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Coronary bifurcation lesions correspond to nearly 20–25% of all percutaneous coronary interventions (PCI) [1, 2]. Interventions in this subset of💱 lesions pose a technical challenge with high early and late complication rates [3]. PCI of bifurcation lesions can be performed💱 using a variety of techniques, depending on the plaque distribution across the main and daughter branches, and the bifurcation geometry💱 [4]. The fractal geometry of coronary bifurcations defines a discrepancy in diameters between the proximal main vessel (MV) and the💱 daughter branches — the distal MV (main branch, MB) and side branch (SB) [5]. Kissing balloon inflation (KBI) has been💱 one of the first proposed stent-optimization techniques specific for bifurcation lesions and continues to play an essential role in bifurcation💱 PCI by optimizing stent apposition and improving SB access. However, the application of KBI requires SB recrossing after main vessel💱 stenting, which adds additional procedure and fluoroscopy time, as well as contrast. It also requires certain operator experience, especially in💱 cases with SB occlusion after stenting. Additional disadvantages of KBI are the elliptical deformation of the proximal MV, which can💱 further compromise long-term results [6]. Proximal optimization technique (POT) has been proposed as a stent-optimization technique able to adjust the💱 tubular design of the coronary stent to the natural bifurcation anatomy [7]. It was expected that POT could correct stent💱 apposition, respecting fractal vessel anatomy, without compromising and even improving SB patency. However, studies demonstrated that for the preservation of💱 SB patency, without any functional vessel flow compromise, an additional SB balloon dilation is required [8]. The optimal result of💱 POT is highly dependent on the precise balloon positioning, and inaccurate placing of the balloon may lead to uncomplete strut💱 apposition to the SB lateral wall [9, 10]. Moreover, it is currently demonstrated that even an appropriately positioned POT balloon💱 (according to the current criteria [4]) could cause further elliptical deformation at SB ostium thus additionally stenosing it [11]. Therefore,💱 proposed herein is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and kissing-balloon inflation.
Stable patients💱 with angiographic bifurcation lesions in a native coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm and SB💱 diameter ≥ 2.0 mm and percentage diameter stenosis (%DS) more than 50% in MV were included. PCI was performed according💱 to the current guidelines [12]. Provisional stenting was the default PCI procedure in all patients. All lesions were stented with💱 second-generation drug-eluting stents. Angiographic success was defined as end procedural MV %DS < 20% and SB stenosis < 50% without💱 significant dissection and flow impairment. Procedure success included angiographic success in the absence of in-hospital major adverse cardiac events (MACE;💱 death, stroke, and myocardial infarction). All patients received double antiplatelet therapy with acetylsalicylic acid 75–100 mg and a P2Y2 inhibitor💱 (clopidogrel, prasugrel, or ticagrelor).
Therefore, the current findings have important clinical implications. This novel stent optimization technique combines the benefits from💱 POT and KBI and may provide improved post-PCI results in bifurcation lesions. POKI technique shortens the procedure time by combining💱 POT and KBI in a one-step approach. The operator should not be concerned about further carina shifting as SB ostium💱 is dilated simultaneously. Furthermore, the visualization of the SB balloon at the stent border provides a firm marker of the💱 carina position and facilitates the positioning of the MV POT balloon. If during inflation the POT balloon slips proximally, it💱 should be positioned one marker distally after deflation, without doubting excessive carina shifting.
Limitations of the study
The study has the following💱 limitations to be considered: first, bench models fail to truly replicate the geometry and elasticity of diseased coronary vessels. Balloon💱 inflation in diseased coronary vessels with differential distribution of fibrosis and calcification may behave differently to silicon. However, the results💱 from this in-vivo evaluation were confirmatory of the on-bench findings. Second, the findings include a relatively low sample size of💱 41 vessels. Third, for the present study intravascular imaging was not performed. Lastly, presented herein are the immediate angiographic and💱 QCA results after the index procedure. Further follow-up study with intravascular ultrasound assessment is currently performed to evaluate the long-term💱 procedural result.
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