In Silico Comparative Analysis of Optimization Techniques for Coronary Bifurcation Provisional Stenting: A Coupled FEA–CFD Procedure

Purpose Provisional stenting is the conventional method for coronary bifurcation lesions; however, the optimal side branch (SB) optimization strategy is still a topic of debate. In a unified mechanical and hemodynamic framework, no prior computational study has directly compared distal proximal optimization technique (POT), proximal POT, kissing balloon inflation (KBI), and ostial optimization technique (OOT). The objective of this investigation was to evaluate the hemodynamic and mechanical consequences of these strategies in a computational model of coronary bifurcation stenting. Methods A sequential finite element analysis (FEA) and computational fluid dynamics (CFD) framework was applied to a Medina 1,1,1 bifurcation using a three-layer hyperelastic vessel wall, hyperelastic–plastic plaque, folded balloons, and a cobalt–chromium stent. Each SB optimization strategy was followed by rePOT. Transient non-Newtonian (Carreau) CFD was performed on the post-deployment geometries during a cardiac cycle. Outcomes included stent stress, wall stress, malapposition, neo-carina length, time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), Q-criterion, helicity, and local normalized helicity (LNH). Results In the modelled anatomy, distal SB access was associated with more favorable hemodynamic metrics. TAWSS < 0.4 Pa, OSI > 0.1, and RRT > 20 was observed in 46.6, 6.2, and 11.0% within the bifurcation core, respectively, compared to 52.3, 12.5, and 18.0% with proximal access resulting in adverse outcomes. Intermediate hemodynamic profiles were observed in KBI and OOT. Proximal access was associated with greater vortex disruption, whereas distal access preserved more coherent helical structures. Mechanically, OOT exhibited the lowest malapposition (13.6%), wall stress (219 kPa), and neo-carina length (0.00 mm). The largest residual neo-carina (0.57 mm) was observed in proximal access. Conclusion In this single idealized Medina 1,1,1 computational model, distal SB access was associated with more favorable simulated hemodynamic characteristics, while OOT achieved favorable mechanical outcomes. These results establish a mechanistic foundation for additional research on the potential impact of SB optimization strategies on the mechanics and flow of the local stent–vessel system. However, the relative performance of these strategies may depend on bifurcation anatomy, plaque distribution, device characteristics, and procedural conditions. Consequently, the current findings should be regarded as hypothesis-generating and require validation across a range of anatomies, devices, and boundary conditions before clinical implications can be established.