Bench Testing Analysis of Perforation Management in the Setting of Bifurcation Coronary Intervention

Background Management of coronary perforation in bifurcation lesions with covered stents remains challenging. Aims We aimed to describe a proper practice and toolbox for “jailed‐branch” management after covered stent deployment. Methods Using a bench model, we tested various wires with a 120° angulated microcatheter for their ability to penetrate covered stents to access jailed side branches (SB). Next, four PCI techniques were assessed: Test #1 (main branch [MB] rupture simulation): MB covered stent, graft penetration, and kissing balloon inflation (KBI) ( n = 7). Test #2: Test #1 completed with Culotte using a drug‐eluting stent (DES) ( n = 3). Test #3: Culotte with two covered stents simulating MB and SB rupture ( n = 3). Test #4: Test #3 plus final DES in MB ( n = 3). Results High tip‐load wires ( > 12 g) successfully penetrated covered stents within 14 s. All procedures were completed successfully. Test #1 showed lumen area reductions of –8% (MB) and –25% (SB), with graft overhang at the SB. Conversion to Culotte with DES (Test #2) improved SB lumen reduction to –8%. Test #3 showed reductions of –7% (MB) and –15% (SB), with graft overhang at MB, corrected in Test #4 by DES implantation, resulting in +9% lumen gain (MB) and improved SB lumen reduction (–11%). Conclusion In this bifurcation perforation in‐bench model, high tip‐load wires effectively penetrated covered stents toward excluded branches after crossover covered stent implantation. Conversion to Culotte, using either a DES or a second covered stent, was feasible. Overhanging graft material following SB fenestration could be addressed by overstenting with a DES.