Korean Circ J.  2018 Jun;48(6):481-491. 10.4070/kcj.2018.0088.

Understanding the Coronary Bifurcation Stenting

• Gwon HC

• KMID: 2412540
• DOI: http://doi.org/10.4070/kcj.2018.0088

Abstract

Coronary bifurcation stenting is still complex and associated with a high risk of stent thrombosis and restenosis even with contemporary techniques. Although provisional approach has been proved to be the standard strategy of treatment, There is still lack of evidences for multiple steps of the procedure. For so many years we have been focused on the optimization of side branch (SB), but the clinical outcome is mostly dependent on the main vessel (MV) stenting. The optimal expansion of MV stent without the compromise of SB is the ultimate goal to achieve in the coronary bifurcation stenting. Understanding the anatomy and physiology of coronary bifurcation lesion should be the most important step to this goal. The relationship of vessel diameter between branches and the anatomical and functional significance of plaque shift and carina shift are two most important concepts to understand. They are the science behind the predictors of SB occlusion, and the rationale of proximal optimization technique and final kissing ballooning. This specific review will be devoted to review those concepts as well as clinical evidences to support them.

Keyword

Bifurcation lesion; Stents; Percutaneous coronary intervention

MeSH Terms

Percutaneous Coronary Intervention
Physiology
Stents*
Thrombosis

Figure

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  Figure 1 Various nomenclature systems of bifurcation lesion. MB = main branch; MV = main vessel; PV = parent vessel; SB = side branch.

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  Figure 2 IVUS of coronary bifurcation lesion. (A) Carina (white arrow) is spared of atherosclerotic plaque. (B) Carina shift (white arrow) by the over-expanded stent (IVUs images as the courtesy of Dr. Koo BK). IVUS = intravascular ultrasonography; MB = main branch; PV = parent vessel; SB = side branch.

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  Figure 3 POT and DOT. (A) POT is performed before SB rewiring by the recommendation of EBC. (B) My personal recommendation. POT is performed after SB rewiring with wire prolapse technique. DOT = distal optimization technique; EBC = European Bifurcation Club; POT = proximal optimization technique; SB = side branch.

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  Figure 4 POT-side-POT (re-POT) (A) MV stent is under-expanded after SB ballooning. (B) Correct positioning of a post-dilating balloon, aligning the proximal edge of distal balloon marker with the tip of stent carina. (C) Post-dilation. (D) MV stent is expanded after post-dilation. MV = main vessel; POT = proximal optimization technique; SB = side branch.

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