speaker or proctorship fees from Abbott, Boston Scientific, Terumo, and Edwards Lifesciences. The other authors have no conflicts of interest to declare.

Figures

Central illustration
Central illustration. Step-by-step pitfalls, technical troubleshooting and pitfall prevention during the implantation of the first stent using the provisional strategy for the treatment of coronary bifurcation lesions.
An example pitfall is shown in the left panels. The red image borders denote where the pitfall occurred. The blue image border denotes the step commonly performed not suspecting the previous pitfall. The panel on the right with the violet border denotes the corrective step that arises from the pitfall. The panel on the right with the green border denotes how to prevent the pitfall. pMV: proximal main vessel; POT: proximal optimisation technique; SB/aSB: side branch/assigned side branch
Figure 1
Figure 1. The recommended 5 essential steps for the PS technique, previously reported in technical consensus papers (adapted from Lassen et al4).
See main text for detailed description. dMV: distal main vessel; LM: left main; KBI: kissing balloon inflation; pMV: proximal main vessel; POT: proximal optimisation technique; PS: provisional stenting; SB/aSB: side branch/assigned side branch
Figure 2
Figure 2. The SB/aSB wire is jailed abluminally beneath the proximal segment of pMV stent.
See main text for detailed description. The green image border denotes the optimal step. The red arrows and image borders denote where potential mistakes may occur (pitfalls). The violet arrows and image borders denote the corrective steps that arise from the pitfalls. The light blue arrows and image borders denote the steps commonly performed not suspecting the previous pitfalls. dMV: distal main vessel; IVUS: intravascular ultrasound; KBI: kissing balloon inflation; OCT: optical coherence tomography; pMV: proximal main vessel; POT: proximal optimisation technique; SB/aSB: side branch/assigned side branch
Figure 3
Figure 3. The SB/aSB wire is jailed intraluminally in the (crushed) proximal segment of the pMV stent. See main text for detailed description.
The green image border denotes the optimal step. The red arrows and image borders denote where potential mistakes may occur (pitfalls). The violet arrows and image borders denote the corrective steps that arise from the pitfalls. The light blue arrows and image borders denote the steps commonly performed not suspecting the previous pitfalls. dMV: distal main vessel; IVUS: intravascular ultrasound; KBI: kissing balloon inflation; OCT: optical coherence tomography; pMV: proximal main vessel; POT: proximal optimisation technique; SB/aSB: side branch/assigned side branch
Figure 4
Figure 4. OCT-guided rescue following undersized stent deployment from the LAD into the LM and loss of the original wire position.
A) Abluminal left main stem (LMS) wire position (black line) with the luminal position in the LAD stent segment (white dotted lines). Cross-sectional OCT imaging of the LMS (a) and LAD (b) demonstrate abluminal and luminal wire positions (white asterisks), respectively. B) Use of a dual lumen catheter, loaded on the abluminal wire (white line), facilitating passage of a second wire (blue line) through the true lumen of the stent, confirmed using 3D bifurcation OCT software (C). LAD: left anterior descending coronary artery; LM: left main; OCT: optical coherence tomography
Figure 5
Figure 5. The catheter stops inside the pMV stent at the level of the SB/aSB origin (after proximal rewiring, KBI and distal POT).
See main text for detailed description. The green arrow and image borders denote the optimal steps. The red arrows and image borders denote where potential mistakes may occur (pitfalls). The violet arrow and image border denote the corrective step that arises from the pitfall. The light blue arrows and image border denote the step commonly performed, not suspecting the previous pitfall. dMV: distal main vessel; IVUS: intravascular ultrasound; KBI: kissing balloon inflation; OCT: optical coherence tomography; pMV: proximal main vessel; POT: proximal optimisation technique; SB/aSB: side branch/assigned side branch
Figure 6
Figure 6. The catheter stops in the aorta at the edge of an ostial LM stent. See main text for detailed description.
The light blue image border denotes the step commonly performed, not suspecting the previous pitfall. The red arrows and image borders denote where potential mistakes may occur (pitfalls). The violet arrows and image borders denote the corrective steps that arise from the pitfalls. dMV: distal main vessel; IVUS: intravascular ultrasound; LM: left main; OCT: optical coherence tomography; POT: proximal optimisation technique; SB/aSB: side branch/assigned side branch
Figure 7
Figure 7. ICI-identified longitudinal LM stent deformation.
A) Acute disruption of a self-expanding nitinol stent device within the LM – disrupted and malapposed struts highlighted with white triangles. B) Guide catheter engaged in an eccentric LM ostium. LM: left main
See this image and copyright information in PMC

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