Technical Complications of Coronary Bifurcation Percutaneous Interventions

Abstract

Coronary bifurcation percutaneous interventions (PCI) comprise a challenging subset of patients with coronary artery disease. Beyond the well-known debate about single versus double stent strategies, which have different outcomes on mid- and long-term follow up, both strategies may be subject, although rarely, to several different technical complications, rarely reported in clinical trials, which need to be defined, classified, and understood by cardiovascular professionals involved in the management of patients with coronary bifurcation disease. The present paper aims to broaden the knowledge of the range of intraprocedural complications and relative treatment during PCI of coronary bifurcations.

Keywords: complications; coronary artery disease; coronary bifurcation; percutaneous coronary interventions.

Figure 1

Medina classification and DEFINITION criteria for coronary bifurcation (left); general appearance of single stent strategy (upper right); general appearance of double stent strategy (lower right). SB: Side branch; MV: Main vessel; MB: Main branch.

Figure 2

Vessel rupture example in a patient with complex significant FFR bifurcation lesion of left anterior descending and left main coronary artery (A). Stent implantation at nominal pressure resulted in vessel rupture and tamponade (B). Recovery was obtained by prolonged balloon inflation and autotransfusion of the blood from the pericardial drainage (red arrow, (C)).

Figure 3

Ostial left anterior descending (LAD) coronary artery treated by crossover stenting from the left main to the LAD (A); note the portion of the balloon uncovered by the 4.0 × 13 mm stent during precise positioning of the stent itself (asterisk, (B)); original stent balloon was removed and a 1.5 mm balloon was inflated at nominal pressure inside the stent, and then the stent was retracted to the desired position (C) with a good final results (D).

Figure 4

Treatment of a complex trifurcation of left anterior descending coronary artery, ramus and left circumflex artery (A). After preparation of the lesion of ramus, a stent was passed with a lot of friction, resulting in stent and wire loss (B,C) across left main and ramus. A conversion to DK-crush technique was performed with good results (D).

Figure 5

Model of a complex bifurcation treated with the double-stenting strategy. Abluminal wiring: blue line and arrow indicate endoluminal wire crossing, while the red line and arrow indicate a wire which has crossed partially between the artery wall and the stent struts.

Figure 6

Stent deformation: a stent was placed crossover in left main and left anterior descending (A,B); an attempt was made to pass a POT balloon through, (C) but this resulted in stent deformation and shortening (white arrow, (D)).

Figure 7

A rare case of stent avulsion in a complex left main (LM) bifurcation disease (A) treated by provisional single stent strategy. After stenting of the LM to left anterior descending (LAD) coronary artery, the left circumflex (LCx) was rewired, and a POT-side-PO sequence was performed with the already-used balloon (B). After forced withdrawal of the LCx balloon, a no-flow on LAD was apparent, (C) and the crossover stent was no longer visible (D). (E) It was recaptured partially fractured outside the guiding catheter.