Practical Technique in Bifurcation Strategy :

Focus on Provisional Stenting

Sodiqur Rifqi

Department of Cardiology and Vascular Medicine, Faculty of

Medicine of Diponegoro University – Dr. Kariadi Hospital
Semarang, Indonesia
 Outline

• Back ground
• Bifurcation Classification(s)
• Understanding vessels size laws in bifurcation
• Understanding kinds provisional stenting
• Understanding of stent deformation as a consequence of each steps
• Step by step of provisional stenting
• Take home message
 Background

• Provisional bifurcation stenting is a standard approach

for treatment of the vast majority of bifurcation lesions

• Provisional SB stenting is a treatment philosophy rather than

technique
N: 326 N: 326
How to perform provisional SB
stenting technique in
bifurcations
 Principle of Bifurcation stenting

• Keep it simple and safe

• Understand and respect the original bifurcation anatomy

• Optimize the flow and functional of a bifurcation

• Limit the stent use

How to perform provisional stenting
Preference for provisional stenting
• Small LCx
• No LCx disease (1,0,0) (1,1,0)
• Lesion in ostial LCx extending > 5 mm
• Wide angle LAD / LCx
• No significant ostial LCx disease by
IVUS
(MLA > 4 mm2 and PB < 50%)

Kang et al. Cath Cardiovasc Interv 2014 ;83:545-52

12
De la Torre Hernandez JM. Interventional Cardiology Clinics. July 2015
 Vessel Size Laws in Bifurcation
 Helping operator for visual estimation
Finet’s law
D1 = 0.678 (D2 + D3)

D2
D1 D2
D1

D3 D3

D13 = D23 + D33

(Murray’s law)
Adapted from Koo et al. EBC 2008
Provisional stenting Baseline
Single stent strategy
 Wiring of both branches

Predilate main branch, SB dilatation on operator decision

Main branch stent positioning
and deployment
Result after main branch stent
deployment
Proximal optimisation – POT
Why must be POT ?

Changed the tubular stent to a tapered device fitting both distal and

proximal diameters of the MB and opened stent strut towards the SB

respecting anatomy of the bifurcation core segment

Effect of Side Branch Dilatation and Kissing Balloon

Post POT
Result after POT
After POT….
• The SB may or may not treated after POT
• If the SB needs attention GW are exchanged and KB or POT/side/PT
(re-POT) is performed
• Ensuring optimal results in the MB should be given priority over
optimizing the appearance in the SB if there is a need for a choice
between the two
• For LM: The selected stent should have sufficient length 8-9 mm in
the LM to accommodate an appropriately sized balloon needed for
the POT
• Covering up the LM ostium
 Side branch rewiring

• Using wire from main branch

• Try to get distal strut at the side branch
Final kissing

Or side branch dilatation

After kissing balloon inflation or side branch
dilataion….

High pressure proximal stent inflation (Second POT)

using a short non-compliant balloon should be
considered for correction of possible stent distortion
after kissing balloon inflation or side branch dilatation
Second POT
Final result
 POT-side-POT : Easy Technique
(Proximal Optimisation Technique)
 Non compliant balloon

Select a short balloon

The balloon diameter should be selected

according to the proximal MB diameter

Individual non-compliant high pressure “ostial

SB” post dilation is mandatory in complex
stenting ( 2 stent) techniques
POT benefit (1)
Why POT ?
POT benefits (2)
PCI Strategy and PCI Guiding
SB stenting in provisional strategy
Double stenting : T or TAP
 Provisional T
Stenting

• The T technique is probably

one of the one most
frequently utilized strategies
to shift from provisional
stenting to stenting the SB.
TAP
• The T technique is associated technique
with the risk of leaving a
small gap between the stent
implanted in the MB and the
stent implanted in the SB;
this gap can be a factor that
contributes to an uneven
distribution of the drug,
leading to ostial restenosis of
the SB.

Colombo A, Stankovic G, Bifurcations and Branch Vessel Stenting, in

Textbook of Interventional Cardiology 7th ed, Topol EJ (eds), 2016
 Provisional Approach –
requiring a 2nd stent in the SB
TAP Internal Crush Culotte

Easy to perform Complete coverage Complete coverage

Advantages
No recrossing of ostium of ostium
Any anatomy
More labourious
Disadvantages Struts protruding Recrossing into SB Rewiring both
into MB 3 layers of struts branches
Double stent layer

Courtesy of Dr. Antonio Colombo

Culottes stenting Technique

Culottes stenting. In this technique the

main branch and side branch vessels are
wired.

A shows the main branch stent deployed

and the side branch rewired and ballooned.

B shows the side branch stent being

deployed in a “pants leg” type fashion with
proximal overlap. As a final step, the main
branch would be rewired and final “ Kissing
Balloon” MUST be performed.
Levy MS, Moussa ID, Bifurcation Lesions and Intervention, in
SCAI Interventional Cardiology Board Review 2nd ed, Kern MJ (eds), 2014.
Schematic representation of the
culotte technique

Colombo A, Stankovic G, Bifurcations and Branch Vessel Stenting, in

Textbook of Interventional Cardiology 7th ed, Topol EJ (eds), 2016
 Culottes stenting

• The culotte technique likely provides the

best coverage of the carina.
• Important caveats about this approach are
that with some closed-cell design stents, the
opening of the struts toward the branches
may only reach a maximum diameter of 3
mm.
• For this reason, the culotte technique
should be used only with stents that have a
design that allows full opening of the struts
toward both branches (open-cell stents)

• Disadvantage : technique is that rewiring

both branches through the stent struts can
be difficult and time consuming

Final Kissing Balloon is a MUST

Position of Provisional Stenting in European PCI
Guidelines
Take home message
• Provisional 1 stent strategy is recommended for most of LM bifurcation
lesion, except for true bifurcation lesion

• Provisional stenting consist of: Crossover technique (1 stent}, Provisional T

stent , TAP (T And small Protrude) and Cullotte technique (2 stent strategy)

• It is mandatory to do POT (proximal optimization technique) after stenting

in Provisional stenting technique, and when side branch is significant, POT-
Side-POT or POT-Kiss-POT maybe necessary

• If 2 stent strategy is performed, Final Kissing Balloon and final POT is

mandatory