Progress in percutaneous management of coronary bifurcation lesions

Bifurcation lesions have been recognized as one of the most important challenges facing the interventional cardiologist since the beginnings of percutaneous coronary intervention (PCI). The potential of periprocedural occlusion of the side branch was discovered to be significant, leading to early attempts at protecting the side branch with a second guide wire and kissing balloon inflation in order to minimize this risk and thus improve the procedural and short-term success of the procedure. The advent of stenting significantly improved the safety of the procedure, although, side branch success continued to be a challenge. A variety of single as well as double stenting techniques were developed that improved the safety and short-term results of percutaneous coronary intervention involving side branches. Long-term success, however, continued to elude, due to an increased need for target lesion revascularization (TLR) and higher major adverse cardiac event (MACE) rates following PCI of bifurcation lesions. Of the techniques, main vessel stenting and balloon inflation of the side branch, T-stenting, and permutations of Y-stenting including the Culotte, emerged. The introduction of drug-eluting stents appears to have brought bifurcation PCI to a new level of long-term efficacy. Specialty bifurcation stents have been developed to provide easy access to the side branch, however, these have to date had little impact on practice and have not been adopted widely. New techniques such as crush stenting and its several permutations, and simultaneous kissing stenting developed specifically for drug-eluting stents have been developed. Debate continues as to which is the most efficacious technique. True randomized comparisons are, however, lacking. It is likely that all of the currently utilized techniques have a place in the interventional cardiologist's quiver and that each is appropriate in a particular anatomical scenario. Nonetheless, well-designed randomized trials evaluating the various bifurcation techniques especially in complex bifurcation lesions are needed.