The second finding is that the opening of struts towards the side branch results in at least partial coverage of the side branch ostium; given the fact that in the majority of coronary bifurcation cases there is no side branch involvement at the beginning of the procedure (false bifurcation) or only ostial involvement (true bifurcation), placement of a single stent followed by final kissing inflation constitutes an optimal treatment of the lesion. Whatever the technique used, a thorough knowledge of these phenomena is essential for delineating the optimal treatment strategy, in appropriately using final kissing inflation in cases when one of the stent struts is opened towards the side branch and in paving the way for development of new dedicated systems.

Lessons from Clinical Trials and Experience

One of the main technical issues when approaching a bifurcation is to determine whether to use one stent or two stents. Most studies conducted in order to address this question are observational and non-randomised and do not provide definitive answers. The common finding of all these studies is that, whatever the technique used, implantation of a single stent compared with two is associated with a lower event rate, including a lower reintervention rate, both in-hospital and at follow-up (see Figure 2).

Figure 2: One or Two Bare Metal Stents in Bifurcation Lesions

The study by Al Suwaidi shed considerable light on the outcome of the techniques used by showing that the excess of adverse events in recipients of two stents was exclusively observed when the culotte technique was used, whereas T-stenting resulted in similar outcomes between recipients of one or two stents. The authors found the same trends in a retrospective study involving more than 1,000 patients. Indeed, the increase in the reintervention rate was directly related to the complexity of the technique used. In order of importance, the lowest intervention rate was associated with the placement of a single stent, followed by T-stenting starting with the main branch, T-stenting starting with the side branch, V-stenting and culotte stenting (see Figure 3).

Figure 3: Target Vessel Revascularisation and Treatment Type

The ‘jailed wire’ technique has become, quite deservedly, very popular. This technique involves stenting the main branch while a wire remains in the side branch, temporarily ‘jailed’ The principal advantage of this technique is that a wire placed in the side branch changes the angulation between the main branch and the side branch which in turn facilitates access to the side branch through the struts of the stent with the main branch wire. The second advantage is that some degree of antegrade flow and patency is maintained in the side branch in the majority of cases. It also facilitates the visualisation of the origin of the side-branch ostium in the occurrence of side branch occlusion following stent placement in the main branch. One of the predictors of side branch occlusion during the procedure is a Y-shaped angle of the bifurcation. This technique should therefore be used in almost all cases because in cases of a Tshaped angle, it can favourably modify side branch access, whereas in cases of Y-shaped angle it serves to maintain the flow or as a good marker of the side branch in case of occlusion.