Bifurcation stenting: current strategies and new devices

Abstract

Based on the results of numerous randomised trials, the provisional approach of implanting one stent on the main branch has become the default approach to most bifurcation lesions. However, bifurcation intervention still remains technically challenging. Dedicated bifurcation stents have been designed to specifically treat coronary bifurcations with the aim of dealing with some of the shortcomings of the conventional percutaneous approach to bifurcation intervention. Most of the devices are aimed at facilitating the provisional approach. They are an exciting and innovative technology that may further simplify the management and current approach to bifurcation treatment. Currently, 11 devices are available that have either completed or are currently undergoing First-In-Man trials. The development of more drug-eluting platforms and larger studies with control groups demonstrating their clinical applicability, efficacy and safety are required before they are widely incorporated into daily practice.

Simple or Complex Stenting for Bifurcation Coronary Lesions

“…Furthermore, Latib et al recommended that an intentional "two-stent" strategy be reserved for bifurcations with a SB that has a relatively large diameter and disease that extends beyond the ostium. 20 From our subgroup analysis, we found no benefit of a complex strategy in these situations, individually or in combination.…”

Carina Shift Versus Plaque Shift for Aggravation of Side Branch Ostial Stenosis in Bifurcation Lesions

“…Currently, the provisional approach of main vessel (MV) stenting followed by optional treatment of the side branch (SB) has become the default approach for most bifurcation lesions. 3 During provisional approach, MV stent implantation often aggravates an SB ostial (SBo) stenosis, inducing SBo compromise, which is the most important procedural complication during bifurcation lesion percutaneous coronary intervention. Previously, the major mechanism of this complication was believed to be plaque shift from the MV to the SBo.…”

A New Angle on Classifying Coronary Artery Bifurcation Stenoses

“…Despite attempts to utilize the preferred provisional strategy, up to 30% of provisionally-treated bifurcation PCI require implantation of a second stent in a pinched or stenotic SB when the SB has a large diameter (>2.0 mm), supplies a large territory, or the stenosis is associated with poor flow, ischemic symptoms, or ischemic electrocardiogram changes. 3 In addition, we currently have very little data on the optimal techniques for treating left main bifurcation stenoses where residual branch stenosis is less likely to be tolerated.…”

“…4 Despite best efforts to utilize a provisional strategy, modern investigations of drug-eluting stent bifurcation stenting demonstrate that bifurcations treated with a provisional strategy will frequently require balloon dilation and bail-out implantation of a second stent in the side branch (SB). 3 Importantly, the rates of bail-out SB stenting following a single-stent MB provisional strategy vary based on trial definitions for when a SB should be treated. In the CACTUS study, SB stenting was recommended following provisional single-stent MB PCI when the SB stenosis was greater than 50%.…”