Current Concepts in Bifurcation Stenting

124 124 © 2018 Indian Heart Journal Interventions | Published by Wolters Kluwer ‑ Medknow
Editorial Review
Current Concepts in Bifurcation Stenting
Rajiv G. Bhagwat, Ronak V. Ruparelia1
Department of Cardiology, Heart Institute, Nanavati Hospital, Mumbai, Maharashtra, 1
Department of Cardiology, Bankers Heart Institute, Vadodara, Gujarat, India
Abstract
A bifurcation lesion is traditionally defined as a coronary artery narrowing occurring adjacent to and/or involving the origin of
a significant side branch. Long before the nomenclature of lesion complexity matured, side-branch involvement was recognized
as an unfavorable determinant of angioplasty success. Miere and associates were among the first to define the risk of side-branch
occlusion associated with parent vessel angioplasty, emphasizing the importance of plaque extension into the side branch as the
predictor of percutaneous coronary intervention (PCI) outcome. PCI of coronary bifurcation lesion poses a challenge to the
operator in terms of difficulty in wiring, passage of hardware, recrossing, and immediate/long-term outcomes. Several important
factors such as anatomic variation, angulation between branches, downstream territory, and the extent of plaque burden should
be taken into consideration when addressing a bifurcation lesion to choose the most appropriate approach and achieve an optimal
result. Factors to be considered before strategizing a bifurcation angioplasty include the extent of disease (whether it is limited
to ostium or extending beyond), size (2.5 mm reference diameter), and area of distribution of side branch. Implantation of a
single stent in the main branch is the most widely used approach and should be considered the default strategy. Two-stent strategy
as “intention to treat” should be considered for large side branches or when the disease extends beyond the ostium or a branch
supplying a significant territory.
Keywords: Bifurcation stenting, double crush stenting, MADS (main, across, distal, side) classification, medina classification,
proximal optimization technique, T-stenting
Introduction
Coronary bifurcations remain one of the most challenging
lesions in interventional cardiology. It carries poor
procedural success rate and worst long-term outcome if
not performed precisely. In this article, we will discuss
the fundamentals of bifurcation anatomy, physiology,
classification, and various strategies to treat coronary
bifurcation stenosis.
What is a Bifurcation Lesion?
Bifurcation lesion is a stenosis involving the origin
(or close proximity to the origin, i.e., up to 3 mm from
bifurcation point) of a “significant” side branch (SB).[1]
It
accounts for 15%–20% of all coronary interventions.[2]
The
stenosis can involve a larger main branch, smaller SB, or
both. Depending on the involvement of the components,
the bifurcation lesion can be divided into true or false
bifurcation lesion [Figure 1].
The European Bifurcation Club (EBC) defines bifurcation
as: “A coronary artery narrowing occurring adjacent
to, and/or involving, the origin of a significant SB.
A significant SB is a branch, whose loss is of consequence
to a particular patient (symptoms, location of ischemia,
viability of the supplied myocardium, collateralizing
vessel, left ventricular function).”[3]
Historical Aspects
Treatment of coronary bifurcation stenosis is an integral
part of the history of coronary angioplasty,[4-6]
and kissing
balloon inflation (KBI) was strongly recommended as
early as the 1980s. In those days, two angioplasty balloons
were positioned using two separate guiding catheters.
Address for correspondence: Dr. Rajiv G. Bhagwat,
Department of Cardiology, Heart Institute (1st Floor),
Nanavati Hospital, S. V. Road,
Mumbai, Maharastra 400056.
E-mail: rgb2204@gmail.com
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How to cite this article: Bhagwat RG, Ruparelia RV. Current concepts
in bifurcation stenting. Indian Heart J Interv 2018;1:124-35.
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Bhagwat and Ruparelia: Bifurcation stenting
Indian Heart Journal Interventions ¦ Volume 1 ¦ Issue 2 ¦ September-December 2018 125
Advent of the coronary stent completely changed
the approach toward bifurcation lesions. Many stent
implantation techniques were described during the 1990s.
Drug-eluting stent (DES) revolutionized the treatment
of bifurcation lesions, it reduced in-stent restenosis to
a great extent. Single-stent technique of stenting of the
main branch with a provisional approach for the SB is the
most widely accepted one. Six randomized studies[7-12]
as
well as various meta-analyses[13-17]
comparing dual-stent
techniques with provisional SB stenting have shown that
complex strategies may not confer greater benefit.
Anatomical Considerations
Coronary tree follows the principle of fractal geometry. It
branches off into asymmetrical sized daughter branches
as it bifurcates. Ramification of the coronary tree, as
all ramifications in nature, follows the rule of minimum
energy cost in providing the underlying myocardium with
the amount of blood required. There are three segments
in a bifurcation (and not two as previously thought),
each one has its own reference diameter [Figure 2]. The
relation between the diameter of the proximal segment of
the main vessel and the two distal segments is governed
by the classic Murray’s law[19]
(Dprox3
– Ddist3
+
Dside3
). The complex formula was recently simplified by
Finet[20]
: Dprox = (Ddist + Dside) × 0.678.
Physiological Considerations
Coronary bifurcation flow has specific characteristics.
It follows the Bernoulli’s principle. In the vicinity of the
carina (flow divider), as on the outside of the curves, the
flow is rapid, linear, and generates intense friction (wall
shear stress) on the vessel wall resulting in antiatherogenic
molecular, histological, and functional modifications.[21,22]
Opposite the carina, as on the inside of the curves, there
is a recirculating, oscillating flow generating low and
pro-atherogenic wall shear stress. Carina is generally
atheroma free, the atheroma develops in the low shear
stress areas in the segments opposite the carina in the
vicinity of the bifurcation. Formation of the atheroma
alters flow patterns. Distal and circumferential expansion
of the plaque may reach as far as the carina.
Classification of Bifurcation Lesions
Many classifications of bifurcation lesion have been
proposed [Figure 3]. Few of them are (1) Medina,
(2) Duke, (3) Sanborn, (4) Lefevre, (5) Safian, and
(6) Movahed. Most of them need to be memorized, except
for the widely accepted Medina classification [Figure 4].
It considers the presence of 50% stenosis as significant
stenosis in a bifurcation lesion. However, it does not take
into account the angle of bifurcation, calcification, lesion
length, and size of the SB. Moreover, it considers 50%
as a significant lesion, which may not be of physiological/
functional significance.
Overall, none of the classifications is perfect, one has to
apply his own experience to decide about the approach
and strategy to treat a bifurcation lesion.
Suggested Approach for Handling a Bifurcation
Lesion
Treating bifurcation lesion is challenging, but a simple
algorithm based on the SB size, stenosis, and angulation
can be used [Figure 5].[18]
The most important issue in a bifurcation intervention
is selecting the most appropriate strategy for an
individual bifurcation and optimizing the performance
of this technique. Latib and Colombo have suggested
that there are three questions [Figure 6], which an
operator needs to answer to decide the appropriate
strategy, is it a true bifurcation, is the SB disease
diffuse, and is the SB suitable for stenting.[16]
These
Figure 2: Newer model of a bifurcation anatomy (Adapted from
Waksman and Ormiston.[18]
). MB = main branch, QCA = quantitative
coronary analysis
Figure 1: True and false bifurcation lesions.[53]
MB = main branch

126 126 Indian Heart Journal Interventions ¦ Volume 1 ¦ Issue 2 ¦ September-December 2018
questions determine the likelihood of success with
a provisional approach and determine whether the
operator is willing to accept a suboptimal result in the
SB with balloon angioplasty only. If the answers to all
these questions are in the affirmative, the bifurcation
may still be treated with one stent, but the operator
should consider a two-stent approach as intention to
treat in view of suboptimal result.[18]
When treating bifurcation lesions, close attention must
be directed toward choosing a guiding catheter large
enough to accommodate two balloons and two stents.
A wire should be placed in the SB, especially if there
is disease at the ostium or with a problematic takeoff.
When the SB is not severely diseased, implantation of a
stent in the main vessel (MV) and provisional stenting of
the SB is the preferred strategy. However, implantation
Figure 6: Selection of strategy based on three questions (Adapted from
Waksman and Ormiston.[18]
). MB = main branch
Figure 5: Strategy to treat a bifurcation lesion based on SB angle, SB
size and SB obstruction (Modified from Waksman and Ormiston.[18]
).
MB = main branch, FKBD = final kissing balloon dilatation
Figure 4: Medina classification.[53]
MB = main branch, SB = side branch
Figure 3: Various classification of bifurcation lesions (Adapted from Waksman and Ormiston.[18]
)

of two stents is recommended when both branches are
large (2.75 mm) and significantly diseased.
Technical Aspects
Manytechniqueshavebeendescribedandusedsuccessfully
in the treatment of bifurcation lesions. Classification
of techniques has been complicated and has caused
confusion in the past. The EBC has suggested a MADS
(main, across, distal, side) classification, taking into
account initial stent deployment, which often corresponds
to a technical strategy related to the importance of the
vessel that is treated first.[23]
As shown in Figure 7, the first family of technique
(M) starts by stent implantation in the proximal main
vessel relatively close to the carina. The opening of the
stent toward both branches may follow this initial step with
subsequent successive or simultaneous stent placement in
one or both distal branches. The second family (A) starts
with the stenting of the proximal main vessel to the distal
main branch across the SB. This may be the first and
the last step of the procedure but may also be followed
by the opening of the stent struts, delivery of a second
stent in the SB, and with or without KBI. The third family
(D) involves the distal branches and historically starts with
simultaneous stent placement at the ostium of both distal
branches (V-stenting). The simultaneous kissing stents
(SKS) technique is a variant that creates a new carina.
The fourth family (S) involves strategies in which the SB
is stented first, either at the ostial level or with a relatively
pronounced protrusion into the proximal main vessel. The
SB stent may be crushed with a balloon inflated in the
main vessel, or a second stent may be deployed in the main
vessel across the SB.[23]
The MADS classification, which is for the treatment of
bifurcation lesions, does not exhaustively describe the
technical aspects of interventional techniques, which
include the use of wires, lesion preparation, single balloon
inflation, KBI, or using one or two stents. Therefore,
Movahed and Stinis[24]
have suggested classifying the most
common bifurcation techniques with regard to stenting
into six categories: one-stent technique, stent with balloon
technique, kissing-stent technique, T-stent technique,
crush-stent technique, and culotte-stent technique.[25]
The most important issue in bifurcation intervention is
selecting the most appropriate strategy for an individual
bifurcation and optimizing the performance of this
technique.[25]
Main branch stenting only
This strategy is used when the SB has ostial or diffuse
disease and is not suitable (too small) for stenting or is
clinically irrelevant.[24]
Provisional SB technique
This is the most frequently used technique for bifurcation
lesions.
The following approach is followed:
I. Both MV and SB are wired. The most difficult
branch should be wired first. Torquing maneuver
of the second wire should be limited to avoid wire
entanglement. Wiring of SB alters the bifurcation
angle, which facilitates access to the SB after
stenting of MV. SB wire also reduces the risk of SB
occlusion following MV stenting and can be used
as a marker in case of SB occlusion. (Tip: MV wire
should be shaped in such a manner that it can be
used to recross into SB if required) (Tip: A jailed
wire, preferably non-hydrophilic, in SB is safe until
and unless the stent is overlapping the radiopaque
segment of the wire)
Figure 7: MADS classification (Adapted from Louvard et al.[3]
) MB = main branch, DM = distal main, PM = proximal main

II. Predilatation depends on operator preference.
Optimal preparation of MV lesion is recommended.
However, predilatation of the SB lesion remains
controversial. Potential risks with SB dilatation
include the risk of dissection, which may end up
with SB stenting and increased risk of SB restenosis.
III. Stenting of MV. (Tip: Stent should be selected as
per the size of distal MV.) Larger stent, if selected
with reference to proximal MV, increases the risk of
carinal shift and distal dissection. Stenting also alters
the geometry of the bifurcation. A large-diameter
stent changes the SB access plane to more parallel
to MV, it may hinder recrossing of the wire as well
as the balloon into the SB. (Tip: Operator must be
aware of the stent platform, especially when dealing
with the left main bifurcations. One must be aware of
the expansion limit of the stent. Detailed discussion
of various stent platforms is beyond the scope of this
article.)
IV. Proximal optimization technique (POT): It restores
the initial physiologic anatomy of the bifurcation in
terms of larger proximal MV and smaller distal MV
accordingtoFinet’slaw.POTallowsstrutprotrusion
into SB with larger strut opening for easy guidewire
access and minimal or no carinal shift. (Tip: MV
stent should be sufficiently proximal to the SB
ostium to accommodate a short, large-diameter
balloon for POT—usually 6–8 mm in length.)
V. Recrossing into SB with a wire. (Tip: Jailed SB wire
should not be removed until recrossing is done with
another wire, alternatively, the MV wire can be used
for this purpose.) (Tip: Exercise caution to retrieve
this jailed wire because guiding catheter tends to get
pulled in while retrieving, it can damage coronary
ostia or can lead to longitudinal deformation of the
stent.) (Tip: Recrossing of the wire into SB should
be done through the cell closest to the carina to
achieve optimal coverage of the SB ostium and
minimize metal load at the carina.) (Tip: Difficult
SB recrossing can be accomplished by repeating
POT at higher pressure or with a bigger balloon.)
VI. Treating SB. Ormiston et al.[26]
showed that the
dilatation of stent struts at SB ostium leads to
marked distortion of MV stent. Hence, isolated
dilatation of SB is not advised. SB dilatation with
kissing has to be performed to avoid distortion
of MV stent. At this stage, failure to advance
the balloon into SB can occur because of wire
entanglement, altered angulation of bifurcation
after stenting, incorrect SB wire positioning, or
poor support. (Tip: Advancement into SB can
be facilitated by using a lowest profile balloon or
anchoring balloon technique. Alternatively, re-POT
at higher pressure can also help.)
VII. FKBI (final kissing balloon inflation). It allows
SB ostium treatment and apposition of the MV
stent struts on the SB ostium. It also facilitates the
correction of stent distortion and correction of
inadequate apposition in MV.
How to perform FKBI?
• Balloon must be sufficiently short to avoid inflation
outside the stent in MV and disease-free area in SB.
• Diameter of balloon must match with that of the two
distal branches.
• Use of noncompliant balloon allows improved stent
expansion in MV while reducing the risk of dissection
in SB.
• Various techniques can be used for FKBI (described
below).
Problem with FKBI:
• It increases procedural complexity, ovalization of
stent, proximal dissection, and suboptimal deployment
of proximal stent segment.
Nordic-BalticBifurcationStudyIII[27]
andCORPALKiss[28]
did not reveal any significant difference in FKBI versus
no-FKBI group in terms of death, non-procedural-related
myocardial infarction (MI), target lesion revascularization,
and stent thrombosis. However, angiographic restenosis
was significantly reduced with FKBI.
VIII. Second stent in SB is considered only if the result is
inadequate.
Indications for second stent are as follows:
• SB 2.5 mm (with thrombolysis in myocardial
infarction flow Grade III or fractional flow reserve
(FFR) 0.80)
• Flow-limiting dissection
• Hemodynamically significant SB
• Residual stenosis of 75%
(Note: FFR may be helpful in decision-making when
there is a significant residual lesion in SB after provisional
stenting.[29]
)
Functional significance of SB can be derived by
FFR as well as myocardial perfusion imaging (MPI).
MPI helps to determine the significance of SB by
calculating the percentage of myocardium at risk.
Revascularization is helpful when SB is supplying
10% myocardium. Recently modified size, number,
highest score has been introduced to determine the
clinical significance of SB.
IX. Various optimization protocols for provisional
stenting.
Multiple provisional stenting optimization protocols have
been described.
1. Classic FKBI: Simultaneous and symmetric inflation
pressure (12 and 12 atmospheric pressure [atm]) in MV
and SB with noncompliant balloons.

2. Modified FKBI as described by Mortier et al.[30]
: KBI
with 12 atm pressure in SB followed by partial deflation
to 4 atm, then inflation of MV to 12 atm, and finally,
simultaneous deflation.
3. POT followed by KBI with symmetric inflation pressure
with noncompliant balloons.
4. POT followed by 12 atm SB inflation (without KBI).
5. POT sequence followed by 12 atm SB inflation and
then final POT (without KBI). The full sequence is
called re-POT.[31]
(Tip: Simultaneous deflation reduces the chances of MV
deformation.)
(Tip: Noncompliant balloon should be used at least in SB to
prevent the occurrence of dissection, and short balloon should
be used to avoid oval distortion in proximal MV segment.)
Newer concepts
The detrimental effects of KBI include oblong proximal
stent deformation caused by the juxtaposition of the two
balloons. Mortier et al.[30]
reported an elipticity index
of 1.26 with KBI. This elliptical shape of proximal MV
stent can have detrimental effects on fluid dynamics.[32]
The balloon juxtaposition in the proximal MV is about
one-half of the balloon length. If the stented length in
the proximal MV is greater than the balloon overlap, the
proximal malapposition predicted by fractal bifurcation
geometry will not be corrected, and circular proximal
malapposition (bottleneck) may be induced.
The re-POT sequence corrects the elliptical deformation
of the proximal MV stent and residual strut malposition
induced on the MV side of the flow divider and on the
side of the bifurcation facing the SB ostium following SB
dilatation after initial POT. That the re-POT sequence can
be accomplished through a 5Fr-guiding catheter through the
radial route is a major advantage in a single-stent strategy.
Two-stent strategy as intention to treat
It requires appropriate patient selection, accurate
assessment of the lesion severity, distribution of SB
territory, and extent of SB lesion.
It should be reserved for true bifurcation with SB with the
following:
1. Relatively large in diameter (2.5 mm)
2. Larger territory of distribution
3. Severe disease that extends well beyond ostium
(10–20 mm)
4. Unfavorable angle for recrossing after MV-stent
implantation
Various two-stent strategies are as follows:
T-stenting
• Most frequently used to shift from provisional stenting
to stenting of SB [Figure 8]
• It is best when angle between MV and SB is close to 90°
• There are different forms of T-stenting, which are as
follows:
Classical T-stenting
• Both branches are wired and dilated
• Stent is deployed at the ostium of SB carefully to avoid
stent protrusion into the MV, at the same time trying to
minimize any possible gap
• Balloon from the SB is removed with wire in place
• Advance and deploy the stent in the MV
• Rewiring of the SB
• SB balloon dilatation
• Final kissing inflation
Modified T-stenting
• Performed by simultaneously positioning stent at the
SB and MV with the SB stent minimally protruding
into the MV.[33,34]
• SB stent is deployed first and then, after the wire and
balloon removal from the SB, the MV stent is deployed.
The procedure is completed with an FKBI.
Reverse T-stenting
• Best suitable bailout technique after initial MV stenting
• Rewiring the SB through the MV stent struts
• Ballooning and stenting of the SB
• Final kissing balloon is recommended for optimal result
Figure 8: T-stenting technique[54]

The main limitation of the above three techniques is
the possibility of stent gap between MV and SB stent.
Additionally, 90° angle between MV and SB is infrequent in
non-left main coronary bifurcation. Moreover, it is not easy
to recross the wire following T-stenting and protrusion (TAP)
in narrow angle. However, the main advantage of T-stenting
is that it is easy and not technically demanding.
T-stenting and protrusion
• Used to enhance SB ostial coverage.[25]
• Initial steps are similar to T-stenting except the position of
the SB stent, which is intentionally kept protruding in MV.
• Rest of the steps remains similar to that of classical
T-stenting technique.
• The KBI reorients the protruding SB stent struts,
resulting in a small neocarina.[35]
(Tip: If SB stent is protruded slightly more into MV, the
strategycanbeswitchedtointernalcrush,andif itisprotruded
extremely into MV, culotte can be performed as a bailout.)
V and SKS technique
• This technique [Figure 9] includes inflating two stents
simultaneously.[36,37]
• In V-stenting, both the stents are pulled back as close
as possible to create new carina as close as possible to
the original one.
• Although in SKS technique, two stents protrude into
the MV with the creation of double barrel and a very
proximal neocarina.
Advantages
• Operator will never lose access to any of the two
branches.
• Whenfinalkissisdone,thereisnoneedtorecrossanystent.
Limitations
• Incomplete proximal alignment of the two stents.
• Limited ability to effectively treat proximal dissections.
• Difficult to recross stent with guidewire (if required).
Crush technique
Minicrush is associated with more complete
endothelialization and in turn, less stent thrombosis,
as well as easier recrossing of the crushed stent
[Figure 10].
Different forms of crush technique are as follows:
Step-crush
Used when there is a need for two stents, and 6Fr-guiding
catheter is the only available option (e.g., radial
approach).
• Both branches are wired and fully dilated.
• Each stent is advanced and deployed separately.
• First, a stent is advanced into the SB protruding a few
millimeters into the MV.
• A balloon, rather than a second stent, is advanced into
the MV.
• Stent in the SB is deployed and the stent balloon is
removed.
• Angiography is performed and if the SB result is
adequate, the wire is also removed.
• MV balloon is then inflated to crush the protruding SB
stent.
• MV stent is advanced and deployed.
• Remaining steps are similar to that of classical crush
technique.
The result is identical to that obtained with the standard
crush technique, except that each stent is advanced and
deployed separately.
Figure 9: V and SKS stenting technique.[54]
MB = main branch

Minicrush
• 7Fr- or 8Fr-guiding catheter.
• Both branches are wired and fully dilated.
• Both SB and MV stents are advanced.
• SB stent is positioned so that approximately 1–2 mm of
the proximal end (minicrush) is within the MV.
• Rest of the steps are similar to that of standard crush
technique.
Double kissing crush technique
Modification of the step-crush procedure in which a
balloon kissing inflation is performed twice: First, after
a MV balloon crushes the SB stent and then the standard
final kissing inflation. The five basic steps of double
kissing (DK) crush are as follows:
• SB stenting
• Balloon crush
• First kissing
• MV stenting and crushing
• Final kissing
DK crush may be superior to the classic crush technique
with respect to acute procedural results and clinical
outcomes by facilitating successful final kissing inflation
in all patients.[38]
(Tip: Wire can traverse through the inadequately crushed
segment in the MV. This has to be identified and rewiring
should be performed.)
The crush may have to be carried out several times to
adequately crush the stent and often with more than
a nominal pressure. Boost images can help to identify
adequately crushed stent.
Reverse (internal) crush
An option in the setting of provisional SB stenting using
a 6Fr-guiding catheter.
• After stenting of MV, if the SB result is suboptimal,
internal crush could be an option to deploy a second
stent in SB.
• Guidewire is inserted into SB through stent and struts
are dilated.
• Second stent is advanced into the SB and left in position
without being deployed.
• A balloon is advanced into MV at the level of the
bifurcation making sure to stay inside the stent,
previously deployed in the MV.
• Stent in SB is retracted approximately 2–3 mm into MV
and deployed.
• Stent balloon is removed and an angiogram is obtained
to verify that a good result is present at the SB.
• Wire from SB is removed and balloon in MV is inflated
to high pressure.
• Remaining steps are similar to that of the crush
technique.
Advantages
• Immediate patency of both branches is assured.
• Important when SB is functionally relevant or difficult
to be wired.
• Confirms to vessel geometry, and complete coverage
of carina is observed, especially with DK crush
technique.
DK crush technique has certain advantages over other
crush techniques. These include the following:
• It achieves complete coverage of the carina with
minimum metal load.
• Barring technical difficulties, it gives the least all cause
mortality, cardiovascular mortality, re-myocardial
infarction and stroke (MACE) rates and target lesion
revascularization/target vessel revascularization in
most studies.
Limitations
• Need to recross multiple struts with wire and balloon.
• An angle of 50° or more between the two branches
has been suggested to be an independent predictor of
MACE after crush stenting.[39]
Ormiston et al.[26,40,41]
have suggested that appropriate SB
and MV dilatation is needed to fully expand the stent at
SB ostium to widen gaps between stent strut overlying the
SB and minimize stent distortion.
Figure 10: Crush stenting[54]

Culotte technique
• It is referred to as Y stenting or trouser legs [Figure 11].
• It was associated with high restenosis rate in the past,
but has regained popularity in the DES era.[42,43]
• It gives maximum coverage at bifurcation at the expense
of an excess of metal covering the proximal MV.[42]
• It can be used in all true bifurcation lesions irrespective
of thebifurcationangleandprovidesmorehomogenous
drug distribution at the side of the bifurcation.
• The only anatomic limitation is when there is a large
mismatch between the proximal MV and SB diameter,
which may lead to malapposition of the SB stent within
the proximal part of the MV.[44]
Culotte can be performed using a 6Fr-guiding catheter.
Following are the main steps:
• Both branches are wired and predilated.
• First, a stent is deployed across the smaller, more
angulated branch, usually the SB.
• Nonstented branch is then rewired through the stent
struts and dilatation is performed to facilitate passage
of the second stent.
• Stent is advanced and expanded into the nonstented
branch, usually the MV.
• Finally,KBIisperformedwithpreferablynoncompliant
balloons, and each limb of the culotte is dilated at
a high pressure individually before simultaneously
inflating both balloons to a nominal pressure.
When rewiring the other branch after stent placement,
it is always reasonable to first place the guidewire distal
into the stented branch to ensure that the wire has not
passed under the stent struts before recrossing into the
nonstented branch.
Advantages
• It guarantees complete coverage of the SB ostium.
Limitations
• Double-stent layer is observed at the proximal MV and
at the level of the carina.
• This technique is not advisable when there is a large
discrepancy between the size of the proximal MV and
the SB because of the risk of incomplete wall apposition
of the SB stent in the proximal MV segment.
• Requires rewiring of both branches through the
stent strut, it can be technically demanding and
time-consuming.
• With the use of some closed cell stents (e.g., Cypher,
Cordis Corporation, USA), the opening of the struts
toward the branches may only reach a maximum diam‑
eter of 3 mm. Because of this, the culotte technique
should only be used with stents that have design allow‑
ing full opening of the struts toward both branches or
when the expected size of the SB 3 mm.
Predictors of in-stent restenosis post-stenting
Irrespective of the technique used, following are the key
determinants of in-stent restenosis post-stenting:
• Preprocedural diameter stenosis of the bifurcation core
• Percentage of SB stenosis preprocedure
• Higher bifurcation angle (60°)
• Diameter ratio of MV and SB
One or two stents in DES era?
Many randomized and nonrandomized trials have
compared one- versus two-stent strategies in non-left
main bifurcations.[7,10-12,28,38,45-49]
Majority of them have
shown no advantage of implanting two stents regardless
of the lesion type [Table 1]. Meta-analysis[50]
of these
randomized trials concluded that both strategies result in
similar outcomes in terms of the risk of cardiac death,
target lesion revascularization, and stent thrombosis.
However, the rate of periprocedural MI was significantly
higher in the complex strategies.[51]
Recently, a 5-year
follow-up of DK Crush II and a 1-year follow-up of DK
Crush V study observed a significant reduction of MACE
rate and target lesion failure in DK Crush Group.
Owing to complexity of other techniques and almost
similar outcome with each individual technique, simple
provisional SB stenting remains the preferred strategy.
Current Guidelines
Consensus from the meeting of the EBC on techniques for
two-stent strategies was the following[52]
:Figure 11: Culotte technique[54]

1. Provisional T-stenting remains the gold standard
technique for most bifurcations.
2. Large SB with ostial disease extending 5 mm from the
carina is likely to require a two-stent strategy.
3. SB whose access is particularly challenging should be
secured by stenting once accessed.
4. KBI for carina reconstruction is mandatory in
two-stent techniques.
5. Noncompliant balloon is recommended for kissing
inflation.
6. Individual noncompliant high-pressure “ostial”
post-inflations are mandatory in complex stenting
techniques to achieve full-stent expansion.
7. High-pressure proximal stent inflation using a short
noncompliant balloon should be considered for the
correction of possible proximal stent distortion after
KBI.
The 2011 American College of Cardiology/American
HeartAssociation/Societyof CardiovascularAngiography
Interventions[23]
guidelines for percutaneous coronary
interventions have made the following recommendations
about bifurcation lesion treatment:
1. Class I: Provisional SB stenting should be the initial
approach in patients with bifurcation lesions when the
SB is not large and has only mild or moderate focal
disease at the ostium (level of evidence A).
2. Class IIa: It is reasonable to use elective double stenting
in patients with complex bifurcation morphology,
involving a large SB where the risk of SB occlusion is
high and the likelihood of successful SB reaccess is low
(level of evidence B).
Summary
Though the ideal approach to bifurcation lesions
seems to be provisional stenting, it coincides with the
minimalist approach to angioplasty. When provisional
approach is not feasible, it leads us to two-stent
techniques as an intention to treat. Often a lesion
can be treated with more than one approach. Each
technique has its own advantages and disadvantages.
The DK crush techniques by and large appear superior
in restoring vessel geometry with complete coverage of
the lesion and carina, though the culotte procedure is
very close to DK crush in terms of long-term results.
For two-stent techniques, the operator should be well
versed with the guiding catheter internal diameter/outer
diameter, wires, use of noncompliant balloons, and the
stent platform, which are very vital in the final result.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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