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Covered Stent Fenestration for Side Branch Salvage in Bifurcation Coronary Perforation: A Systematic Bench-Test
Troels Yndigegn1,2, Per Bondesson1,2, Göran K Olivecrona1,2
1Division of Cardiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
Background:
Coronary perforation at a bifurcation level is a life-threatening emergency. Covered stents may seal the defect but risk side-branch occlusion. We evaluated the feasibility and technical considerations of guide wire fenestration at coronary bifurcations and present a case where a covered side branch was successfully salvaged.
Methods:
A transparent bifurcation phantom replicating coronary anatomy was constructed and integrated into a pulsatile flow system. Three fenestration strategies were evaluated: (1) a balloon-blocking approach, in which inflation of a balloon in the main branch after covered stent deployment was hypothesized to facilitate wire redirection and fenestration; (2) a microcatheter-assisted approach; and (3) a wire-only approach. These strategies were tested by 15 percutaneous coronary intervention operators with varying levels of experience. Seven guide wires with differing characteristics and tip loads ranging from 3 to 12 g were used.
Results:
The balloon occlusion strategy achieved fenestration in all tests (n = 15) using both 12 g and 3 g wires, as did microcatheter-assisted fenestrations (n = 2). Wire-only strategy succeeded in 14 of 17 attempts across wires ranging from 3 to 12 g; however, 3 of 6 attempts using 3 g wires required conversion to balloon occlusion. Median time to fenestration was 69 seconds for both balloon occlusion and microcatheter strategies, compared with 81 seconds, 94 seconds, and 167 seconds for wire-only approaches using 12 g, 6 g, and 3 g wires, respectively. Angiography and micro-computed tomography demonstrated satisfactory results, but endoscopic analysis revealed polyurethane membrane recoil reducing the ostial area by up to 75%, necessitating side-branch stenting. All evaluated side-branch stenting techniques improved the ostial lumen area.
Conclusions:
Covered stent fenestration is a feasible bailout strategy for preserving side-branch patency in critical bifurcation perforations.