From the Guidelines
Provisional side branch stenting is the preferred approach for most bifurcation lesions in coronary interventions. This strategy involves initially stenting only the main vessel across the side branch, followed by selective stenting of the side branch only if necessary, as recommended by the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention 1. The approach begins by wiring both the main vessel and side branch, then placing the stent in the main vessel. After deploying the main vessel stent, the side branch is assessed for significant compromise (>70% stenosis, TIMI flow <3, or significant pressure gradient). If the side branch appears compromised, kissing balloon inflation using appropriately sized balloons for both vessels is performed. Side branch stenting is only considered if significant issues persist after balloon angioplasty. The T-stenting, TAP (T-stenting and protrusion), or culotte techniques can be employed depending on the bifurcation angle.
The provisional approach is preferred because routine two-stent strategies have not shown improved outcomes compared to provisional stenting and are associated with increased procedure time, contrast use, radiation exposure, and risk of stent thrombosis, as noted in the guideline 1. The provisional approach allows for adequate treatment of the main vessel while avoiding unnecessary complications from complex stenting when the side branch remains functionally adequate. It is also supported by the executive summary of the 2011 ACCF/AHA/SCAI guideline, which states that provisional side-branch stenting should be the initial approach in patients with bifurcation lesions when the side branch is not large and has only mild or moderate focal disease at the ostium 1.
Key considerations in the decision to proceed with provisional side branch stenting include the size of the side branch and the extent of disease at the ostium. For patients with low-risk bifurcation lesions, provisional stenting yields similar clinical outcomes to elective double stenting, with a lower incidence of periprocedural biomarker elevation 1. However, in patients with high-risk bifurcations, elective double stenting may be associated with higher angiographic success rates and better long-term patency of the side branch. Ultimately, the choice between provisional side branch stenting and elective double stenting should be guided by the individual patient's anatomy and clinical characteristics, with the goal of minimizing morbidity, mortality, and improving quality of life.
From the Research
Provisional Side Branch Stenting Overview
- Provisional side branch stenting is a recommended treatment strategy for bifurcation lesions, with long-term clinical results comparable to those of non-bifurcation lesions 2.
- The technique has matured over the past decade, with advances in knowledge leading to improvements in the technical approach 2.
Clinical Outcomes
- A study comparing provisional side branch stenting versus a two-stent strategy for true coronary bifurcation lesions found no significant difference in clinical outcomes at 2 years 3.
- Another study found that contemporary techniques, including newer generation drug-eluting stents, improved outcomes in patients undergoing provisional side branch stenting for coronary bifurcation lesions 4.
- The use of rotational atherectomy followed by cutting-balloon plaque modification has been shown to be efficacious in treating severely calcified lesions, resulting in a larger final stent cross-sectional area 5.
Antiplatelet Therapy
- Dual antiplatelet therapy with a thienopyridine and aspirin is used to reduce the risk of late stent thrombosis and complications after placement of a drug-eluting stent 6.
- Early discontinuation of clopidogrel has been associated with a higher risk of stent thrombosis and clinical events 6.
- Triple antiplatelet therapy may be beneficial in certain high-risk patients, but its use is not without increased risk of bleeding events 6.