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Review
. 2025 Oct 16;12(10):410.
doi: 10.3390/jcdd12100410.

Coronary Bifurcation PCI-Part I: Fundamentals

Sara Pollanen  1 , Rongras Damrongwatanasuk  2 , Ju Young Bae  3 , Jason Wen  4 , Michael G Nanna  5 , Abdulla Al-Damluji  6 , Mamas A Mamas  7 , Elias B Hanna  8 , Jiun-Ruey Hu  4
Affiliations
Review

Coronary Bifurcation PCI-Part I: Fundamentals

Sara Pollanen et al. J Cardiovasc Dev Dis. .

Abstract

Percutaneous coronary intervention (PCI) of bifurcation lesions remain one of the most technically challenging areas in interventional cardiology. Careful planning and execution are needed to preserve main vessel and side branch patency, with evolving evidence guiding the choice between provisional and two-stent strategies, and between individual techniques. This narrative review, which represents the first installment of a two-part series, synthesizes current knowledge on bifurcation PCI, detailing the anatomical classifications, lesion assessment tools, procedural planning, and execution of techniques including T and Protrusion (TAP), double-kissing (DK) crush, mini-crush, culotte, V-stent, and emerging modifications. We contextualize the choice of strategy within lesion complexity, procedural goals, and patient-specific considerations. This review is intended as a visual, practical, technique-focused reference for interventionalists and interventional trainees involved in the management of bifurcation lesions.

Keywords: bifurcation lesions; bifurcation stenting; coronary artery disease; primary coronary intervention.

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Conflict of interest statement

Nanna reports current research support from the American College of Cardiology Foundation, the Patient-Centered Outcomes Research Institute (PCORI), the Yale Claude D. Pepper Older Americans Independence Center (P30AG021342), and the National Institute on Aging (K76AG088428). Nanna also reports being a consultant for Novo Nordisk, Merck, and HeartFlow, Inc. All other authors report no disclosures relevant to the present work.

Figures

Figure 5
Figure 5
TAP Technique. Original illustration.
Figure 10
Figure 10
Mini/Nano Crush using 7 Fr Technique. Original illustration.
Figure 1
Figure 1
Medina Classification, with prevalence data taken from [14]. Original illustration.
Figure 2
Figure 2
ABCD Classification of bifurcation and trifurcation disease. Original illustration.
Figure 3
Figure 3
Relationship between diameter of the proximal main branch vessel, distal main branch vessel, and SB vessels in a bifurcation or trifurcation, according to Finet’s formula. Original illustration.
Figure 4
Figure 4
Provisional Stenting Technique. If SB flow is compromised after provisional stenting, the SB can be rewired either in a 2-wire technique or 3-wire technique, followed by ballooning into the SB. Original illustration.
Figure 6
Figure 6
Wire crossing into the SB at a distal strut versus proximal strut prior to T-and-protrusion technique after provisional technique. Top row: (Step 1) Rewiring through the MV stent struts into the SB should be done through a distal cell. (Step 2) SB balloon dilation lifts the MB stent and allows it to scaffold the upper arm of the SB, such that subsequent (Step 3) delivery and (Step 4) deployment of the SB stent in TAP technique results in (Step 5) a final result with minimal protrusion of the SB stent into the MV. Bottom row: (Step 1) Rewiring through the MV struts should not be done through a proximal cell. (Step 2) SB balloon dilation deforms the MV stent at an angle that opens perpendicularly into the SB wall rather than into the SB lumen, such that subsequent (Step 3) delivery and (Step 4) deployment of the SB stent in TAP technique results in (Step 5) a final result with significant, undesired protrusion of the SB stent into the MV. This illustration is magnified for the reader to visualize the effects of distal versus proximal crossing. Original illustration.
Figure 7
Figure 7
T Technique. Original illustration. Please note that the description for steps 1 through 9 are identical to that of TAP (Figure 5), except for step 4. In step 4, if the SB stent is deployed with no protrusion into the main branch, it is a T. If the SB stent is deployed more proximally with a 1–2 mm protrusion into the main branch, it is a TAP.
Figure 8
Figure 8
Reverse Crush (Internal Crush) Technique. Original illustration.
Figure 9
Figure 9
Classic Crush Technique, as originally proposed. Subsequent versions of crush (not illustrated here) introduced the concept of re-wiring the SB through the jailed struts and performing kissing balloon inflation, as well as proximal optimization. Original illustration.
Figure 11
Figure 11
Mini/Nano Crush using 6 Fr Technique. Original illustration.
Figure 12
Figure 12
DK Crush Technique. Original illustration.
Figure 13
Figure 13
Culotte Technique. Original illustration.
Figure 14
Figure 14
V-Stent Technique. Original illustration.
Figure 15
Figure 15
SKS Technique. Original illustration. Please note that the description for steps 1 through 8 are identical to that of V-stenting (Figure 14), except for step 6. In step 6, if the protrusion into the proximal MV is only 1-2mm, it is V-stenting. If the protrusion into the proximal MV is significantly more than 1-2mm, it is SKS, creating a tall neocarina with a significant double barrel.
Figure 16
Figure 16
The MADS classification for defining and grouping coronary artery bifurcation stenting strategies based on the final position of the stent(s) and the implantation order. Original illustration.
See this image and copyright information in PMC

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