Tamara M. Atkinson, MD, FSCAI, Crispin H. Davies, MD, FSCAI, Huu Tam Truong, MD, FSCAI, and Faisal Latif, MD, FSCAI

Bifurcation percutaneous coronary intervention (PCI) is associated with increased risk of in-stent restenosis, stent thrombosis, and major adverse cardiovascular events. The majority of bifurcation lesions can be managed with a provisional strategy (one stent); however, a two-stent strategy may be needed for a subset of these complex lesions.¹ The DEFINITION study defined complex lesions as Medina 1,1,1/0,1,1 with major criteria, including left main (LM) side branch (SB) > 70% stenosis or non-LM SB > 90% stenosis, side branch (SB) > 2.5mm, and SB lesion length > 10mm with two minor criteria: moderate to severe calcification, multiple lesions, bifurcation angle < 45, main vessel (MV) diameter < 2.5mm, thrombus, and MV lesion length > 25mm. ²

In this “Tip of the Month (TOTM),” we will review some tips and tricks when performing bifurcation stenting.

Provisional (One-Stent) vs. Two-Stent Strategy

The provisional versus two-stent strategy is determined by the SB and lesion complexity, as previously defined. Operators should be comfortable with at least one of the two-stent techniques (DK-crush, crush, T/T and small protrusion [TAP], and culotte), the description of which is outside the scope of this TOTM. Both strategies should include the following techniques, which aim to reduce SB complications:

1. Wiring both the MV and SB
2. Meticulous lesion preparation
3. Intracoronary imaging pre- and post-PCI 
4. Adequate stent length in the proximal MV to facilitate the proximal optimization technique (POT)
5. MV stent sizing 1:1 to the distal MV 
6. Using noncompliant (NC) balloons sized 1:1 with the MV for POT and kissing balloon inflation (KBI) 
7. Mandatory use of KBI for two-stent techniques but not for provisional techniques
8. Always finishing with a 1:1 POT in the proximal MV

POT is critical in both provisional and two-stent strategies to ensure proximal strut expansion and apposition, open stent cells across the SB, reduce the risk of abluminal rewiring, and facilitate SB recross.³ When utilizing a provisional strategy, a final POT with the distal balloon shoulder positioned at the level of the carina is still necessary.⁴ Final KBI has not shown to improve outcomes in a provisional strategy, but it can be performed when the SB is compromised. Further interrogation with coronary physiology should be considered after provisional stenting if SB compromise is a concern.⁵

When utilizing a two-stent strategy, the use of a DK-crush technique facilitates the recross with improved rates of final KBI and improved outcomes in LM bifurcations.⁶

Failed Provisional Stenting

Bail-out strategies for a failed provisional approach include T, TAP, and culotte. Prior to proceeding with a second stent, the following steps should be considered:⁴

1. Give intracoronary nitroglycerin.
2. Ensure adequate POT was performed.
3. While leaving the jailed wire in place, rewire the SB through a distal strut and then pull the jailed wire.
4. Perform KBI with NC balloons sized 1:1 with distal MV and 1:1 with SB. 
5. Reperform POT on the proximal MV.
6. Consider the use of an alternative to KBI, which is POT-side-POT: Perform POT in the MV; dilate the SB ostium; and reperform POT on the MV.
7. If the SB is still compromised, then proceed with a two-stent technique.

Making the Recross a Success

As outlined in Figure 1, the following steps can be used to facilitate SB rewiring:^{7, 8}

1. Maintain the jailed wire until successful rewiring is performed with a separate wire.
2. Always perform POT on the MV with a distal balloon tip marker positioned at the level of the carina before rewiring.
3. Minimize the passage of wire behind the MV stent by utilizing one or more of the following:
   1. Use a J configuration when advancing the wire into the MV stent.
   2. Use a dual lumen microcatheter.
   3. Pull back the MV wire to wire the SB.
4. Shape the wire with a long tip (4–6mm) and a wide or double bend.⁸ If one shape fails, reshape the tip or consider changing to a stiffer, hydrophilic, or graded transition wire.  
5. Use the pullback technique, where the wire is advanced past the carina and then pulled back to catch the proximal (DK-crush) or distal strut (provisional or culotte). 
6. Use a dual lumen angled or steerable microcatheter to direct the wire into the SB.
7. Inflate the balloon in the distal MV to direct the wire into the SB (balloon block and support technique).⁹
8. Use a different angiographic view.

Balloon-Crossing Tips

When the balloon won’t cross into the SB, the following techniques can be performed to facilitate balloon crossing:

• Confirm that the SB wire is not behind the MV stent by using the techniques previously mentioned above and/or performing intracoronary imaging.
• Have a low threshold to rewire the SB to improve the crossing location.
• Reperform POT in the MV.
• Use a smaller-sized profile balloon.
• Advance a microcatheter across to create a channel for balloon passage. The microcatheter also may be used to exchange for a stiffer wire.

Summary

Bifurcation lesions can be challenging, but the following five principles can be applied to reduce SB complications:

1. Become comfortable with at least one of the two-stent technique and one bailout technique.
2. Perform lesion preparation and intracoronary imaging, which are essential
3. Wire both branches.
4. Always leave enough length in the MV to allow for a final POT.
5. Perform POT before every recross and after the final KBI. All bifurcation stenting should end with a POT.

In the end, the technique does not matter as much as the final result.

Figure 1

References

1. Burzotta F, Lassen JF, Lefèvre T, et al. Percutaneous coronary intervention for bifurcation coronary lesions: the 15th consensus document from the European Bifurcation Club. EuroIntervention. 2021 Mar 19;16(16):1307–1317.
2. Chen SL, Sheiban I, Xu B, et al. Impact of the complexity of bifurcation lesions treated with drug-eluting stents: the DEFINITION study (Definitions and impact of complEx biFurcation lesIons on clinical outcomes after percutaNeous coronary IntervenTIOn using drug-eluting steNts). JACC Cardiovasc Interv. 2014 Nov;7(11):1266–76.
3. Hoye A. The Proximal Optimisation Technique for Intervention of Coronary Bifurcations. Interv Cardiol. 2017 Sep;12(2):110–115.
4. Burzotta F, Lassen JF, Louvard Y, et al. European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions. Catheter Cardiovasc Interv. 2020 Nov;96(5):1067–1079.
5. Koo BK, Park KW, Kang HJ, et al. Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using fractional flow reserve. Eur Heart J. 2008 Mar;29(6):726–32.
6. Chen SL, Zhang JJ, Han Y, et al. Double Kissing Crush Versus Provisional Stenting for Left Main Distal Bifurcation Lesions: DKCRUSH-V Randomized Trial. J Am Coll Cardiol. 2017 Nov 28;70(21):2605–2617.
7. Ijioma N. Left Main Bifurcation Stenting: Tips and Tricks. Cardiology Magazine. 2021 Dec;50(12):28–30.
8. Burzotta F, De Vita M, Sgueglia G, et al. How to solve difficult side branch access? EuroIntervention. 2010 Dec;6 Suppl J:J72–80.
9. Li L, Liu J, Jin Q, et al. Case report of a novel maneuver to facilitate wire access to the side branch in bifurcation intervention-balloon block and support technique. Medicine (Baltimore). 2018 Jan;97(3):e9673.