Active side branch protection in provisional stenting: techniques, case-based insights, and practical considerations

Provisional stenting (PS) remains the default strategy for most bifurcation lesions, but the risk of side branch (SB) compromise continues to be a concern. Active SB protection strategies were developed to mitigate this risk, as an extension of PS with a jailed wire. They have a common goal: to preserve SB patency while decreasing the need for complex two-stent strategies, particularly in difficult anatomical or clinical situations. This review aims to provide a comprehensive, case-based overview of different contemporary active SB protection methods, including techniques developed in Asia which have not yet been widely adopted elsewhere. We highlight the practical aspects of conventional, contemporary, and modified jailed balloon techniques; active transfer of plaque; jailed microcatheter strategies; and emerging adaptations, such as jailed drug-coated balloon use. Case examples illustrate the mechanisms of stent deformation, rescue manoeuvres, and correction with intravascular imaging. Ultimately, active SB protection may enhance the safety and consistency of PS across a broad spectrum of patients and lesion types.