Treatment of coronary bifurcation lesions

About fifteen to twenty percent of the coronary interventions are for the treatment of bifurcation lesions. Treatment of bifurcation lesions are more technically challenging, have lower success rates and worse clinical outcome than non bifurcation lesions. With the availability of drug eluting stents (DES), the results of bifurcation strategies are approaching that of non bifurcation lesions. Bare metal stent (BMS) is still indicated when there are contraindications to prolonged dual antiplatelet therapy. In the setting of acute myocardial infarction with primary PCI (percutaneous coronary intervention), BMS is preferred in bifurcation stenting because of potential risk of stent thrombosis. In short lesions of the main branch of non-true bifurcation lesions also, BMS may be preferred. There has long been a question of whether one stent or two stents should be used for bifurcation stenting. Now there is clear evidence that one stent strategy with provisional stenting of side branch in case of any problems is preferred to elective two stent strategy. That means stenting only the main branch with balloon angioplasty of the side branch has a better outcome in terms of restenosis of either the main branch or the side branch and the need for repeat revascularization. If a two DES approach is used, it makes the procedure more prolonged, with higher fluroscopy times, contrast volumes and more procedure-related release of cardiac biomarkers. Suboptimal result in the sided branch can be accepted if there is a TIMI III flow in the side branch and when the clinical relevance of the territory of distribution is limited. This strategy does not apply in the treatment of left main bifurcation lesions or in the case of a major diagonal. It applies very well to a small obtuse marginal branch.

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