Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2024 Aug 5;20(15):e915-e926.
doi: 10.4244/EIJ-D-24-00160.

Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club

Francesco Burzotta  1   2 , Yves Louvard  3 , Jens Flensted Lassen  4 , Thierry Lefèvre  3 , Gérard Finet  5 , Carlos Collet  6 , Jacek Legutko  7 , Maciej Lesiak  8 , Yutaka Hikichi  9 , Remo Albiero  10 , Manuel Pan  11 , Yiannis S Chatzizisis  12 , David Hildick-Smith  13 , Miroslaw Ferenc  14 , Thomas W Johnson  15 , Alaide Chieffo  16   17 , Olivier Darremont  18 , Adrian Banning  19 , Patrick W Serruys  20 , Goran Stankovic  21
Affiliations
Review

Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club

Francesco Burzotta et al. EuroIntervention. .

Abstract

The 2023 European Bifurcation Club (EBC) meeting took place in Warsaw in October, and the latest evidence for the use of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to optimise percutaneous coronary interventions (PCI) on coronary bifurcation lesions (CBLs) was a major focus. The topic generated deep discussions and general appraisal on the potential benefits of IVUS and OCT in PCI procedures. Nevertheless, despite an increasing recognition of IVUS and OCT capabilities and their recognised central role for guidance in complex CBL and left main PCI, it is expected that angiography will continue to be the primary guidance modality for CBL PCI, principally due to educational and economic barriers. Mindful of the restricted access/adoption of intracoronary imaging for CBL PCI, the EBC board decided to review and describe a series of tips and tricks which can help to optimise angiography-guided PCI for CBLs. The identified key points for achieving an optimal angiography-guided PCI include a thorough analysis of pre-PCI images (computed tomography angiography, multiple angiographic views, quantitative coronary angiography vessel estimation), a systematic application of the technical steps suggested for a given selected technique, an intraprocedural or post-PCI use of stent enhancement and a low threshold for bailout use of intravascular imaging.

PubMed Disclaimer

Conflict of interest statement

F. Burzotta has received speaker fees from Medtronic, Abiomed, Abbott, and Terumo. J.F. Lassen has received speaker fees from Medtronic, Boston Scientific, Biotronik, and Abbott. R. Albiero has received speaker fees from Medtronic and Abbott. J. Legutko has received speaker fees from Abbott, Insight Lifetech, Philips, and Procardia. M. Pan has received speaker fees from Abbott, Boston Scientific, and Asahi. Y.S. Chatzizisis has received speaker fees/consultancy/research funding from Boston Scientific and Medtronic; and is co-founder of ComKardia Inc. T.W. Johnson has received speaker/consultancy fees from Abbott, Boston Scientific, Cordis, Medtronic, Shockwave Medical, and Terumo; and has received research funding from Abbott. A. Chieffo has received speaker/consultant fees from Abbott, Abiomed, Biosensors, Boston Scientific, Medtronic, and Menarini. G. Stankovic has received speaker fees from Medtronic, Abbott, Boston Scientific, and Terumo. M. Lesiak has received speaker fees from Abbott, Biotronik, Boston Scientific, Medtronic, Philips, and Terumo. T. Lefèvre has received minor fees from Terumo, Boston Scientific, Abbott, and Edwards Lifesciences. C. Collet has received a research grant and speaker fees and been on advisory board for Boston Scientific; has received a research grant and speaker fees from GE HealthCare, Insight Lifetech, Siemens Healthineers, HeartFlow, and Shockwave Medical; has received a research grant from Medis Medical Imaging, and Pie Medical; has stock options in Medyria; and has been a research director and equity holder of CoreAalst. O. Darremont reports support from Boston Scientific, Abbott, and Edwards Lifesciences. P.W. Serruys has received consulting fees from SMT, Meril Life Sciences, Novartis, Philips, and Xeltis. The other authors have no conflict of interest to declare.

Figures

Figure 1
Figure 1. Schematic representation of coronary bifurcation and trifurcation with the corresponding Finet’s law formula explaining the relationship between the different segments.
dMV: distal main vessel; pMV: proximal main vessel; SB: side branch
Figure 2
Figure 2. Bench test comparison of final stent conformation obtained by provisional stenting using two different stent platforms by the same manufacturer.
A) SYNERGY (Boston Scientific) 3.5 mm×20 mm DES implanted at nominal pressures followed by POT and kissing. B) SYNERGY (Boston Scientific) 4 mm×20 mm DES implanted at low pressure followed by POT and kissing. Cr: chromium; DES: drug-eluting stent; LAD: left anterior descending artery; LCx: left circumflex artery; LM: left main artery; POT: proximal optimisation technique; Pt: platinum
Figure 3
Figure 3. Sequence of stepwise provisional stenting and its clinical performance with step-by-step stent enhancement.
dMV: distal main vessel; KBI: kissing balloon inflation; MV: main vessel; pMV: proximal main vessel; POT: proximal optimisation technique; SB: side branch
Figure 4
Figure 4. Optimal SB rewiring site check by angiography resulting in good OCT results after 1-stent (A-D) and 2-stent techniques (E-H).
A) Baseline angiography in a patient treated by provisional. B) “Pullback rewiring” manoeuvre. C) Angiography confirming the achievement of distal rewiring. D) Post-PCI 3D OCT showing wide opening of the side branch. E) Baseline angiography in a patient treated by DK crush. F) Advancement of the wire towards the side branch ostium after balloon crush; G ) Fluoroscopic image confirming the “non-distal” rewiring site. H) Post-PCI OCT at the level of bifurcation showing optimal crushing of the side branch stent.
Figure 5
Figure 5. Suboptimal stent implantation revealed by stent enhancement imaging during bifurcation PCI.
A) Stent underexpansion caused by the calcified plaque (arrow); the incomplete crush of the SB stent (arrowhead). B) Incomplete POT in the proximal segment of the LM stent (brace). C) Partial stent deformation caused by the guiding catheter at the LM ostium. D) Uncovered SB ostium (arrow) due to a too distal stent implantation. E) Abluminal SB rewiring and SB stent deformation after kissing balloon inflation (brace). F) Neocarina displacement (arrow) towards the SB ostium caused by a too distal final POT. LM: left main artery; PCI: percutaneous coronary intervention; POT: proximal optimisation technique; SB: side branch
Figure 6
Figure 6. Example of recognised cause for intraprocedural thrombus formation during a 2-stent bifurcation stenting procedure.
A) Intraprocedural angiography showing filling defect (arrow) at the SB ostium during a DK crush procedure on the LM. B) Stent enhancement revealing major deformation after kissing balloon inflation due to abluminal LM stent wiring. DK: double-kissing; LM: left main artery; SB: side branch
Central illustration
Central illustration. Key points for achieving an optimal angiography-guided PCI.
The key points for achieving an optimal angiography-guided PCI include a thorough analysis of pre-PCI images (computed tomography angiography, multiple angiographic views, quantitative coronary angiography vessel estimation), a systematic application of the technical steps suggested for a given selected technique, an intraprocedural or post-PCI use of stent enhancement and a low threshold for bailout use of intravascular imaging. CT: computed tomography; dMV: distal main vessel; IVUS: intravascular ultrasound; KBI: kissing balloon inflation; MV: main vessel; OCT: optical coherence tomography; PCI: percutaneous coronary intervention; pMV: proximal main vessel; POT: proximal optimisation technique; SB: side branch; TIMI: Thrombolysis in Myocardial Infarction
See this image and copyright information in PMC

References

    1. Burzotta F, Lassen JF, Lefèvre T, Banning AP, Chatzizisis YS, Johnson TW, Ferenc M, Rathore S, Albiero R, Pan M, Darremont O, Hildick-Smith D, Chieffo A, Zimarino M, Louvard Y, Stankovic G. Percutaneous coronary intervention for bifurcation coronary lesions: the 15th consensus document from the European Bifurcation Club. EuroIntervention. 2021;16:1307–17. - PMC - PubMed
    1. Burzotta F, Lassen JF, Banning AP, Lefèvre T, Hildick-Smith D, Chieffo A, Darremont O, Pan M, Chatzizisis YS, Albiero R, Louvard Y, Stankovic G. Percutaneous coronary intervention in left main coronary artery disease: the 13th consensus document from the European Bifurcation Club. EuroIntervention. 2018;14:112–20. - PubMed
    1. Burzotta F, Lassen JF, Louvard Y, Lefèvre T, Banning AP, Daremont O, Pan M, Hildick-Smith D, Chieffo A, Chatzizisis YS, Džavík V, Gwon HC, Hikichi Y, Murasato Y, Koo BK, Chen SL, Serruys P, Stankovic G. European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions. Catheter Cardiovasc Interv. 2020;96:1067–79. - PMC - PubMed
    1. Albiero R, Burzotta F, Lassen JF, Lefèvre T, Banning AP, Chatzizisis YS, Johnson TW, Ferenc M, Pan M, Daremont O, Hildick-Smith D, Chieffo A, Louvard Y, Stankovic G. 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. EuroIntervention. 2022;18:e362–76. - PMC - PubMed
    1. Lassen JF, Albiero R, Johnson TW, Burzotta F, Lefèvre T, Iles TL, Pan M, Banning AP, Chatzizisis YS, Ferenc M, Dzavik V, Milasinovic D, Darremont O, Hildick-Smith D, Louvard Y, Stankovic G. Treatment of coronary bifurcation lesions, part II: implanting two stents. The 16th expert consensus document of the European Bifurcation Club. EuroIntervention. 2022;18:457–70. - PMC - PubMed

MeSH terms