1) Two-stent strategies can be used either as bail-out during provisional stenting if the side branch is compromised, or electively for complex bifurcation anatomies with predictors of side branch compromise. 2) Common two-stent techniques discussed include T/TAP stenting, mini-crush, culotte, and DK crush. Factors such as vessel diameters, angles, and lesion lengths help determine the appropriate technique. 3) Key steps discussed include optimal kissing balloon inflation, proximal optimization of the main vessel stent, and respecting the bifurcation anatomy. Being familiar with one or two techniques and using intravascular imaging is recommended.

1. Two-stent strategies:
A step by step approach
Ahmed Elborae
Assistant Lecturer, Cairo University
Aswan Heart Centre, Magdi Yacoub Heart Foundation

2. Agenda
• When ?
• Which ?
• How ?

3. Metanalysis of 21 RCT > Favoring provisional strategy with exception of DK-Crush

4. Two-stent was better
78% DK-Crush
82% Medina 1.1.1
62% LAD-D, 29% LMT
Relative risk reduction 57 %

5. Heterogeneous
Appropriate strategy for appropriate patient

6. When
1. Bail-out : Compromised SB during the provisional stenting strategy
-More than 75% SB stenosis with impaired TIMI flow < 3
-Chest pain and ECG changes
-Flow-limiting dissection
-FFR < 0.8 (DK VI trial)
Data from RCTs : Only needed in 5-20%

7. Accepted SB result
Yes
That’s it
No
Rewire-(PTCA/Kissing)-POT
Accepted SB result
That’s it
Bailout 2-stents technique
Provisional
stenting
Yes
No
“Provisional is a philosophy rather than technique”

8. TAP
Culotte
If a second stent needed

9. When
2. Elective : Complex bifurcation anatomy with predictors of
important SB compromise
“A Side branch you don’t want to lose”
-Diameter >2.5 mm
-Severe stenosis >5-10 mm beyond ostium
-Unfavourable angle for recrossing

11. "IF YOU FAIL TO PLAN, YOU ARE PLANNING TO FAIL"
“Benjamin Franklin’s”

12. • 1- The working view
• 2- Respect the anatomy
• 3-Optimal Kissing
• 4-Ideal POT
• 5- Know your tools
Five Fundamentals of 2-stents strategy

13. Point of the SB
take-off
Not always the
standard one
No overlap
No foreshortening
Hyung Yoo et al.JACC 2017
1-The working view
Need a 3rd eye ? > Intravascular imaging

14. 2-Respect the anatomy
1. The 3 diameters of a bifurcation.
Choosing strategy
DMV= SB > Culotte technique
Kissing balloon size
PMV DMV
SB
Finet et al. Eurointervention.2007
POT balloon size MV stent size

15. 2- Lesion length
SB lesion length
-Longer lesion length> more prone for occlusion,
Favoring 2 stents- strategy
-SB length>73 mm supply 10% myocardial mass
PMV lesion length
- Ensure enough stent length
for POT
PMV DMV DMV lesion length
- Ensure enough stent length
for kissing
SB
2-Respect the anatomy

16. • 3. Bifurcation angle
Hahn et al. Atherosclerosis. 2008 Dec
Bifurcation angle B
-More acute> More prone to SB compromise
-Determine bifurcation strategy
-Determine prognosis (Acute> worse)
B
A
Bifurcation angle A
-More acute> More difficult wiring
and re-crossing
Take care that angle might change after wiring or MV pre-dilatation
2-Respect the anatomy

17. 3- Optimal Kissing
Korean Circ J. 2018 Jun
-SB 1st then Simultaneous in/deflation

18. Why?
Darremont et al. Eurointervention.2015
Less struts in front of the SB

19. 3-Optimal Kissing
Korean Circ J. 2018 Jun
-SB 1st then Simultaneous in/deflation
-Short proximal overlap & respect Finet’s Law

20. Whenever kiss end with POT

21. 4-Ideal POT
Correction of mal-apposition in the proximal MB & facilitate rewiring
COBIS II registry: a significant difference in terms of a combined endpoint (MACCE) at 36-month follow-
up in favor of the POT group

22. 4-Ideal POT
• know the shortest available NC balloon 1:1 PMV
• Positioning is crucial ( distal marker opposite to carina)
Proximal optimisation technique in the bench with Kaname stent (Terumo, Tokyo, Japan)

23. 5-Know your tools (Balloons)
Shoulder at marker
Shoulder distal to marker

24. 5- Know your tools (Stents)
Courtesy of Jean Fajadet

25. 5- Know your tools (Stents)

26. 5- Know your tools (Stents)

27. Agenda
• When ?
• Which ?
• How ?

28. The best two-stent technique is the one you
are familiar with

29. MADS classification
D
Double
Provisional bailout
I-
Planned 2 stents

30. Preferred if the 2 branches are equal in size
You can start with either branches
Courtesy of E.Brilakis

31. Agenda
• When ?
• Which ?
• How ?

33. POT before re-wiring
Finish with a kiss
POT after kiss
General rule in all 2-stent strategies

34. Two-Stent Strategies
• T-Stenting / TAP
• Mini-Crush (Step Crush/DK Crush)
• Culotte technique
• V-Stenting
• Simultaneous Kissing Stenting (SKS technique)

35. T-Stenting
• Advantages:
- Suitable for angle 90
- Easy
• Disadvantages:
- Protrusion of SB stent
- Ostial gap (Restenosis)
Latib et al. EuroIntervention 2010
Rarely used nowadays

36. TAP-Technique
• Ensure full ostium coverage
• Bail-out” or Elective
• Create new metallic carina
Classic T
Courtesy of Francesco Burzotta, EBC
TAP
Proximal view

37. TAP-Technique
MB stent+ POT
“Provisional”
-Distal rewiring
-SB stent+ minimal protrusion
-Uninflated balloon in the MV
FKB Final POT

38. -SB balloon should be deflated last during kissing inflation to avoid distortion by the MB balloon
-If further SB/MB post-dilatation is needed , always finish with kissing/POT
SB
MB
Important Tips

39. Wire Recross
Courtesy of John Ormiston, EBC 2009
Allowing the projection of struts in the ostial segment of
the SB opposite the carina
Re-cross rule
All distal re-cross
Except crush

40. Two-Stent Strategies
• T-Stenting / TAP
• Mini-Crush (Step Crush/DK Crush)
• Culotte technique
• V-Stenting
• Simultaneous Kissing Stenting (SKS technique)

41. Classic crush (Too much protrusion)
• 7 Fr guiding catheter (2 stents)
• Rate of FKBI failure : 20%
• Failed kiss  high rate of ST and ISR
Ormiston et al.JACC: Cardiovascular Interventions,2018
Rarely used nowadays

42. Mini-Crush (Minimal protrusion)
Latib et al. EuroIntervention 2010
• 7 Fr guiding catheter (2 stents)
• Rate of FKBI failure : 20%
• Failed kiss  high rate of ST and ISR
Rarely used nowadays

43. Step mini-crush
• Advantages:
- 6F guide catheter (use MB balloon)
- Complete coverage SB ostium
- Secure SB 1st
• Disadvantages:
- Not suitable for wide angle
- Difficult SB Recross for FKBI
SB stent
Angio
+/- wire
Crush
Re-cross
Prox. MB stent Kissing

44. DK-Crush
• DK-Crush I : Less TLR and MACE (DK-Crush vs. classic Crush)
• DK-Crush II : Less TLR but not MACE (DK-Crush vs. Provisional T)
• DK-Crush III : Less MACE (DK-Crush vs. Culotte)
• DK-Crush V : Less TLR in LMT (DK-Crush vs. Provisional)
• DK-Crush VIII: Ongoing (IVUS guided vs angiographic guided DK crush)

46. SB stent
Angio
+/- wire
Crush
Re-cross
Prox.
1st Kissing
MB stent 1st POT Re-cross
Prox.
2nd Kissing
2nd final POT
DK-Crush
Sawaya et al. ACC: Cardiovascular Interventions,2016

47. Two-Stent Strategies
• T-Stenting
• Mini-Crush (Step Crush/DK Crush)
• Culotte technique
• V-Stenting
• Simultaneous Kissing Stenting (SKS technique)

48. Culotte Technique
• Advantages:
- Complete SB ostial coverage
- You can start with either branches
(Classic= MB 1st)
• Disadvantages:
- Excess metal proximal MB (Mini-Culotte)
- Not suitable for large size
mismatch
- Multiple rewiring (DK Culotte might facilitate?)
Latib et al. EuroIntervention 2010

49. Wiring both MB stent 1st POT Re-wiring SB
SB balloon
Or Kiss
SB Stent 2nd POT
Re-wiring MB Kissing 3rd final POT
Culotte Technique

50. Two-Stent Strategies
• T-Stenting
• Mini-Crush (Step Crush/DK Crush)
• Culotte technique
• V-Stenting
• Simultaneous Kissing Stenting (SKS technique)

51. V-Stenting
• Advantages:
- Suitable for normal proximal MB (rare)
- No need for rewiring
- Emergency technique
• Disadvantages:
- Geographic miss in proximal MB
- Large guiding 7 or 8 Fr
Latib et al. EuroIntervention 2010

52. Two-Stent Strategies
• T-Stenting
• Mini-Crush (Step Crush/DK Crush)
• Culotte technique
• V-Stenting
• Simultaneous Kissing Stenting (SKS technique)

53. SKS-Technique
• Advantages:
- Suitable for large proximal MB
- No need for rewiring
-Emergency technique
• Disadvantages:
- Large guiding 7 or 8 Fr
- Diaphragmatic membrane
-Challenging dealing with stent failure
A B
C

54. Recommended

55. • Where possible, keep it Simple, Swift and Safe
• Be familiar with 1 or 2 techniques , remember “ The one you know is the better one”
• Angiography is half of the truth and intravascular imaging is the other half
• Know your kit “balloons and stents” and more importantly respect it
• Always POT before re-wiring and re-POT after kiss
Take home message

56. Thank you