Percutaneous Coronary Intervention for Bifurcation Lesions: A State-of-the-Art Review of Techniques and Dedicated Devices

Abstract

Percutaneous coronary intervention (PCI) has become an integral step in the management of patients with ischaemic heart disease. Bifurcation lesions are commonly encountered in PCI and are regarded as the most technically challenging lesions to treat. The literature is saturated with studies that explore the best way to treat these lesions, with a variety of techniques introduced to enable stenting of both vessels. However, the optimal method is still undetermined. In this state-of-the-art review, we discuss the various strategies that are currently regarded as ideal, particularly those which involve one or two-stent techniques. Moreover, dedicated bifurcation devices have been developed to facilitate bifurcation stenting and improve outcomes. The role of these devices in this context is also uncertain, therefore we will discuss the current evidence for their use. Finally, a road map on the ‘tips and tricks’ to successfully perform bifurcation PCI is mentioned, which will aid any interventionist performing this procedure in an optimal manner.

Clinical and angiographic assessment of the culotte technique for the treatment of complex coronary bifurcation lesions

“…The most important decision when facing a coronary angioplasty of a bifurcation is whether to use a single-stent or a complex 2-stent strategy 3,5 . If using a single-stent strategy, the decision involves the completion of the provisional stenting technique, in which after implanting the stent in the main branch, it will be decided whether a balloon dilation or a second stent implantation in the side branch should be performed, establishing as criteria to treat the side branch, the presence of residual stenosis > 50%, TIMI <3 flow, or of side branch ostial dissection 2 .…”

“…Although the two-stent strategy is more demanding in terms of the operator learning curve, fluoroscopy time, amount of contrast used, and structural changes of the lesion during the procedure, there are situations where the use of two stents should be considered as the first option, like cases with > 2 mm diameter side branches, significant obstructive lesions > 70% in the origin of the side branch, diffuse lesions (> 20 mm) involving the origin and third proximal of the side branch, and left coronary artery main trunk lesions. The most relevant angioplasty techniques involving two stents are skirt, T stenting, TAP, culotte, V stenting, Y stenting, Crush, and DK-Crush, using for the planning of the procedure the MADS (main, across, distal, and side) classification that presents stenting procedures step by step, depending on the technique chosen 3,5 .…”

“…The current standard treatment for bifurcation lesions is the provisional stent technique that entails implanting a single stent in the main branch. However, in certain cases, the use of more complex techniques that require double stenting should be considered to treat both branches [3][4][5] . This study was aimed to perform a clinical and angiographic assessment of patients with true bifurcation lesions treated with the two-stent culotte technique.…”