Coronary Bifurcation PCI-Part II: Advanced Considerations

Performance of percutaneous coronary intervention (PCI) for bifurcation lesions involves complex decision-making informed by anatomic, hemodynamic, technical, and clinical factors. Building on the procedural foundations discussed in the companion paper in this two-part series, this second paper focuses on advanced considerations in bifurcation PCI. Factors associated with side branch (SB) compromise are discussed, including bifurcation angle and distribution of plaque location, along with strategies for SB protection and SB rewiring. Outcomes of landmark randomized controlled trials of provisional versus two-stent approaches, as well as specific two-stent techniques, are summarized. Based on these factors, an algorithmic approach for bifurcation PCI is outlined. Lastly, the use of drug-coated balloons, dedicated bifurcation stents, bioresorbable vascular scaffolds, bioadaptor stents, physiologic testing, intravascular imaging, and other emerging innovations are explored to provide a perspective on the future of bifurcation PCI.