Stenting of Bifurcation Lesions

With regard to stenting of bifurcation lesions, the choice between one and two stents, the need for kissing balloon inflation (KBI) following implantation of a single stent, and the optimal two-stent technique have been controversial issues. Some recent s

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Stenting of Bifurcation Lesions

With regard to stenting of bifurcation lesions, the choice between one and two stents, the need for kissing balloon inflation (KBI) following implantation of a single stent, and the optimal two-stent technique have been controversial issues. Some recent studies have provided evidence that the proximal optimization technique (POT) is useful for bifurcation stenting, while other reports have suggested the importance of understanding the relationship between the diameters of the two distal vessels and that of the proximal vessel when performing PCI for bifurcation lesions. Various dedicated bifurcation stents and balloons have been developed. The usefulness of bioresorbable vascular scaffold (BVS) systems when performing PCI for bifurcation lesions has also been suggested. This chapter reviews several stenting strategies and techniques that can be used for bifurcation lesions. Although there is no evidence to support the superiority of these strategies/techniques over others, there also seem to be no data to justify the solutions to the previous controversies. For example, the controversy over the choice between one and two stents appears to have been resolved with the conclusion that a single stent is better, but is this really correct? The angiographic and clinical outcomes after bifurcation stenting using general-purpose stents may be influenced by several factors, including (1) the stent design, (2) the stenting technique (provisional T-stenting, culotte stenting, crush stenting, etc.), (3) the details of stent implantation (point of

stent wire crossing, use of the Crusade, timing of proximal optimization, kissing balloon inflation [KBI], etc.), (4) the extent of jailing or stent malapposition, and (5) unfavorable stent deformation. Some stents are not designed for bifurcation stenting, while others are only compatible with certain stenting techniques. If a stent with an unsuitable design is selected, it may be impossible to prevent jailing or malapposition when it is used for a bifurcation lesion. KBI may not sufficiently expand the proximal part of some stents. The stenting technique has an influence on the risk of jailing, stent malapposition, and stent deformation. The outcome of single versus double stenting of bifurcation lesions should be compared after optimization of all these factors, but it is doubtful that previous studies comparing one versus two stents achieved optimization of other factors. If any of these factors is undergoing clinical evolution, at least the best-available current combination of stenting techniques and stent implantation methods should be employed when comparing single and double stenting. However, none of the previous studies comparing one or two stents employed a standardized (optimized) stenting protocol with regard to stent design and the details of stent implantation. This chapter describes the evolving state-of-the-art procedures for bifurcation stenting using general-purpose stents and reviews the rationale for current practice.

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