European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions

Abstract

Background Defining the optimal conduction of percutaneous‐coronary‐intervention (PCI) to treat bifurcation lesions has been the subject of many clinical studies showing that the applied stenting technique may influence clinical outcome. Accordingly, bifurcation stenting classifications and technical sequences should be standardized to allow proper reporting and comparison. Methods The European Bifurcation Club (EBC) is a multidisciplinary group dedicated to optimize the treatment of bifurcations and previously created a classification of bifurcation stenting techniques that is based on the first stent implantation site. Since some techniques have been abandoned, others have been refined and dedicated devices became available, EBC promoted an international task force aimed at updating the classification of bifurcation stenting techniques as well as at highlighting the best practices for most popular techniques. Original descriptive images obtained by drawings, bench tests and micro‐computed‐tomographic reconstructions have been created in order to serve as tutorials in both procedure reporting and clinical practice. Results An updated Main‐Across‐Distal‐Side (MADS)‐2, classification of bifurcation stenting techniques has been realized and is reported in the present article allowing standardized procedure reporting in both clinical practice and scientific studies. The EBC‐promoted task force deeply discussed, agreed on and described (using original drawings and bench tests) the optimal steps for the following major bifurcation stenting techniques: (a) 1‐stent techniques (“provisional” and “inverted provisional”) and (b) 2‐stent techniques (“T/TAP,” “culotte,” and “DK‐crush”). Conclusions The present EBC‐promoted paper is intended to facilitate technique selection, reporting and performance for PCI on bifurcated lesions during daily clinical practice.

Assessment of single and double coronary bifurcation stenting techniques using multimodal imaging and 3D modeling in reanimated swine hearts using Visible Heart® methodologies

“…According to EBC recommendations [3][4][5], the minimal treatment for bifurcated coronary lesions is stent implantation in the MV (also called "crossover" stenting) with the stent sized 1:1 according to the distal MV, followed by POT with the balloon sized 1:1 according to the proximal MV.…”

“…During one-stent strategies, after stenting the MV, it may become clinically necessary to intervene on the SB. To do this, physicians typically perform SB rewiring, followed by kissing balloon inflation [3][4][5]. Since the SB rewiring site is known to influence final stent deformations [13], we performed side-cell crossing to the SB using a pullback technique [14] in order to facilitate "distal" stent frame rewiring.…”

“…In some specific anatomic conditions, the selection of an "inverted" provisional strategy might considered [3][4][5]. This technique is executed by implanting the stent from the SB into the proximal MV, then following the same steps of provisional (POT, distal rewiring, kissing, and re-POT).…”

“…A culotte procedure may begin by deploying a stent in the MV (according to crossover stenting provisional approach) or covering the SB and proximal MV (according to inverted provisional approach) [3][4][5]. Regardless of beginning strategy, both stents must be appropriately sized to fit each of the distal branches as well as the proximal MV.…”

Summary of Practice Considerations for Percutaneous Coronary Intervention of Left Main Bifurcation Disease

“…imaging and functional severity, and supported by current guidelines and publications, the following practice considerations are recommended. [1][2][3][4][5][6]…”