There are very few disadvantages to the jailed wire technique. Guide-wire rupture is very rare and in the author’s experience has only occurred when jailed hydrophilic wires were used. When the main branch stent is deployed with more than >1 balloon–artery diameter, withdrawing the jailed guidewire may result in inadvertent forward advancement of the guiding catheter with subsequent damage to the proximal left or right coronary artery. Deployment of the stent with a balloon–artery ratio of 0.9 to one is therefore recommended. Guide wire exchange can then be undertaken and stent deployment is completed with final kissing-balloon inflation.

Pre-dilatation Technique

The occurrence of dissection in either branch of the bifurcation during pre-dilatation should be avoided as this could create access difficulties, particularly to the side branch. The size of the pre-dilatation balloon should therefore be carefully selected according to the size of each branch distal to the bifurcation. For the same reason, there is no advantage in pre-dilating with kissing-balloon inflations.

Secondly, in patients with acute coronary syndromes, the target lesion is usually a soft plaque that can be treated by direct stenting of the main branch using the ‘jailed’ wire technique followed by kissing-balloon inflation. Avoiding predilatation can reduce the risk of side branch dissection and therefore increase the rate of using only one stent.

Thirdly, the length of the pre- and post-dilatation balloon-catheters should be carefully selected in order to avoid ‘geographical miss’. This consideration is of even greater importance in the era of DES.

Dedicated Devices

The development of bifurcated stents has been virtually abandoned. The current technological limitations of this type of stent with two branches lie in its poor profile, poor flexibility and its limited rotational ability to be in phase with the two branches of the bifurcation. Other non-bifurcated dedicated devices providing easy side branch access throughout the procedure, good side branch ostial scaffolding and allowing provisional side branch T-stenting (see Figure 4) are currently being developed. The MultiLink Frontier stent (Guidant Corporation) has been evaluated in a pilot study of 105 patients. Technical success was obtained in 91% of cases and procedural success in 93%. All patients had coronary angiogram at follow-up. At six months the cumulative MACE rate was 17% (including a target lesion revascularisation (TLR) of 13%). There were no deaths and no stent thrombosis. A new generation of DES multilink frontier stent will be evaluated in 2005.

Figure 4: Stents and Dedicated Delivery Systems

A comparable approach has been developed by Advanced Stent Technologies with the SLK-View™ stent and more recently the Petal stent which is currently being evaluated. A new dedicated stent and delivery system stent from Invatec is also under evaluation in a small pilot European dual centre study. A self-expanding nitinol stent (from Devax) designed for bifurcation lesions employs a reverse tapering conical design to spread the carina, theoretically decreasing plaque shift into the side branch to avoid the necessity for side branch stenting. This device is currently under evaluation in a European multicentre registry.

DES for Bifurcation Lesions

The next advance in the interventional treatment of bifurcation lesions will involve the prevention of restenosis with DES. The first important study was a small multicentre pilot study with two objectives – firstly to assess the safety and feasibility of using the Cypher stent in the treatment of bifurcation lesions and secondly to randomly assess the use of one (main vessel only) compared with two (main vessel plus side branch) stents. A total of 86 patients were included. A very high cross-over rate was observed in the group randomised to only one stent in the main branch (52%). of DES multilink frontier stent will be evaluated in 2005.