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Background The aim of this study was to investigate the impact of ticagrelor monotherapy following 1-month dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for bifurcation lesions. Methods GLOBAL LEADERS was a randomized, superiority, all-comers trial comparing 1-month DAPT with ticagrelor and aspirin followed by 23-month ticagrelor monotherapy (experimental treatment) with standard 12-month DAPT followed by 12-month aspirin monotherapy (reference treatment) in patients treated with a biolimus A9-eluting stent. The primary endpoint was a composite of all-cause death or new Q-wave myocardial infarction (MI) at 2 years. Results Among the 15,845 patients included in this subgroup analysis, 2,498 patients (15.8%) underwent PCI for at least one bifurcation lesion. The incidence of the primary endpoint was similar between the bifurcation and nonbifurcation groups (4.7 vs. 4.0%, p = .083). The experimental treatment had no significant effect on the primary endpoint according to the presence/absence of a bifurcation lesion (bifurcation: hazard ratio [HR]: 0.74, 95% confidence interval [CI]: 0.51-1.07; nonbifurcation: HR: 0.90, 95% CI: 0.76-1.07, p for interaction = .343), but was associated with significant reduction in definite or probable stent thrombosis (p for interaction = .022) and significant excess of stroke (p for interaction = .018) when compared with the reference treatment. Conclusions After PCI for bifurcation lesions using 1-month of DAPT followed by ticagrelor monotherapy for 23 months did not demonstrate explicit benefit regarding all-cause death or new Q-wave MI as in the overall trial. AstraZeneca; Biosensors International Group; Medicines company

Introduction Angioplasty of bifurcation lesions remains challenging. In most studies, long-term outcomes were less favourable compared to non-bifurcation lesions. Patients with bifurcation lesions were excluded from most of the randomised studies of AMI. Purpose The aim of this study was to determine the prognostic impact of bifurcation lesion on three-year outcome in a prospective cohort of NSTE-ACS patients. Bifurcation lesions (BFLs) remain a challenging lesion subset, often associated with lower success rates than less complex lesions. There are few data regarding the impact of BFLs in the setting of NSTE-ACS. Methods Patients admitted for NSTE-ACS and indication for coronary angiography were prospectively evaluated. Patients were divided into 2 groups according to whether infarct-related-artery lesions were vs. were not a bifurcation lesion. Major outcomes were assessed at 3 years. Results A total of 296 patients were evaluated: mean age was 62±12 years and 58% were male. The three-year mortality was 12.2% (36 patients) and the three-year MACCE was 26.4% (78 patients). The bifurcation lesion group included 62 patients (20.9%).The three-year mortality and MACCE in the patients of the bifurcation lesion group was significantly higher (19.4% vs. 10.3%; p=0.046) and (45.2% vs. 21.4%; p≤10–3) respectively. Conclusion In NSTE-ACS, bifurcation lesions portend worse prognosis. This may guide prognostication and decision making in treatment. Funding Acknowledgement Type of funding sources: None. MACCE occurrence: Bifurcation impact

Guidewire recrossing into the branch through the stent strut is difficult when that branch was injured or occluded after stenting in the true bifurcation lesion. A 72-year-old man with chronic total occlusion in both mid-left anterior descending coronary artery (LAD) and 2nd diagonal branch (D) was admitted to our hospital. We put a 2.25 × 38 mm drug-eluting stent from the LAD to the D with culotte stenting. However, the LAD occluded after stenting. Although we tried to recross, it was impossible because the guidewire migrated subintimal space which was caused by guidewire manipulation. So, we advanced a 2.25 mm balloon catheter on the 1st guidewire which had already been placed outside of the stent in the LAD, and inflated it at bifurcation to compress the subintimal space. Subsequently, we advanced another guidewire through the strut along the surface of the balloon catheter. Immediately after the deflation of the balloon, the guidewire slipped into the distal LAD without resistance. Large branch occlusion after stenting is a serious complication in true bifurcation treatment. Our new bailout technique is effective for recrossing a guidewire into the dissected branch to preserve it.

Introduction and objectives: Coronary bifurcation lesions are a common scenario in our interventional practice and can be challenging for our routine clinical practice. Yet despite the existence of well-defined techniques, side-branch compromise is still the most important problem. Currently, the standard strategy recommended is a 1-stent technique: balloon angioplasty and provisional stenting. Published non-randomized data reveal that in up to 26% of the cases the indication for rotational atherectomy was to preserve the side-branch. A randomized comparison between rotational atherectomy and provisional stenting (RAPS) and standard strategy (SS) for the management of bifurcation lesions is needed at this point. Methods: We conducted a single center, prospective, randomized pilot study of consecutive patients from our center with bifurcation lesions. We compared the RAPS strategy to the SS. Lesions had to be located in the main vessel only. The bifurcation lesion angle was recorded. The primary endpoint was the need for side-branch therapy. Results: 148 patients were included: 74 patients (95 rotational atherectomy) were enrolled in the RAPS group and 74 patients in the SS group. The bifurcation lesion most frequently treated was that of the proximal left anterior descending coronary artery. The primary endpoint was lower in the RAPS group compared to the SS group (1.1 vs 31.2%; P < .001). Target vessel failure (TVF) was 13.1% and 24.8% (P = .04) in RAPS and SS, respectively. Both the primary endpoint and TVF were higher with bifurcation lesion angles < 70º compared to bifurcation lesion angles ≥ 70º (P = .03 and P = .02) in both groups. Conclusions: The need for side-branch therapy and TVF was lower when the RAPS strategy was used compared to the SS. Bifurcation lesion angles < 70º are associated with higher side-branch compromise and TVF rates. The SS was associated with a 4.92-fold higher risk of side-branch compromise compared to the RAPS strategy with bifurcation lesion angles < 70º. These data reinforce the idea of the overall clinical relevance of the RAPS strategy regarding the patency of the side-branch.

Background: Proximal optimization technique (POT) has been proposed to adapt the conventional drug-eluting stent (DES) with the fractal anatomy of the bifurcation. However, only few DES are labeled for post-expansion beyond 5.0 mm. Furthermore, recrossing in the side branch (SB) through the main vessel (MV) stent cells may be challenging. Objectives: To compare the sirolimus-eluting, balloon-expandable dedicated bifurcation stent BiOSS LIM DES versus the second generation DES in the treatment of distal unprotected left main coronary arteries (ULMCAs) lesions. Methods: Forty-two consecutive patients with distal ULMCA lesions were treated with the BiOSS LIM (BiOSS LIM group) in our center. A matched-group of patients treated with second-generation DES was selected from our database (Control group). The primary endpoint was the procedural complication rate, including (a) SB occlusion, defined as intraprocedural TIMI flow grade

BACKGROUND Coronary bifurcation lesions are technically and clinically more challenging compared to nonbifurcation lesions. Sex-related differences in diagnostic and invasive therapeutic coronary procedures have been described in the literature. Our objective was to assess the impact of sex on outcomes of bifurcation lesion percutaneous coronary intervention (PCI). METHODS Our data were taken from a prospective registry of consecutive patients undergoing PCI for bifurcation lesions at our medical centre between 2004 and 2019. We compared rates of death and major adverse cardiac events (MACE) between men and women at 1 year and 3 years. MACE comprised cardiac death, myocardial infarction, target vessel revascularization or stroke. RESULTS A total of 1209 patients were included, 948 (78.4%) were male and 261 (21.6%) were female. Women were older (mean age 69.7 ± 11 years vs. 63.1 ± 11 years, P < 0.01), and had more comorbidities than men. Female patients had more angiographically calcified (38.1% vs. 30.1%, P = 0.017) lesions. At 1-year follow up, there was no significant difference of MACE (18.8 vs. 15.2%, P = 0.183) or all-cause mortality (5.7% vs. 3.9%, P = 0.242) between sexes. At 3-year follow up, there was a significantly higher rate of MACE in women (29.1% vs. 22.5%, P = 0.026), this was driven by a significantly higher all-cause mortality (13.8% vs. 6.5%, P < 0.01). CONCLUSION Women undergoing bifurcation PCI are older and have more comorbidities than their male counterparts. Intermediate term follow-up outcomes are similar between sexes. Poorer long-term outcomes of women are likely due to baseline higher risk profile.

The optimal management of bifurcation lesions has received significant interest in recent years and remains a matter of debate among the interventional cardiology community. Bifurcation lesions are encountered in approximately 21% of percutaneous coronary intervention procedures and are associated with an increased risk of major adverse cardiac events. The Medina classification has been developed in an attempt to standardise the terminology when describing bifurcation lesions. The focus of this article is on the management of the Medina 0,0,1 lesion (‘Medina 001’), an uncommon lesion encountered in

Purpose: To evaluate the vascular response after directional coronary atherectomy (DCA) for left main (LM) bifurcation lesion.Methods: This study was a retrospective, single-center study enrolling 31 patients who underwent stent-less therapy using DCA followed by drug-coated balloon angioplasty for LM bifurcation lesion. We compared the intravascular ultrasound (IVUS) findings pre- and post DCA. Results: After DCA, the lumen and vessel areas significantly increased whereas the plaque area (PA) and %PA significantly decreased. When the lesions were divided into small and large vessel groups using the median vessel area value, the maximum balloon pressure of the DCA catheter was greater in the large than in the small vessel group. Changes in the lumen and vessel areas were also significantly greater in the large than in the small vessel group. Conversely, the PA and %PA changes were similar between the groups. Conclusion: The main vascular responses associated with lumen enlargement after DCA were plaque reduction and vessel expansion. Contribution of vessel expansion to lumen enlargement was larger than the effect of plaque reduction in large than in small-vessel lesions.

Background Coronary bifurcation lesions make up around 15 to 20 percent of interventions. Especially for younger interventionalists, they pose a steep difficulty curve due to the daunting set of ways treatment can diverge from the initial plan based on plaque shift or other complications. Purpose BifurcAID 3D was designed to intuitively show some of the key phenomena during bifurcation lesion treatment. Plaque shift, the importance of proximal optimization, the opening of a jailed side branch, and the overlapping layers of stent in the Culotte technique are among some of the aspects of bifurcation lesion treatment that can benefit from a clear visual format. Methods Iterating on the bifurcation algorithm developed at a high volume metropolitan PCI center, this fully animated application has many branching points where plaque shift is assessed and the treatment plan and animation varies accordingly to show reactive balloon angioplasty, stenting, or entirely switching to dedicated two stent techniques. Results The resulting application is an easy-to-navigate algorithm for left and non left main bifurcation lesion treatment with fully animated clear depictions of bifurcation lesion treatments including provisional, bail-out strategies, and dedicated two stent techniques alongside descriptive text. Conclusions Creating free educational content for aspiring and current physicians serves to elevate the field and lower the barriers to entry. BifurcAID 3D will make available intuitive education on complex bifurcation lesion treatment worldwide. Representative Images of BifurcAID 3D Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Vascular Education Grant

Background Quadfurcation of single coronary artery (SCA) from the right is an extremely rare anomaly and acute coronary syndrome in such patients is catastrophic. Case summary We report a 56-year-old Bangladeshi male who presented with an acute inferior wall ST-elevation myocardial infarction. He was taken to the Cath lab for primary percutaneous coronary intervention which showed the presence of SCA arising from the right aortic sinus with multiple lesions including a bifurcation lesion. Percutaneous coronary intervention was done successfully in two sessions. Discussion Tackling multiple lesions in a case of SCA with quadfurcation was challenging especially in the setting of SCA and bifurcation lesions. This is first reported case of this kind.

Coronary bifurcation stenting is still complex and associated with a high risk of stent thrombosis and restenosis even with contemporary techniques. Although provisional approach has been proved to be the standard strategy of treatment, There is still lack of evidences for multiple steps of the procedure. For so many years we have been focused on the optimization of side branch (SB), but the clinical outcome is mostly dependent on the main vessel (MV) stenting. The optimal expansion of MV stent without the compromise of SB is the ultimate goal to achieve in the coronary bifurcation stenting. Understanding the anatomy and physiology of coronary bifurcation lesion should be the most important step to this goal. The relationship of vessel diameter between branches and the anatomical and functional significance of plaque shift and carina shift are two most important concepts to understand. They are the science behind the predictors of SB occlusion, and the rationale of proximal optimization technique and final kissing ballooning. This specific review will be devoted to review those concepts as well as clinical evidences to support them.

A 69-year-old man underwent percutaneous coronary intervention of a left anterior descending coronary artery (LAD) diagonal bifurcation lesion with 2 platinum-chromium everolimus-eluting stents with the culotte technique in September 2014. Dual-antiplatelet therapy was maintained for 1 year. In

During provisional stenting (PS) of a bifurcation lesion (BL), evaluation of the side branch (SB) result can be challenging [(1)][1]. To our knowledge, no studies have evaluated the feasibility of using a pressure wire (PW) as a jailed wire for the evaluation of SB results during PS. Thus, we

Ostial lesions present unique challenges for percutaneous coronary intervention (PCI). These lesions are often more calcified, fibrotic, rigid, and more prone to elastic recoil. Intervention on these lesions is associated with higher procedural complications and higher rates of restenosis. Ostial lesions require precise stent placement in the ostium with the absence of side branch compromise. Accurate stent placement in the ostium without side branch compromise is difficult to accomplish with angiography alone. The Szabo technique uses two coronary guidewires for the correct placement in the aorto-ostial or bifurcation lesion. One guidewire is passed through the final cell of the stent strut and acts as the anchor wire. It helps to prevent migration of the stent beyond the ostium and facilitates the precise stenting at the ostium. This technique has several advantages including less reliance on angiography, lower rates of stent malposition and lower rates of incomplete stent coverage. Potential disadvantages include stent distortion and dislodgement from stent manipulation. We describe two cases of successful PCI to bifurcation lesions using the Szabo technique and confirmation of correct placement in the ostium with optical coherence tomography.

Background Percutaneous coronary intervention (PCI) for bifurcation lesions (BL) using 2 stents technique is known to be associated with high rates of procedural failure especially on the side branch (SB) mainly due to stent incomplete apposition. Stent deployment at very high pressure (SDHP) may lead to better stent expansion and apposition. However, SDHP may also be at the origin of deeper wall injury resulting into major cardiac adverse events. No data are available on evaluation of SDHP in BL treated by a mini-crush stent technique. Methods One hundred and thirteen consecutive patients underwent PCI for BL (Medina 1, 1, 1) using a mini-crush stent technique with SDHP defined as ≥20 atm. An angiographic follow-up was performed at 6 month and clinical follow-up was obtained at a median of 3 years. Results Stent deployment mean pressures were 20 ± 1.4 atm (range 20–25) in the main vessel (MV) and 20 ± 1.5 atm (range 20–25) in SB. Simultaneous final kissing balloon was used in 92% of cases. PCI was successful in 100%. Angiographic follow-up was obtained in 83% of patients. Restenosis rate was 13% (12% restenosis in the SB) with only one case (0.8%) of SB probable thrombosis. Another case of late stent thrombosis occurred at a 3 years clinical follow-up. Conclusion Compared with previously published studies in which stents were deployed at lower pressure, SDHP does not increase the restenosis rate in BL using mini-crush stent technique but seems to reduce the rate of stent thrombosis.

Percutaneous coronary intervention (PCI) in bifurcation lesions is associated with lower success rate, higher acute complication rates and higher event rates in follow-up. The reason for this higher than usual complication rate relates to the relationship between anatomy, flow, and atheroma distribution in bifurcation lesions. Further, stenting these lesions can be a prolonged procedure and can be technically more demanding. The most common complication is the loss of significant side branch (SB). Main vessel (MV) stenting may enhance the carina displacement and atheroma shift across the SB ostium leading to SB ostium narrowing. Finally, complications, if they occur, are more difficult to manage. Dedicated bifurcation stent has been developed to overcome the number of limitations associated with conventional bifurcation PCI. The main advantage of most dedicated bifurcation stents is to allow the operator to perform the procedure on a bifurcation lesion without the need to rewire the SB.

Background/Introduction The Medina classification is the most widespread method to describe bifurcation lesions. However, little is known regarding the prognostic impact of the classification. Purpose To assess the prognostic significance of the Medina classification following percutaneous coronary intervention (PCI). Methods The study included 738 consecutive patients from a prospective bifurcation registry. There were 609 patients (82.5%) with “true bifurcation” (TB) lesions (Medina class 1.0.1, 1.1.1, 0.1.1) and 129 (17.5%) in all other categories (“non-true bifurcation” = NTB). We compared rates of death and major adverse cardiac events (MACE: cardiac death, myocardial infarction, or target vessel revascularization) at 12 months and 3 years. Results Patients with TB had lower rates of previous bypass surgery (9.4% vs. 12.2%, p=0.03) and hyperlipidemia (75.2% vs. 79.0%, p=0.04). TB lesions were more likely to be calcified (33.8% vs. 28.2%, p=0.03) and ulcerated (8.9% vs. 3.4%, p Conclusions TB lesions, according to the Medina classification, portend worse prognosis for patients undergoing bifurcation PCI. This may guide prognostication and decision making in treatment.

A reverse guidewire technique along with double lumen catheter has become a standard technique for extremely angulated bifurcation lesions. A-72-year-old male underwent coronary angiography, which revealed a severe stenosis of the left anterior descending artery with an extremely angulated diagonal branch. We introduced the Crusade (Kaneka, Osaka, Japan) accompanied with the reversed guidewire to the lesion, but the Crusade with the reversed guidewire could not cross the lesion. We kept the Crusade at the just proximal to the stenosis, and advanced the only reversed guidewire to the lesion. The reversed guidewire successfully crossed the lesion, and then we pulled back the reversed guidewire to lead the reversed guidewire’s tip into the diagonal branch retrogradely. In this modified reverse guidewire technique, the Crusade does not need to cross the lesion, but needs to bring the reversed guidewire at the just proximal of the lesion. Because the profile of the reversed guidewire alone is smaller than that of the Crusade accompanied with the reversed guidewire, the reversed guidewire alone has greater chance to cross the severe stenosis. Our modification may increase the success rate of the reverse guidewire technique, and expand the indication of this technique.

Bifurcation lesion with an extreme angulated side branch remains a challenge in coronary intervention. Reverse wire technique was originally described by Dr. Kawasaki and nowadays this can be done by double-lumen catheter. We report a novel "simplified reverse wire technique with a specialized angle tip microcatheter," Supercross microcatheter™ (Teleflex). This can facilitate wiring of extreme angulated side branch by this simple and feasible method without using double lumen catheter.

Treatment of bifurcation lesions remains technically challenging for interventional cardiologists. Previous idealized in vitro bench models have shown that kissing balloon inflation (KBI) might result in a less circular stent shape, worse stent apposition and lower endothelial shear stress (ESS)

Bifurcation lesion management still represents a challenge for interventional cardiologists and currently there is a number of different approaches/techniques involving coronary stents. The use of a drug-coated balloon for native coronary vessel management is emerging as an alternative treatment, although in selected patient populations only. In particular, this technology has been tested for the treatment of bifurcations, both for the main vessel and the side branches. Several studies have evaluated this treatment as an alternative or as a therapeutic option complementary to stents, with conflicting and debatable results. However, the perspective of leaving lower metallic burden in this type of lesions is highly appealing and should be deeply investigated. We review here the currently available scientific data and future perspectives on drug-coated balloon use for bifurcation lesions.

Despite tremendous advances in technology and skills, percutaneous coronary intervention (PCI) of bifurcation lesion (BL) remains a particular challenge for the interventionalist. During bifurcation PCI, safe guidewire placement in the main branch (MB) and the side branch (SB) is the first step for successful procedure. However, in certain cases, the complex pattern of vessel anatomy and the mix of plaque distribution may make target vessel wiring highly challenging. Therefore, specific techniques are required for solving this problem. Hereby, we describe a new use of side-branch technique for difficult guidewire placement in BL.

Key Points Presents the intermediate term results of BVS in bifurcation lesions from a large database. Emphasizes the optimal technique of BVS implantation in this lesion subset which may influence outcomes. Prospective, large, protocol driven registries would define the role of BVS in bifurcation lesion.

Sažetak Background: Provisional stenting is a favorable option for most bifurcation lesions, while two stent techniques show benefits in true bifurcation performed by experts. Using one stent and DCB in true bifurcation lesions still remains questionable.1, 2 Case report: 76-year-old male presented with persisting chest pain. ECG showed no specific ischemic changes, while hsTnI was highly elevated. He had gone PCI LAD 14 years ago. Diagnosis: right coronary angiography revealed occlusion of RCA, while left coronary angiography revealed LLS of 20% in proximal LAD stent, 70% stenosis of mid LAD, and acute occlusion of secondary OM branch on bifurcation level, while CxA was stenosed 70-80%. Management: PCI CxA-OM2 was performed with DES Xience expedition 2, 75/33mm in CxA-OM2 with POT 3, 25/12mm proximally, then after rewiring and adequate lesion preparation a DEB Sequent please 2, 5/25mm in CxA distally was performed. After two months we performed an elective PCI LAD and checked out the result of CxA bifurcation which was optimal. Conclusion: Using one stent and DCB in true bifurcation lesions still remains questionable. There are no data from a prospective study, while there are data from the observational study which enrolled 130 patients. DCB-only strategy was performed in 54% patients, 34.6% had at least one stent in the main branch, 8.5% had at least one stent in the side branch and 3.1% at least one stent in the main branch and side branch. Study follow up lasted for 9.8 months. The TLR rate was 4.5%, MACE was 6.1%, and no stent thrombosis was detected. This study suggested that the DCB+one stent, and DCB-only strategy was safe and effective in selected bifurcations, possibly allowing for an abbreviated antiplatelet regimen.

Recurrent in-stent restenosis (ISR) poses high risk for adverse cardiovascular events, especially in left main (LM) lesions. Intracoronary brachytherapy (ICBT) may be a salvage option in this setting. A 71-year-old woman with ischemic cardiomyopathy, severe COPD and inoperable LM disease presented

Background The majority of coronary bifurcation lesions are treated with a provisional single‐stent strategy rather than an up‐front 2‐stent strategy. This approach is supported by multiple randomized controlled clinical trials with short‐ to medium‐term follow‐up; however, long‐term follow‐up data is evolving from many data sets. Methods and Results Meta‐analysis of randomized controlled trials evaluating long‐term outcomes (≥1 year) according to treatment strategy for coronary bifurcation lesions. Nine randomized controlled trials with 3265 patients reported long‐term clinical outcomes at mean weighted follow‐up of 3.1±1.8 years. Provisional single stenting was associated with lower all‐cause mortality (2.94% versus 4.23%; risk ratio: 0.69; 95% confidence interval, 0.48–1.00; P =0.049; I 2 =0). There was no difference in major adverse cardiac events (15.8% versus 15.4%; P =0.79), myocardial infarction (4.8% versus 5.5%; P =0.51), target lesion revascularization (9.3% versus 7.6%; P =0.19), or stent thrombosis (1.8% versus 1.6%; P =0.28) between the groups. Prespecified sensitivity analysis of long‐term mortality at a mean of 4.7 years of follow‐up showed that the provisional single‐stent strategy was associated with reduced all‐cause mortality (3.9% versus 6.2%; risk ratio: 0.63; 95% confidence interval, 0.42–0.97; P =0.036; I 2 =0). Conclusions Coronary bifurcation percutaneous coronary intervention using a provisional single‐stent strategy is associated with a reduction in all‐cause mortality at long‐term follow‐up.

Bifurcations are particularly prone to errors in visual estimation of diameter stenosis. Dedicated bifurcation QCA software confirmed only 26-27% of side branch lesions visually estimated to have >50% DS. Validation against physiologic measures is necessary to determine whether bifurcation QCA software has value.

Patient Initials or Identifier Number I.O ### Relevant Clinical History and Physical Exam A 70’s-year-old man was admitted with exertional chest pain for 1 month. His coronary risk factors were hypertension and smoking. His past history was IgA nephropathy and prostatic hypertrophy. ###

Patient Initials or Identifier Number SDFL ### Relevant Clinical History and Physical Exam A 78-year-old lady was admitted to another hospital due to acute non-ST-elevation myocardial infarction 9 days ago. She underwent coronary angiography that showed calcified left main with the triple

Patient Initials or Identifier Number BS ### Relevant Clinical History and Physical Exam A 53 years old patient was referred to National Cardiovascular Center Harapan Kita with symptoms of stable angina pectoris for 3 months before. He had a history of hypertension and diabetes mellitus. He

Patient Initials or Identifier Number 201531589 ### Relevant Clinical History and Physical Exam A 79-year old man was admitted with effort angina for several months. Physical examination was normal. The cardiac enzyme and BNP were unremarkable. His cardiovascular risk factor was hypertension

As bifurcation PCI can often be resource-demanding due to the use of multiple guidewires, balloons and stents, different technical options are sometimes being explored, in different local settings, to meet the need of optimally treating a patient with a bifurcation lesion, while being confronted with limited material resources. Therefore, it seems important to keep a proper balance between what is recognised as the contemporary state of the art, and what is known to be potentially harmful and to be discouraged. Ultimately, the resource-tailored approach to bifurcation PCI may be characterised by the notion of minimum technical requirements for each step of a successful procedure. Hence, this paper describes the logical sequence of steps when performing bifurcation PCI with provisional SB stenting, starting with basic anatomy assessment and ending with the optimisation of MB stenting and the evaluation of the potential need to stent the SB, suggesting, for each step, the minimum technical requirement for a successful intervention.

This study sought to investigate the long-term clinical effects of stent generation and stent strategy for left main coronary artery (LMCA) bifurcation lesion treatment.Limited data are available to assess long-term clinical outcomes after stenting, including use of current-generation drug-eluting stent (C-DES) for treatment of LMCA bifurcation lesions.A total of 1,353 patients who were recorded in 2 multicenter real-world registries were treated by either early-generation drug-eluting stent (E-DES) (n = 889) or C-DES (n = 464). Primary endpoint was major adverse cardiovascular events (MACE). MACE was defined as a composite of cardiac death or myocardial infarction, stent thrombosis, and target lesion revascularization rates during 3-year follow-up. The authors further performed propensity-score adjustment for clinical outcomes.During 3-year follow-up, the overall MACE rate was 8.7%. Use of a 1-stent strategy resulted in better clinical outcomes than use of a 2-stent strategy (4.7% vs. 18.6%, hazard ratio [HR]: 3.71; 95% confidence interval [CI]: 2.55 to 5.39; p 0.001). Use of C-DES resulted in a lower MACE rate compared with using E-DES (4.6% vs. 10.9%, HR: 0.55; 95% CI: 0.34 to 0.89; p = 0.014), especially for the 2-stent strategy. For patients with C-DES, the presence of chronic kidney disease and pre-intervention side branch diameter stenosis ≥50% were significant independent predictors of MACE.Intervention of LMCA bifurcation lesions using DES implantation demonstrated acceptable long-term clinical outcomes, especially in C-DES patients. Use of a 1-stent strategy resulted in better clinical benefits than using a 2-stent strategy.

A 62-year old male underwent treatment of a bifurcation lesion in the left anterior descending coronary artery using provisional stenting with a jailed wire technique. Severe longitudinal stent deformation and unravelment of the stent part proximal of the bifurcation occurred when we tried to pull the jailed wire from the side branch. The described case poses a caution on the use of this specific stent(-design) in bifurcation lesions.

Background Several studies investigated the combination of bare metal stents in the main branch and drug-eluting balloons in the side branch in bifurcation lesions, but data on the combination of drug-eluting stents and drug-eluting balloons are scarce. We aim to assess the feasibility of provisional stenting with an everolimus-eluting stent in the main branch and a paclitaxel-eluting balloon in the side branch. Methods In this prospective, multi-center study conducted in 5 Australian sites, 35 patients with bifurcation lesions were enrolled. Angiographic and intravascular ultrasound assessments were conducted at 9 months; clinical follow-up was conducted until 12 months. Results The primary endpoint, late lumen loss in the side branch measured by quantitative coronary angiography, was 0.10 ± 0.43 mm. No binary restenosis was observed. One patient died; 3 myocardial infarctions (one suspected and two in non-target vessels) and one target lesion revascularization occurred. No probable or definite stent thrombosis was observed. Conclusion The combination of an everolimus-eluting stent in the main branch and a paclitaxel-eluting balloon in the side branch appears to be a safe, effective and novel treatment option for bifurcation lesions.

The aim of this study was to investigate clinical outcomes of patients treated with a provisional stenting (PS) versus a double stenting (DS) strategy for coronary bifurcation lesions with bioresorbable scaffolds (BRS). There are limited data available with regards to outcomes following BRS implantation for bifurcation lesions. A total of 132 bifurcation lesions treated with BRS between 2012 and 2014 were analyzed. Of the total of 132 bifurcation lesions, 10 lesions were treated without crossover stenting. 99 lesions (81%) were treated with a PS strategy and 23 lesions (19%) with a DS strategy. The DS group consisted of patients with a greater number of true bifurcation lesions (PS 52.0% vs. DS 91.3%: P < 0.001). In the PS group, seven lesions (7.1%) were crossed-over to T-stenting. In the DS group, 13 lesions (57%) were treated with BRS to the side branch (SB). A hybrid stenting technique [BRS to the main branch, and metallic drug-eluting stent (DES) to the SB] was utilized in 10 (43%) lesions. Target lesion revascularization (TLR) rates were 5.5% for PS and 11.2% for DS (P = 0.49) at 1-year follow-up. Definite scaffold thrombosis did not occur at the site of any bifurcation lesion. These findings suggest that BRS implantation for bifurcation lesions is technically feasible. The rates of TLR tended to be higher in the DS group compared to when a PS strategy was employed. Larger studies are eagerly awaited to determine longer-term follow-up of this treatment strategy.

Coronary angiography is unable to visualise the atherosclerotic involvement of the arterial wall. Bifurcation lesions are particularly difficult to assess by angiography because overlapping mother and daughter vessels often obscure the lesion and carina. On the contrary, IVUS imaging allows for precise, real-time, cross-sectional assessment of all bifurcation lesion segments, enabling measurements of luminal and vessel areas. Moreover, IVUS evaluation of stent expansion, apposition and edge problems is also superior to angiographic assessment. In spite of the lack of adequately powered randomised trials, there is growing evidence from large registries and meta-analyses showing better acute and long-term outcomes of DES implantation guided by IVUS, in comparison to angiography-guided procedures. In this review, we summarise current scientific evidence, the European Society of Cardiology recommendations and the European Bifurcation Club consensus for the use of IVUS in bifurcation stenting.

Background Little is known about the clinical outcomes of patients with different types of coronary bifurcation lesions. We sought to compare long-term clinical outcomes of patients with true or non-true bifurcation lesions who underwent percutaneous coronary intervention. Methods and results We compared major adverse cardiac events (MACE: cardiac death, myocardial infarction [MI], or target lesion revascularization) between 1,502 patients with true bifurcation lesions (51.8%) and 1,395 with non-true bifurcation lesions (48.2%). True bifurcation lesions were defined as Medina classification (1.1.1), (1.0.1), or (0.1.1) lesions. During a median follow-up of 36 months, MACE occurred in 296 (10.2%) patients. Patients with true bifurcation lesions had a significantly higher risk of MACE than those with non-true bifurcation lesions (HR 1.39; 95% CI 1.08-1.80; P=0.01). Among true bifurcation lesions, Medina (1.1.1) and (0.1.1) were associated with a higher risk of cardiac death or MI than Medina (1.0.1) (HR 4.15; 95% CI 1.01-17.1; P=0.05). During the procedure, side branch occlusion occurred more frequently in Medina (1.1.1) and (1.0.1) than Medina (0.1.1) lesions (11.5% vs. 7.4%, P=0.03). Conclusions Patients with true bifurcation lesions had worse clinical outcomes than those with non-true bifurcation lesions. Procedural and long-term clinical outcomes differed according to the type of bifurcation lesion. These findings should be considered in future bifurcation studies.