BIFURCATION STENTING TIPS AND TRICKS

1. BIFURCATION STENTING
AJAY PRATAP SINGH
DEPARTMENT OF CARDIOLOGY
DR. RAM MANOHAR LOHIA HOSPITAL, NEW DELHI.

2. • Bifurcation lesions account for 15–20% of all percutaneous coronary interventions (PCIs)
• Coronary bifurcation stenting is still complex and associated with a high risk of stent thrombosis
and restenosis even in this era of drug-eluting stent (DES).
Serruys PW, Onuma Y, Garg S, et al. 5-year clinical outcomes of the ARTS II (Arterial Revascularization Therapies Study II) of the sirolimus-eluting stent in the
treatment of patients with multivessel de novo coronary artery lesions. J Am Coll Cardiol. 2010;55(11):1093-1101. doi:10.1016/j.jacc.2009.11.049

3. • The inherent difficulty of bifurcation PCI stems from the fact that stent implantation in the main branch (MB) may
lead to acute impairment of coronary blood flow in the side branch (SB).
• However clinical relevance of an SB is notoriously difficult to standardize, it mostly depends on an operator’s
subjective judgement, considering individual patient factors:
• such as SB diameter and length,
• angle between the SB and MB,
• the amount of the myocardium subtended by the SB,
• myocardial viability,
• collateralizing vessels,
• ischemic symptoms,
• comorbidities and
• left ventricular function.
EuroIntervention 2018;13:e1804-e1811 published online November 2017 published online e-edition February 2018. DOI: 10.4244/EIJ-D-17-00580

4. • Apart from the acute risk of periprocedural SB occlusion, bifurcation PCI is associated with an
increased risk of long-term stent-related ischemic adverse events, including stent thrombosis.
Iakovou I, Schmidt T, Bonizzoni E, Ge L, Sangiorgi GM, Stankovic G, Airoldi F, Chieffo A, Montorfano M, Carlino M, Michev I, Corvaja N, Briguori C, Gerckens U,
Grube E, Colombo A. Incidence, predictors, and outcome of thrombosis after successful implantation of drug-eluting stents. JAMA. 2005;293:2126-30.

5. STEP 1: UNDERSTANDING THE CORONARY ANATOMY
• Regardless of the stenting technique chosen, the initial step for a successful bifurcation PCI
strategy begins with a good understanding of bifurcation anatomy.
• The main points when assessing bifurcation anatomy may be summarised as follows:
1. Assessment of the three diameters of a bifurcation.
2. Assessment of the lesion length and plaque distribution.
3. Assessment of the bifurcation angle and SB ostium.

6. • At the present time, there are SEVEN different classifications of bifurcation lesions
1. DUKE
2. SANBORN
3. SAFIAN
4. LEFEVRE
5. SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery study)
6. MEDINA
7. MOVAHED
• In routine practice, the Medina classification is still the simplest and most widely used approach to classify the
distribution of atherosclerotic plaque at the bifurcation site
Medina A, Suarez de Lezo J, Pan M: A new classification of coronary bifurcation lesions. Rev Esp Cardiol 59:183, 2006.

7. Textbook of Intervention cardiology by Topol. 7th edition. Chapter 22
Does not consider
1. Length of disease in the ostium of the SB
2. Length of the LMCA before the
bifurcation
3. Trifurcation
4. Vessel angulation
5. no differentiation is made between a
normal segment (lesion free segment)
and a<50% lesion
6. presence of calcifications is not identified

9. • Given the tri-dimensional structure of bifurcations, it is impossible to avoid foreshortening when trying
to obtain a clear image of the three bifurcation segments. Consequently, it is necessary to record several
views from various angles.
• When assessing the anatomy, it is important to evaluate whether a lesion fits the concept of a true
bifurcation, i.e., if there is a significant narrowing of the lumen in both the MB (proximal and/or distal)
and the SB.
• This is of practical importance, since intervening on true bifurcations carries an increased risk of SB
compromise.

10. STEP 2: ASSESSING THE IMPORTANCE OF THE SB
• There has been considerable historical debate about how to assess the relative importance of a side
branch. This debate arises from an element of inevitable uncertainty about the likely consequences
of SB occlusion.
• Data using CT angiography and fractional flow reserve (FFR) confirm that an SB supplies less
myocardium than the main branch (MB) and that stenosis of the SB is less likely to cause relevant
ischaemia than a similar stenosis of the MB
EuroIntervention 2019;15:90-98. DOI: 10.4244/EIJ-D-19-00144

11. • Although higher levels of troponin elevation are clinically relevant, especially when accompanied
by symptoms and evidence of new infarction on myocardial imaging
• SBs with length measured by CT >73 mm were most likely to supply at least 10% of fractional
myocardial mass
• IVUS and OCT assessment can be done depending on the resource allocation in the center.
• Size >2.5 mm and significant extension of disease into the SB >5 mm may be suggestive of SB
compromise or possible intervention in it.

12. PROVISIONAL v/s TWO STENT TECHNIQUES
Ford TJ, McCartney P, Corcoran D, et al. Single- Versus 2-Stent Strategies for Coronary Bifurcation Lesions: A Systematic Review and Meta-Analysis of Randomized
Trials With Long-Term Follow-up. J Am Heart Assoc. 2018;7(11):e008730. Published 2018 May 25. doi:10.1161/JAHA.118.008730

14. • The provisional single-stent strategy is the currently recommended default strategy for approaching
bifurcation PCI
• The main postulates of the provisional single-stent strategy are optimal MB stenting and a
possibility of subsequent SB stenting only in case of significant flow impairment and/or severe
stenosis with hemodynamic relevance for a clinically important myocardial territory

15. STEP 3: WIRING THE LESION
• Periprocedural occlusion of a large SB (>2.5 mm) has been a recognized contributor to impaired post-PCI prognosis, whereas
the jailed wire technique has been shown to improve the rates of SB reopening in case of closure
• The rationale for wiring the SB prior to MB stenting is mainly built upon the following observations:
1. Jailed wire may serve as a marker for rewiring of the SB through the MB stent struts.
2. SB wiring reduces the bifurcation angle, thus setting a more favorable anatomical position for rewiring and
advancement of balloons and stents into the SB.
3. Jailed wire may improve SB patency after MB stenting.
4. In case of a clinical urgency and after multiple failed attempts at SB rewiring, a small balloon may be advanced over
the jailed wire between the stent and the vessel wall to facilitate acute SB reopening.
5. Jailed wire may serve as an anchor for deeper intubation of the guiding catheter, thus increasing the support in case
of difficult SB balloon crossing
Hahn JY, Chun WJ, Kim JH, Song YB, Oh JH, Koo BK, Rha SW, Yu CW, Park JS, Jeong JO, Choi SH, Choi JH, Jeong MH, Yoon JH, Jang Y, Tahk SJ, Kim HS, Gwon HC.
Predictors and outcomes of side branch occlusion after main vessel stenting in coronary bifurcation lesions: results from the COBIS II Registry (COronaryBIfurcatio n Stenting). J
Am Coll Cardiol. 2013;62:1654-9.
Burzotta F, Trani C, Sianos G. Jailed balloon protection: a new technique to avoid acute side-branch occlusion during provisional stenting of bifurcated lesions. Bench test report
and first

16. • Elective SB wiring is recommended in all cases where the operator deems the SB clinically important, and
always when treating true bifurcation lesions.
• The most angulated branch should be wired first to avoid wire wrap
• Following MB stenting, the SB is rewired with the MB wire (wire exchange) before removing the jailed wire
• An additional wire (third wire) could be used for rewiring the SB after MB stenting, if it is important that the
MB wire remains in position
• Polymer-coated (hydrophilic) guidewires, that are mostly used in cases of challenging SB wiring, can safely
be jailed by the MB stent, and may even be more resilient to damage compared to non-polymer coated wires
EuroIntervention 2018;13:e1804-e1811 published online November 2017 published online e-edition February 2018. DOI: 10.4244/EIJ-D-17-00580

17. • Avoid pushing the MB wire too distally to maintain the shape of the wire tip which will be used to wire the
SB through the MB stent and reduce the risk of distal dissection/perforation.
• When SB wiring access is difficult, plaque modification with rotablation or occasionally balloon dilatation
may facilitate passage of a wire prior to stenting
• A slow controlled withdrawal pressure on the wire is advised in order to prevent guide catheter traction
• The risk of complications during trapped wire removal can be reduced in calcified vessels by minimizing
the length of the trapped wire behind the stent and lowering post-dilation pressures
Banning AP, Lassen JF, Burzotta F, et al. Percutaneous coronary intervention for obstructive bifurcation lesions: the 14th consensus document from the European
Bifurcation Club. EuroIntervention. 2019;15(1):90-98. doi:10.4244/EIJ-D-19-00144

18. WIRE CURVES
FOR SB ACCESS
Two bend in wire(primary curve is as per the diameter of the
distal vessel) resembles JL
Progressive curve (resembles EBU)

19. STEP 4: PREDILATATION
• After wiring both branches the MB is identified. Predilation of the MB facilitates the bifurcation procedure and
allows planning about the length of stent required to facilitate a safe POT dilation, proximal to the bifurcation.
• SB ostium predilatation is controversial because of an inherent danger of creating a dissection plane at the SB
ostium, which may lead to one or more of the following:
1. Unintended access to the SB through a proximal strut of the MB stent.
2. Increasing the dissection distally in the SB when rewiring.
3. Suboptimal angiographic result in the SB ostium (e.g., haziness) after MB stenting.
• Hitherto only one randomized trial has compared SB predilatation vs. no SB predilatation with a provisional
single-stent strategy. This showed higher SB TIMI flow immediately after MB stenting in patients with SB
predilatation, albeit with no difference in final TIMI flow in the SB and no difference in clinical outcomes.
Pan M, Medina A, Romero M, Ojeda S, Martin P, Suarez de Lezo J, Segura J, Mazuelos F, Novoa J, Suarez de Lezo J. Assessment of side branch predilation before a
provisional T-stent strategy for bifurcation lesions. A randomized trial. Am Heart J.2014;168:374-80.

20. • Routine SB predilatation is not mandated by the currently available evidence.
• SB predilatation could be performed:
1. If SB access is difficult.
2. In cases of severe and/or calcified SB lesions.
3. If SB flow is compromised after initial wiring.
• If SB predilatation is performed, the SB ostium should be carefully assessed before MB stenting and,
if needed, switching to a planned two-stent strategy may be necessary.
Lassen JF, Holm NR, Banning A, Burzotta F, Lefevre T, Chieffo A, Hildick-Smith D, Louvard Y, Stankovic G. Percutaneous coronary intervention for coronary
bifurcation disease: 11th consensus document from the European Bifurcation Club. EuroIntervention. 2016;12:38-46.

21. STEP 5: MB STENTING
• Appropriate sizing of the MB stent is important for securing favourable long-term outcomes and should
mainly allow:
1. Avoiding malapposition in the proximal MB.
2. Scaffolding of the SB ostium.
• Drug-eluting stents are recommended for bifurcation PCI.
• MB stent diameter should be selected according to the reference diameter of the distal MB.
• The MB stent should extend at least 8-10 mm proximal to the carina in order to prevent balloon trauma at
the proximal stent edge during the performance of the proximal optimization technique (POT)

22. • The operator must be familiar with design characteristics of the off-the-shelf stent platforms, i.e.,
1. the maximum expansion capacity
2. the stent cell size,
3. radial strength in order to avoid stent distortions and fractures.
4. Consider stent opacity
5. Struts size (thin preferred)
6. Recoil tendency
• Oversizing the MB stent (above the reference diameter of the distal MB) may increase the rate of SB occlusion
due to carina shift and the risk of distal dissections that would necessitate implantation of further stents in the MB
• Closed-cell stent platforms are not recommended for bifurcation PCI with large diameter SBs.

23. STEP 6:PROXIMAL OPTIMISATION TECHNIQUE (POT)
• POT should be performed routinely during the bifurcation procedure as it optimizes stent
deployment/apposition and restores the fractal geometry of the vessels
• It should be performed before SB rewiring as it facilitates access towards the SB, by reducing the possibility
that the wire might cross into the SB behind the MB stent, and it may also facilitate crossing into a distal cell
within the MB stent.
• POT involves inflating a short appropriately sized balloon just proximal to the carina.
• The diameter ratio between the balloon and the proximal MB reference segment should be 1/1 and a non-
compliant balloon should be used.
Colombo A, Stankovic G. Bifurcations and branch vessel stenting. In: Topol EJ, Teirstein P, eds. Textbook of interventional cardiology, 6th Edition. Philadelphia, PA,
USA: Saunders Elsevier; 2015. p. 375-393.

25. • Careful positioning of the balloon for POT is crucial as, if it is too distal, it increases the risk of SB occlusion
(caused by carina shift) and, if it is too proximal, it has no effect on pushing the stent strut towards the SB ostium.
• Technical challenges of POT:
1. Accurate position of the balloon within the 3D geometry of the bifurcation; (USE OF STENT BOOST)
2. Positioning of the distal marker compared to the distal shoulder of the balloon may vary between
manufacturers.
3. When the balloon does not span the entire stented proximal mb stent segment, there may be stent struts
prolapse at the proximal end, hence pot should be done covering the proximal edge of the stent in such
case.

26. STEP 7: SB TREATMENT – OPENING
• The fundamental advantage of the provisional approach is that SB treatment remains an alternative at
any stage throughout the procedure
• Opening the distal stent strut (close to the carina) of the MB stent towards the SB improves ostial SB
scaffolding and decreases the need for a second stent
• In order to increase the odds of crossing the distal strut, the recommended technique is to have a
perpendicular view of the SB ostium and to pull back the MB wire (or a third wire in the same
direction)

27. 1. Re-crossing into the SB through a proximal cell leads to a significant lower area of the SB lumen free of struts
and a higher rate of strut malapposition in front of the flow divider (neo-carina)
2. Struts left unapposed in the path of the central highest velocity components produce high shear disturbance. High
shear rate is known to induce platelet activation and potential thrombosis cascade
EuroIntervention 2015;11:V81-V85. DOI: 10.4244/EIJV11SVA18

28. • “jailed wire” can be used as a marker for facilitating recrossing of SB as the distance from jailed wire can
guide us for proximal and diatal point of entry.
• The position of the wire cross and its position relative to the stent can be accurately assessed by OCT
• HOW TO AVOID WIRE ENTANGLEMENT
1. To wire the more angulated branch first
2. Avoid 360-degree rotation and prefer 180-degree rotation
3. Keep wire separate during the procedure using markers.

29. KISSING BALLOON INFLATION
• The KBI (kissing balloon inflation) technique is considered the default strategy for the two-stent approach in
real world practice. Studies comparing KBI and No-KBI in patients undergoing the one-stent approach have
reported conflicting results.
Zhong M, Tang B, Zhao Q, Cheng J, Jin Q, Fu S. Should kissing balloon inflation after main vessel stenting be routine in the one-stent approach? A
systematic review and meta-analysis of randomized trials. PLoS One. 2018;13(6):e0197580. Published 2018 Jun 27. doi:10.1371/journal.pone.0197580

30.  KBI allows SBostium treatment &apposition of MB stent struts on SB ostium.
 It also enables correction of stent distortion &inadequate apposition.
 Achieve a central position of the carina
 Drawbacks :
 Procedural complexity ,
 Stent ovalization
 Chances of proximal dissection.
EuroIntervention 2015;11:V81-V85. DOI: 10.4244/EIJV11SVA18

31. • Due to conflicting evidence a new technique of POT-side-POT is proposed but in 14th EBC consensus statement
POT-Kiss-POT technique is proposed due to lack of RCT evidence in real world.
Banning AP, Lassen JF, Burzotta F, et al. Percutaneous coronary intervention for obstructive bifurcation lesions: the 14th consensus document from the European
Bifurcation Club. EuroIntervention. 2019;15(1):90-98. doi:10.4244/EIJ-D-19-00144

32. STEP 8: SB TREATMENT – STENTING
• Use of a second stent may be needed in 10% of cases treated with a provisional approach.
• The decision to stent the SB is of seminal importance, since an inappropriate implantation technique may
jeopardise the result in the MB, which is the main determinant of favourable long-term outcomes.
• This decision should not be based solely on the angiographic appearance of the SB but be made in conjunction
with clinical and functional parameters, i.e., in case of clinically manifest ischaemia due to SB flow
impairment or functional significance of the SB stenosis.

33. • SB stenting should be considered in
1. When there is significant SB disease extending >5 mm or more in length from take-off
2. Significant area of distribution
3. It should be considered after MB stenting when
>75% residual stenosis present
Type B dissection or above at ostia
FFR value <0.75
Textbook of Intervention cardiology by Topol. 7th edition. Chapter 22

36. • The T and small protrusion (TAP) technique is a
modification of the T-stenting technique and is based
on an intentional minimal protrusion of the SB stent
inside the MB stent.
• After SB stent deployment, the SB stent balloon should
be pulled back a few mm inside the MB and inflated to
flare the protruded part of the SB stent in the MB prior
to KBI.
• The advantages of the TAP technique are compatibility
with 6 Fr guiding catheters, full coverage of the side
branch ostium and facilitation of KB
Textbook of Intervention cardiology by Topol. 7th edition. Chapter 22
T STENTING

37. T-stenting and TAP are recommended in bifurcations with wide angles (>70°). In TAP, the operator should try to
limit the protrusion of the SB stent inside the MB and reduce the length of the neocarina. When final POT is
performed in TAP, precise balloon positioning is crucial to avoid crushing the metallic neocarina. Stent
enhancement software may be used for precise balloon positioning.

38. Snuggle T and protrusion (S-TAP) technique
• Positioning of the SB stent during TAP
can be challenging due to the poor radio-
opacity of the stent, technical problems
such as an unintentional movement of the
SB stent or patient obesity. In order to
prevent malpositioning of the SB stent
and subsequent displacement of the
neocarina.
• Modifications of TAP
• K-TAP
• S-TAP
Dahdouh Z, Fadel BM, Roule V, Sarkis A, Grollier G. Snuggle T and protrusion (S-TAP) technique for coronary bifurcation stenting: A step-by-step angiographic and
illustration demonstration. Cardiovasc Revasc Med. 2017;18(6S1):14-16. doi:10.1016/j.carrev.2017.02.002

39. CULOTTE STENTING
• Favourable for:
1. Large side branch
2. Diffuse ds in SB
3. Similar sizes of MB and SB
4. Narrow angle <70-degree
• It provides near-perfect coverage of the
carina & SB ostium at the expense of an
excess of metal covering in proximal MB.
• Two layers of metal in MB

40. DK CRUSH
• This technique facilitates access to the SB
in addition to optimising stent apposition
at theSBostium
• DK crush technique has better
predictability and operator control
• Drawbacks: tedious (multiple re-wiring)
and can’t be done with a provisional
stenting strategy.

41. REVERSE CRUSH TECHNIQUE
• The main purpose in performing the
reverse crush is to allow an
opportunity for provisional SB
stenting.
• This technique was developed with
the intent to minimize any possible
stent gap between the MB and SB
stents.
• The reverse crush can be performed
using a 6F guiding catheter

42. MINI- CRUSH TECHNIQUE
• The need to obtain full coverage of the ostium of the SB
prompted the idea of allowing some protrusion of the SB stent
into the MB.
• The main advantage of the crush technique is that immediate
patency of both branches is ensured.
• The main disadvantage is that the performance of final kissing
balloon inflation makes the procedure more laborious because of
the need to recross multiple struts with a wire and a balloon.
• The performance of the crush technique requires a 7F or 8F
guiding catheter and the technique commits the operator to
implant two stents
• Slight modification of CRUSH technique enabling for 6-F
compatibility is STEP-CRUSH. Where each stent is deployed one
at a time.

43. WIRE CROSSING
IN CASE OF CRUSH
TECHNIQUE: PROXIMAL OR
CENTRAL CROSSING
SHORT CRUSH PORTION:
PROXIMAL CROSSING
LONG CRUSH PORTION:
CENTRAL
IN ANY OTHER
TECHNIQUE: DISTAL
STRUTS

45. V /SKS STENTING
• The main advantage of the V technique is that the operator will never
lose access to any of the two branches.
• In addition, when final kissing inflation is performed, there is no need
to recross any stent.
• Using the V technique, a metallic neocarina is created within the
vessel proximal to the bifurcation. Theoretical concerns about the risk
of thrombosis related to this new carina have not been confirmed,
todate.
• Ideally, the angle between the two branches should be less than 90
degrees. The V technique is also suitable for other bifurcations,
provided the portion of the vessel proximal to the bifurcation is free of
disease and there is no need to deploy a stent more proximally.

47. In this network meta-analysis, DK-crush was associated with fewer MACE, driven by lower rates of repeat
revascularization, whereas no significant differences among techniques were observed for cardiac death,
myocardial infarction, and stent thrombosis. A clinical benefit of 2-stent techniques was observed over
provisional stenting in bifurcation with side branch lesion length ≥10 mm.

48. Double-kissing crush resulted in a lower
risk of the primary endpoint target lesion
failure at 1 year compared with
provisional stenting.
Chen SL et al. Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial. J Am Coll
Cardiol 2017;70:2605–2617
In LM true bifurcation lesions, double-
kissing crush has the most favourable
outcome data.a
a=Results from a multicenter, randomized,
prospective DKCRUSH-III study. J Am Coll
Cardiol 2013;61:1482–1488.

51. ROLE OF PHYSIOLOGY/IMAGING IN BIFURCATION STENTING

52. IVUS IN BIFURCATION
• IVUS can be used before stent implantation to assess the following:
1)Risk of side branch (SB) compromise. Patients who have a “vulnerable” carina – the eyebrow sign
(SPIKY CARINA) or significant calcium identified by IVUS longitudinal reconstruction – are at
particular risk of adverse carina shift towards the LCx.
2)Stent length & diameters.
4) can be used to plan the size and length of the “proximal optimisation technique (POT) balloon” to
ensure that it fits within the stent from carina to the proximal stent edge.
EuroIntervention 2018;14:e467-e474 published online April 2018 published online e-edition July 2018. DOI: 10.4244/EIJ-D-18-00194

53. EuroIntervention 2018;14:e467-e474 published online April 2018 published online e-edition July 2018. DOI: 10.4244/EIJ-D-18-00194

54. • The EBC recommends IVUS guidance for patients undergoing LMCA intervention.
– Given the unique prognostic implications of LMCA disease, the EBC recommends using a threshold
MLA cut-off of 6 mm2 to indicate an LMCA that should be treated with revascularisation in a European
population.
– Disengage the guiding catheter prior to image acquisition and ideally image from both the LAD and
LCx to the LMCA with at least one pullback to the aorta.
– The vessel with the angiographically least apparent disease should be imaged back to the LMCA as a
minimum guide for bifurcation strategy.
CURRENTLY DK-CRUSH 7 TRIAL IS GOING ON FOR THE SAME.
EuroIntervention 2018;14:e467-e474 published online April 2018 published online e-edition July 2018. DOI: 10.4244/EIJ-D-18-00194

55. OCT ASSESSMENT IN BIFURCATION
• In preprocedural OCT, assessment of plaque distribution, calcification and lipidic plaque is important in
planning the stenting strategy. Special attention should be paid in case of a narrow carina tip angle (<50°) as
assessed on OCT.
• Either external elastic membrane areas or lumen areas can be used for sizing of the vessel. Whenever the
proximal vessel is too large to measure the EEM, stent sizing according to lumen area measurement is
recommended. (OPINION and ILUMIEN III TRIALS)
• Acute incomplete stent apposition with a distance of ≤300 microns is likely to be resolved at follow-up.
Additional post-dilatation is considered when the malapposition distance is >300 microns with a longitudinal
extension ≥1 mm.
• Most edge dissection detected on OCT is clinically silent, whereas additional stenting may be performed if
the width of the distal edge dissection is ≥200 microns
EuroIntervention 2019;14:e1568-e1577 published online November 2018. DOI: 10.4244/EIJ-D-18-00391

56. BIFURCATION INVOLVING LEFT MAIN
• CAUTION:
1. The SB is usually the Cx which most often has a large reference diameter and is angulated making it difficult
to access with guidewires.
2. The T-shaped, bifurcation angle of the left main stem (LMS) may also affect implantation technique, and a
highly angulated LCx take-off may impact on prognosis after LM stenting
3. The LM is the only bifurcation where the proximal MB originates directly from the aorta. This increases
complexity because of the interaction with the guide catheter and the potential for guidewires to go behind LM
stent struts
4. The proximal reference diameter may reach 6 mm – which is close to the dilatation limit of many coronary
stents
• Ostial disease of the LAD and LCx arteries would ideally be treated percutaneously by stenting from the LMCA into
the diseased main branch with provisional SB stenting (MEDINA 0,1,0/0,0,1)
• ISOLATED DIAGONAL DISEASE (MEDINA 0,0,1) is a special consideration where provisional stenting with
inverted T/TAP can be used.

59. DEDICATED BIFURCATION STENTS
• Dedicated bifurcation stents may potentially overcome the limitations of conventional stents in bifurcations
(SB protection, multiple layers, distortion, SB access, crossing through side of the stent, gaps in scaffolding).
• However, although efforts to produce dedicated bifurcation stent delivery systems are strongly encouraged
and research is fostered, none of the currently available systems can now challenge the results offered by the
provisional T stent strategy in most bifurcation lesions.
• Stents for provisional side branch stenting that facilitate or maintain access to the SB after MB stenting, and
which do not require recrossing of MB stent struts (Petal, former AST stent, from Boston Scientific, Multi-
link Frontier/ Pathfinder from Abbott Vascular Devices)
• Stents that usually require another stent implanted in the bifurcation (The Tryton and Sideguard stents are
designed to treat the SB first and require recroseeing for final KBI, Axxess Plus stent)

60. THANK YOU