Coronary Artery Bifurcation Lesions: A Review of Contemporary Techniques in Percutaneous Coronary Intervention

Percutaneous intervention of coronary bifurcation lesions continues to challenge interventional cardiologists. Nonetheless, the past decade has seen an explosion in the development of clinical novel techniques and well-conducted trials validating the relative efficacy and safety of these techniques. For the most part, consensus has emerged regarding the preferred technique, that being provisional stenting of the side-branch (SB), based on the results of several randomised trials that, with the exception of one, have shown no benefit of a two-stent approach, utilising any one of several techniques, including the crush, culotte, or other modifications. Only the double-kiss (DK) crush appears to confer better clinical outcomes, possibly because of the superiority of the technique in optimising access to the SB. Trial data are still pending regarding the efficacy of two-stent techniques in patients with complex SB lesions and with large-calibre SBs. The use of second-generation drug-eluting stents is associated with better results compared to historical data. Preliminary data from studies utilising dedicated bifurcation stents similarly shows favourable results. Bifurcation stenting using bioresorbable vascular scaffolds is at an early stage, with prospective trial data needed to validate this technology for the use in this subset of patients. Modern imaging tools such as intravascular ultrasound and optical coherence tomography, as well as physiological assessment of SB lesions, are now utilised in decision-making regarding stent strategy, though trial data showing better outcomes with routine use of these tools are lacking.