Recommended Approach for Bifurcation Stenting
For most bifurcation lesions, provisional side-branch stenting should be the initial approach, especially when the side branch is not large and has only mild or moderate focal disease at the ostium. 1
Understanding Bifurcation Lesions
Bifurcation lesions represent 15-20% of all percutaneous coronary interventions (PCIs) and present unique challenges due to:
- Complex anatomy and plaque distribution
- Higher risk of side-branch occlusion (8-80% of cases)
- Increased risk of major adverse cardiac events and restenosis
- Technical complexity in ensuring adequate coverage
Evidence-Based Stenting Strategy Algorithm
1. Initial Assessment
- Evaluate bifurcation morphology (Medina classification)
- Assess side branch characteristics:
- Size (diameter ≥2.5mm indicates significant branch)
- Length and severity of ostial disease
- Plaque burden at side-branch ostium
- Bifurcation angle
2. Stenting Strategy Selection
Provisional Stenting (First-Line Approach):
- Stent the main vessel first
- Only treat the side branch if results are suboptimal
- Indicated for:
- Low-risk bifurcations
- Side branches with minimal/moderate ostial disease (≤50% stenosis)
- Focal lesions (5-6mm length)
- Small side branches
Elective Double Stenting:
- Reasonable for complex bifurcation morphology involving a large side branch where:
- Risk of side-branch occlusion is high
- Likelihood of successful side-branch reaccess is low 1
- Associated with higher angiographic success rates and better long-term patency of side branches in high-risk bifurcations
3. Technical Considerations
For Provisional Stenting:
- If side branch result is unsatisfactory after main vessel stenting:
- Try balloon angioplasty of side branch first
- Use kissing balloon inflation to avoid main branch stent distortion
- Add side branch stent only if necessary
For Double Stenting:
- Several techniques available:
- Crush
- Culotte
- T-stent
- V-stent
- Always perform final kissing balloon inflation after elective double stenting 1
Stent Selection
- Drug-eluting stents (DES) yield better outcomes than bare-metal stents (BMS) for bifurcation lesions 1
- Sirolimus-eluting stents show better outcomes than paclitaxel-eluting stents 1
- For small vessels (<2.5 mm), DES with strong antiproliferative properties (late lumen loss ≤0.2 mm) are preferred 1
Advanced Techniques
- Intravascular ultrasound (IVUS) guidance is recommended for complex bifurcations to optimize stent deployment
- Proximal optimization technique (POT) improves outcomes by ensuring proper stent apposition
- Consider dedicated bifurcation stents for complex anatomies
Potential Complications and Management
- Side-branch occlusion is associated with Q-wave and non-Q-wave MI 1
- Restenosis rates are higher at side branch ostium
- Stent thrombosis risk is increased in bifurcation lesions compared to simple lesions
- Dual antiplatelet therapy (DAPT) for at least 12 months is essential after DES implantation 1
Important Caveats
- Provisional stenting yields similar clinical outcomes to elective double stenting in low-risk bifurcations, with lower incidence of periprocedural biomarker elevation 1
- The most favorable outcomes for bifurcation lesions are achieved with DES rather than BMS 1
- Bifurcation lesions are specifically listed as a scenario where DES are generally preferred over BMS due to efficacy considerations 1
- Avoid complex techniques when simpler approaches will suffice, as increased stent layers can lead to higher thrombosis risk
The evidence strongly supports a stepwise approach to bifurcation stenting, with provisional stenting as the default strategy for most lesions, reserving more complex techniques for specific anatomical scenarios where side branch protection is critical.