The approach to bifurcation lesions is based on the angiographic configuration of
the lesion(s) in the main branch and the side branch
Significant disease (>50% stenosis) in the ostium of the side branch increases the
likelihood of side-branch closure as well as the restenosis rate after PCI
ONE STENTVSTWO STENT STRATEGY
Default approach is one-stent technique ± provisional angioplasty/stent to side
Use two-stent technique if side branch is significant and has high-risk features for
The risk of side-branch closure with an ostial narrowing approaches 15%
PCI across an uninvolved side branch carries a less than 1% risk of occlusion
7 F or 8 F guiding catheter should be selected if the operator anticipates using
A 6 F guiding catheter can accommodate only two monorail balloon
8 F guiding catheter can accommodate two stent systems as well as other large-
diameter PCI devices such as the Rotablator or the Flextome Cutting Balloon
The maximum Rotablator burr that can be used with a 6 F guiding catheter is 1.5
It may be prudent to “upsize” guiding catheters when approaching any
bifurcation lesion so that all options remain available if trouble occurs during the
To protect the side branch, two guidewires are placed, one in the side branch and
one in the main vessel
The order of inflation is relatively unimportant
Wire markers or using two different wire types is helpful to reduce confusion
during balloon inflations and wire repositioning
When using a two-guidewire system, the guidewires may become entangled after
multiple wire manipulations
. Efforts should be made to avoid guidewire entanglement, which will prevent
advancement of the balloon and may result in failure to recross the stenosis.
Standard balloon use
Different balloon sizes may be required for each branch
Sequential balloon inflations or simultaneous “kissing” balloon inflations can be
performed with elimination of plaque shifting being the advantage of the latter
It is important to make sure that the main vessel can accommodate both balloon
diameters when performing kissing balloon inflations (proximal vessel should be
at least two thirds of the combined balloon diameters)
After stent placement in the main branch and the side branch, simultaneous
kissing balloon inflations are critical to restore the circular and fully expanded
stent to each lumen
Failure to perform final kissing balloon inflation will likely lead to restenosis
SEQUENTIAL BRANCH INFLATIONS
Dilate the main vessel first, the side branch second, and finish dilation in the main
A sequential main-side-main branch inflation strategy provides a safe and
Sequential inflations may result in suboptimal main vessel dilation and plaque
shifting , requiring repeated dilatations
An unprotected major vessel dissection will require reinstrumentation and
jeopardize further attempts to open the side branch
Serial inflations, first in one branch then in the other, as opposed to simultaneous
balloon inflations in both branches, may limit the need for extra manoeuvres.
T STENTING-2 STENTS
The side branch off ostium ,therefore
Angle <70 degree
Bend branch stenting first
Side branch stenting protrudes into
and get crushed after main stent
ONLY FOR EXPERTS
Angle is < 70 degree
Excellent coverage in excellent hand
Wire both vessels
Two stents are then advanced and positioned into each vessel of the bifurcation
with the proximal end of the side-branch stent in the main vessel
The side-branch stent is deployed first
The main-branch stent is then deployed
The side branch then needs to be rewired and balloon dilated
Final kissing balloon inflation is then performed to complete the procedure
JAIL FOR ONLY UNPARDONABLE MISTAKE
Physiologic Guidance for Bifurcation or Jailed Side-Branch Stenting is decided
by IVUS and FFR
To overcome visual elusion of best result
By using FFR, the “jailed” side branches with an FFR >0.75 have a very low clinical
event rate without further balloon or stent therapy to the side branch
Performing FFR of ostial side-branch lesions that appear to be <70% from
angiography can prove that most of these lesions are not physiologically
KEEP IT SIMPLE STUPID: KISS
Wire both main branch and side branch if side-branch loss is important.
Consider treating side branch first (i.e., balloon dilatation, rotational atherectomy, or cutting balloon).
Dilate and stent main branch; reassess side branch (can use FFR to determine hemodynamic significance).
Provisional PTCA + stent side branch. If stenting side branch, stent with pullback technique.
Choice of two-stent technique depends on size of proximal vessel, an assessment of the importance and risk of side-
branch closure, and operator expertise and preference.
Use two wires if side branch loss is important.
Dilate smaller branch first or use Rotablator or cutting balloon.
Dilate and stent main branch; reassess side branch.
Redilate side branch.
Stent side branch through main stent only when absolutely necessary; use FFR to assess physiologic significance of side
If a two-stent technique is used, final kissing balloon inflation is necessary to optimize outcomes