Skip to main content
SpringerLink
Log in

Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: Latest Evidence

  • Coronary Artery Disease (D Feldman and V Voudris, Section Editors)
  • Published:
Current Treatment Options in Cardiovascular Medicine Aims and scope Submit manuscript

Abstract

Purpose of review

This paper provides a synopsis of the best evidence to guide bifurcation percutaneous coronary intervention (PCI), with a focus on recent studies. This is with the aim of guiding the interventional cardiologist in choosing the best, evidence-based technique, to treat commonly encountered coronary bifurcations.

Recent findings

Current evidence supports the use of provisional stenting for most anatomically suitable bifurcation lesions. Newer techniques for side branch protection in provisional stenting have been developed. When a two-stent strategy is required, use of a double-kissing crush technique is favoured, particularly in left main bifurcations. For bifurcation PCI, as in all complex procedures, intravascular imaging plays a key adjunctive role in improving procedural success.

Summary

PCI for coronary bifurcation lesions is an ever-growing field with significant advancements in techniques and technology.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the nordic bifurcation study. Circulation. 2006;114(18):1955–61.

    PubMed  Google Scholar 

  2. Shanmugam VB, Psaltis PJ, Tay L, et al. Procedural and clinical outcomes in management of bifurcational lesions in ST elevation myocardial infarction. Heart Lung and Circulation. 2019:10–1.

  3. Louvard Y, Medina A. Definitions and classifications of bifurcation lesions and treatment. Eurointervention. 2015;11(Suppl V):V23–6.

    PubMed  Google Scholar 

  4. Medina A, Suárez de Lezo J, Pan MA. New classification of coronary bifurcation lesions. Revista Española de Cardiología (English Edition). 2006;59(2):183.

    Google Scholar 

  5. Banning AP, Lassen JF, Burzotta F, et al. Percutaneous coronary intervention for obstructive bifurcation lesions: the 14th consensus document from the European Bifurcation Club. EuroIntervention. 2019;15(1):90–8.

    PubMed  Google Scholar 

  6. Sawaya FJ, Lefèvre T, Chevalier B, et al. Contemporary approach to coronary bifurcation lesion treatment. J Am Coll Cardiol Intv. 2016;9(18):1861–78.

    Google Scholar 

  7. Ford TJ, McCartney P, Corcoran D, et al. Single- versus 2-stent strategies for coronary bifurcation lesions: a systematic review and meta-analysis of randomized trials with long-term follow-up. J Am Heart Assoc. 2018;7(11):1–10.

    Google Scholar 

  8. Kang SH, Ahn JM, Lee JB, Lee CH, Kang DY, Lee PH, et al. Temporal changes in characteristics, treatment strategies, and outcomes of coronary bifurcation lesion interventions. Coron Artery Dis. 2019;30(1):33–43.

    PubMed  Google Scholar 

  9. Choi KH, Song YB, Jeong JO, et al. Treatment strategy for STEMI with bifurcation culprit lesion undergoing primary PCI: the COBIS II registry. Revista Espanola de Cardiologia. 2018;71(10):811–9.

    PubMed  Google Scholar 

  10. Zhou Y, Chen S, Huang L, Hildick-Smith D, Ferenc M, Jabbour RJ, et al. Definite stent thrombosis after drug-eluting stent implantation in coronary bifurcation lesions: a meta-analysis of 3,107 patients from 14 randomized trials. Catheter Cardiovasc Interv. 2018;92(4):680–91.

    PubMed  Google Scholar 

  11. Kim MC, Ahn Y, Sun Sim D, Joon Hong Y, Han Kim J, Ho Jeong M, et al. Comparison of the planned one- and elective two-stent techniques in patients with coronary bifurcation lesions with or without acute coronary syndrome from the COBIS II registry. Catheter Cardiovasc Interv. 2018;92(6):1050–60.

    PubMed  Google Scholar 

  12. Zhang D, Xu B, Yin D, Li YP, He Y, You SJ, et al. Clinical and angiographic predictors of major side branch occlusion after main vessel stenting in coronary bifurcation lesions. Chin Med J. 2015;128(11):1471–8.

    PubMed  PubMed Central  Google Scholar 

  13. Lee SH, Lee JM, Song YB, Park TK, Yang JH, Hahn JY, et al. Prediction of side branch occlusions in percutaneous coronary interventions by coronary computed tomography: the CT bifurcation score as a novel tool for predicting intraprocedural side branch occlusion. EuroIntervention. 2019;15(9):e788–95.

    PubMed  Google Scholar 

  14. Bai J, Yue Y, Feng HQ, Hao SX, Peng L, Zhang M, et al. Impact of main vessel calcification on procedural and clinical outcomes of bifurcation lesion undergoing provisional single-stenting intervention: a multicenter, prospective, observational study. J Geriatr Cardiol. 2019;16(2):156–63.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. Palinggi BP, Firman D. Carina bifurcation angle and side branch occlusion in coronary bifurcation lesions intervention: angiographic lesions characteristic role in determining its relation. Int J Angiol. 2019;28(02):137–41.

    PubMed  Google Scholar 

  16. Zhao Z, Zhang D, Xu B, Wang H, Gao G, Yin D, et al. Is side branch lesion length an independent predictor of acute side branch occlusion in provisional strategy? Analysis of 524 consecutive bifurcation lesions. Catheter Cardiovasc Interv. 2018;91:599–607.

    PubMed  Google Scholar 

  17. Mohsin M, Khan HS, Saleem M, Afzal A. Assessment of predictors of side branch occlusion after main vessel stenting in coronary bifurcation lesions in patients undergoing percutaneous coronary intervention. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP. 2018;28(10):744–7.

    PubMed  Google Scholar 

  18. Hoye A. The proximal optimisation technique for intervention of coronary bifurcations. Interventional Cardiology Review. 2017;12(2):110–5.

    PubMed  PubMed Central  Google Scholar 

  19. Shen H, Yang LX, Wang ZJ, Ji Z, Liu B, Li XQ, et al. Efficacy and safety of active transfer of plaque versus provisional stenting with drug-eluting stents for the treatment of coronary bifurcation lesions. Zhonghua Xin Xue Guan Bing Za Zhi. 2019;47(7):549–53.

    CAS  PubMed  Google Scholar 

  20. Jin Z, Song L, Zheng Z, Zhang S, Wang M. Balloon-stent kissing technique versus jailed wire technique for interventional treatment of coronary bifurcation lesions: comparison of short- and long-term clinical outcomes. Medicine. 2019;98(20):e15633.

    PubMed  PubMed Central  Google Scholar 

  21. Qu WB, Zhang W, Liu JY, et al. Modified balloon-stent kissing technique avoid side-branch compromise for simple true bifurcation lesions. BMC Cardiovasc Disord. 2019;19(1):1–11.

    CAS  Google Scholar 

  22. Burzotta F, Shoeib O, Aurigemma C, Porto I, Leone AM, Niccoli G, et al. Procedural impact of a kissing-balloon predilation (pre- kissing) technique in patients with complex bifurcations undergoing drug-eluting stenting. The Journal of Invasive Cardiology. 2019;31(4):80–8.

    PubMed  Google Scholar 

  23. Zhou Y, Liu W. Transradial approach for unprotected left main lesions. In: Zhou Y, Kiemeneij F, Saito S, Liu W, editors. Transradial approach for percutaneous interventions. Dordrecht: Springer; 2017. p. 147–8.

    Google Scholar 

  24. Lee SH, Song YB, Lee JM, et al. Effect of side branch predilation in coronary bifurcation stenting with the provisional approach - results from the COBIS (coronary bifurcation stenting) II registry. Circ J. 2018;82(5):1293–301.

    CAS  PubMed  Google Scholar 

  25. Zhang W, Ji F, Yu X, Wang X. Long-term treatment effect and adverse events of a modified jailed-balloon technique for side branch protection in patients with coronary bifurcation lesions. BMC Cardiovasc Disord. 2019;19(1):1–7.

    Google Scholar 

  26. Vinayakumar D, Mohanan KS, Goyal KK. Balloon embedded bifurcation stenting with single stent for side branch protection - preliminary results from an Indian population. Indian Heart J. 2018;70(2018):S299–302.

    PubMed  PubMed Central  Google Scholar 

  27. Ermiş E, Uçar H, Demirelli S, İpek E, Gür M, Çaylı M. Assessment of side branch patency using a jailed semi-inflated balloon technique with coronary bifurcation lesions. Turk Kardiyoloji Dernegi Arsivi. 2018;46(5):340–8.

    PubMed  Google Scholar 

  28. Jurado-Román A, Rubio-Alonso B, García-Tejada J, et al. Systematic isolated post-dilatation of the side branch as part of the provisional stent technique in the percutaneous treatment of coronary bifurcations. CR12 registry. Cardiovascular Revascularization Medicine. 2018;19(5):493–7.

    PubMed  Google Scholar 

  29. Zhong M, Tang B, Zhao Q, et al. Should kissing balloon inflation after main vessel stenting be routine in the one-stent approach? A systematic review and meta-analysis of randomized trials. PLoS One. 2018;13(6):1–11.

    Google Scholar 

  30. Liu G, Ke X, Huang ZB, Wang LC, Huang ZN, Guo Y, et al. Final kissing balloon inflation for coronary bifurcation lesions treated with single-stent technique: a meta-analysis. Herz. 2017;44(4):354–62.

    PubMed  Google Scholar 

  31. Koo BK, Kang HJ, Youn TJ, Chae IH, Choi DJ, Kim HS, et al. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol. 2005;46(4):633–7.

    PubMed  Google Scholar 

  32. Koo BK, Park KW, Kang HJ, et al. Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using fractional flow reserve. Eur Heart J. 2008;29(6):726–32.

    PubMed  Google Scholar 

  33. Omori H, Kawase Y, Hara M, et al. Feasibility and safety of jailed-pressure wire technique using durable optical fiber pressure wire for intervention of coronary bifurcation lesions. Catheter Cardiovasc Interv. 2019:9–10.

  34. Shaheen M, Mokarrab M, Youssef A, et al. Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using instantaneous wave-free ratio. Indian Heart J. 2018;70(2018):S254–8.

    PubMed  PubMed Central  Google Scholar 

  35. •• Crimi G, Mandurino-Mirizzi A, Gritti V, et al. Percutaneous coronary intervention techniques for bifurcation disease: a network meta-analysis reveals superiority of double kissing crush. Canadian J Cardiol. 2019. This meta-analysis compares clinical outcomes in patients undergoing provisional stenting, double kissing-Crush, T-and-protrusion, Culotte, dedicated bifurcation stents, original crush, and T-stenting.

  36. Chen E, Cai W, Chen LL. Crush versus culotte stenting techniques for coronary bifurcation lesions: a systematic review and meta-analysis of clinical trials with long-term follow-up. Medicine. 2019;98(14):e14865.

    PubMed  PubMed Central  Google Scholar 

  37. • Yang JH, Lee JM, Park TK, et al. The proximal optimization technique improves clinical outcomes when treated without kissing ballooning in patients with a bifurcation lesion. Korean Circulation Journal. 2019;49(6):485. This study describes the efficacy of proximal optimisation technique in patients undergoing bifurcation percutaneous coronary intervention.

    PubMed  PubMed Central  Google Scholar 

  38. • Chen L, Xu T, Xue XJ, et al. Intravascular ultrasound-guided drug-eluting stent implantation is associated with improved clinical outcomes in patients with unstable angina and complex coronary artery true bifurcation lesions. International Journal of Cardiovascular Imaging. 2018;34(11):1685–96. This study describes the efficacy of utilising intravascular ultrasound in bifurcation percutaneous coronary intervention.

    PubMed  Google Scholar 

  39. Shrestha R, Shrestha A, Kan J, Chen S. A review in enormity of OCT and its enduring understanding of vulnerable plaque in coronary bifurcation lesion. Int J Cardiovasc Imaging. 2018;34(11):1679–84.

    PubMed  Google Scholar 

  40. Longobardo L, Mattesini A, Valente S, Mario CD. OCT-guided percutaneous coronary intervention in bifurcation lesions. Interventional Cardiol Rev. 2019;14(1):5.

    Google Scholar 

  41. Watanabe M, Okura H, Okamura A, et al. Usefulness of longitudinal reconstructed optical coherence tomography images for predicting the need for the reverse wire technique during coronary bifurcation interventions. Catheter Cardiovasc Interv. 2018;94(2):E54–60.

    PubMed  Google Scholar 

  42. Stone GW, Kappetein AP, Sabik JF, et al. Five-year outcomes after PCI or CABG for left main coronary disease. New England Journal of Medicine. 2019.

  43. Mäkikallio T, Holm NR, Lindsay M, Spence MS, Erglis A, Menown IB, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388(10061):2743–52.

    PubMed  Google Scholar 

  44. Chen SL, Xu B, Han YL, Sheiban I, Zhang JJ, Ye F, et al. Comparison of double kissing crush versus culotte stenting for unprotected distal left main bifurcation lesions: results from a multicenter, randomized, prospective DKCRUSH-III study. J Am Coll Cardiol. 2013;61(14):1482–8.

    PubMed  Google Scholar 

  45. Chen SL, Zhang JJ, Han Y, Kan J, Chen L, Qiu C, et al. Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial. J Am Coll Cardiol. 2017;70(21):2605–17.

    PubMed  Google Scholar 

  46. Cho S, Kang TS, Kim JS, et al. Long-term clinical outcomes and optimal stent strategy in left main coronary bifurcation stenting. J Am Coll Cardiol Intv. 2018;11(13):1247–58.

    Google Scholar 

  47. Ferenc M, Banholzer N, Hochholzer W, et al. Long-term results after PCI of unprotected distal left main coronary artery stenosis: the Bifurcations Bad Krozingen (BBK)-Left Main Registry. Clin Res Cardiol. 2019;108(2):175–84.

    PubMed  Google Scholar 

  48. D’Ascenzo F, Omedè P, De Filippo O, et al. Impact of final kissing balloon and of imaging on patients treated on unprotected left main coronary artery with thin-strut stents (from the RAIN-CARDIOGROUP VII study). Am J Cardiol. 2019;123(10):1610–9.

    PubMed  Google Scholar 

  49. Kawamoto H, Chieffo A, D’Ascenzo F, et al. Provisional versus elective two-stent strategy for unprotected true left main bifurcation lesions: insights from a FAILS-2 sub-study. Int J Cardiol. 2018;250:80–5.

    PubMed  Google Scholar 

  50. Lee CH, Choi SW, Hwang J, Kim IC, Cho YK, Park HS, et al. 5-year outcomes according to FFR of left circumflex coronary artery after left main crossover stenting. J Am Coll Cardiol Intv. 2019;12(9):847–55.

    Google Scholar 

  51. Triantafyllis AS, Bennett J, Pagourelias E, McCutcheon K, Adriaenssens T, Sinnaeve PR, et al. Long-term outcomes after percutaneous revascularization of complex coronary bifurcation lesions using a dedicated self-expanding biolimus-eluting stent system. Cardiol J. 2018;25(4):470–8.

    PubMed  Google Scholar 

  52. Gil RJ, Bil J, Kern A, Pawłowski T. First-in-man study of dedicated bifurcation cobalt-chromium sirolimus-eluting stent BiOSS LIM C® - three-month results. Kardiol Pol. 2018;76(2):464–70.

    PubMed  Google Scholar 

  53. Konigstein M, Srdanovic I, Gore AK, Rahim HM, Généreux P, Ben-Yehuda O, et al. Outcomes of the Tryton-dedicated bifurcation stent for the treatment of true coronary bifurcations: individual-patient-data pooled analysis. Catheter Cardiovasc Interv. 2019;93(7):1255–61.

    PubMed  Google Scholar 

  54. Genereux P, Kumsars I, Lesiak M, et al. A randomized trial of a dedicated bifurcation stent versus provisional stenting in the treatment of coronary bifurcation lesions. J Am Coll Cardiol. 2015;65(6):533–43.

    PubMed  Google Scholar 

  55. Genereux P, Kumsars I, Schneider JE, et al. Dedicated bifurcation stent for the treatment of bifurcation lesions involving large side branches: outcomes from the Tryton Confirmatory Study. J Am Coll Cardiol Intv. 2016;9(13):1338–46.

    Google Scholar 

  56. Bhatheja S, Fuster V, Chamaria S, Kakkar S, Zlatopolsky R, Rogers J, et al. Developing a mobile application for global cardiovascular education. J Am Coll Cardiol. 2018;72(20):2518–27.

    PubMed  Google Scholar 

  57. Bhatheja S, Chamaria S, Zlatopolsky R, et al. Bifurcaid: an app defining a new era of innovative medical education in cardiovascular medicine. J Am Coll Cardiol. 2018;71(11 Suppl).

    Google Scholar 

  58. Zhang JJ, Gao XF, Han YL, et al. Treatment effects of systematic two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: rationale and design of a prospective, randomised and multicentre DEFINITION II trial. BMJ Open. 2018;8(3):1–7.

    Google Scholar 

  59. Holm NR, Andreasen LN, Walsh S, Kajander OA, Witt N, Eek C, et al. Rational and design of the European randomized Optical Coherence Tomography Optimized Bifurcation Event Reduction Trial (OCTOBER). Am Heart J. 2018;205:97–109.

    PubMed  Google Scholar 

  60. Miyazaki Y, Muramatsu T, Asano T, et al. On-line three-dimensional OFDI guided PCI vs . angiography guided in bifurcation lesions : design and rationale of the randomized OPTIMUM trial. Eurointervention. 2019.

Download references

Funding

Dr. Zaman has been supported by a fellowship (101993) from the National Heart Foundation of Australia.

Author information

Authors and Affiliations

  1. MonashHeart, Monash Health, Monash Medical Centre, 246 Clayton Road, Clayton, Melbourne, Victoria, 3168, Australia

    Sean Tan MBBS, John Ramzy MBBS & Sarah Zaman MBBS, PhD

  2. The University of New South Wales, Sydney, NSW, Australia

    Sonya Burgess MBChB, BSc

  3. Department of Cardiology, Nepean Hospital, Sydney, NSW, Australia

    Sonya Burgess MBChB, BSc

  4. Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia

    Sarah Zaman MBBS, PhD

Authors
  1. Sean Tan MBBS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. John Ramzy MBBS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sonya Burgess MBChB, BSc
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sarah Zaman MBBS, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sarah Zaman MBBS, PhD.

Ethics declarations

Conflict of Interest

Sean Tan declares that he has no conflict of interest. John Ramzy declares that he has no conflict of interest. Sonya Burgess declares that she has no conflict of interest. Sarah Zaman declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Coronary Artery Disease

Electronic Supplementary Material

ESM 1

(AVI 218 kb)

ESM 2

(AVI 177 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tan, S., Ramzy, J., Burgess, S. et al. Percutaneous Coronary Intervention for Coronary Bifurcation Lesions: Latest Evidence. Curr Treat Options Cardio Med 22, 6 (2020). https://doi.org/10.1007/s11936-020-0806-4

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-020-0806-4

Keywords

Search

Navigation