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Coronary bifurcation lesions correspond to nearly 20–25% of all percutaneous coronary interventions (PCI) [1, 2]. Interventions in this subset of🎅 lesions pose a technical challenge with high early and late complication rates [3]. PCI of bifurcation lesions can be performed🎅 using a variety of techniques, depending on the plaque distribution across the main and daughter branches, and the bifurcation geometry🎅 [4]. The fractal geometry of coronary bifurcations defines a discrepancy in diameters between the proximal main vessel (MV) and the🎅 daughter branches — the distal MV (main branch, MB) and side branch (SB) [5]. Kissing balloon inflation (KBI) has been🎅 one of the first proposed stent-optimization techniques specific for bifurcation lesions and continues to play an essential role in bifurcation🎅 PCI by optimizing stent apposition and improving SB access. However, the application of KBI requires SB recrossing after main vessel🎅 stenting, which adds additional procedure and fluoroscopy time, as well as contrast. It also requires certain operator experience, especially in🎅 cases with SB occlusion after stenting. Additional disadvantages of KBI are the elliptical deformation of the proximal MV, which can🎅 further compromise long-term results [6]. Proximal optimization technique (POT) has been proposed as a stent-optimization technique able to adjust the🎅 tubular design of the coronary stent to the natural bifurcation anatomy [7]. It was expected that POT could correct stent🎅 apposition, respecting fractal vessel anatomy, without compromising and even improving SB patency. However, studies demonstrated that for the preservation of🎅 SB patency, without any functional vessel flow compromise, an additional SB balloon dilation is required [8]. The optimal result of🎅 POT is highly dependent on the precise balloon positioning, and inaccurate placing of the balloon may lead to uncomplete strut🎅 apposition to the SB lateral wall [9, 10]. Moreover, it is currently demonstrated that even an appropriately positioned POT balloon🎅 (according to the current criteria [4]) could cause further elliptical deformation at SB ostium thus additionally stenosing it [11]. Therefore,🎅 proposed herein is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and kissing-balloon inflation.
After stent🎅 deployment in MV (sized according to the distal vessel diameter) the POKI technique includes the following steps: (1) Proximal optimization🎅 technique with a non-compliant (NC) balloon sized according to the proximal MV diameter; (2) SB recrossing with a wire and🎅 removal of jailed wire; (3) Kissing balloon inflation using a NC balloon in the SB, with proximal marker of the🎅 balloon into the stent borders and an NC POT balloon in the MV, with distal balloon marker positioned parallel to🎅 carina tip.
Figure 1. Schematic representation (above) and bench visualization (below) of each step of the proximal optimization with kissing balloon🎅 inflation (POKI) technique. I) The stent is implanted in main vessel (MV). Stent sizing is performed according to the distal🎅 reference diameter. II) Proximal optimization balloon is inflated in the proximal MV. The exact positioning is made by placing the🎅 distal balloon marker proximal from the carina tip. The proximal optimization technique (POT) balloon is inflated several times to ensure🎅 complete stent strut apposition in proximal region. III) The balloon positioning for POKI — in MV the distal balloon marker🎅 touches the carina tip, the side branch balloon is positioned with proximal marker exactly at the stent struts borders. The🎅 proximal SB balloon marker and MV balloon distal marker could be in parallel or MV balloon marker could be a🎅 little bit distally in the direction to the carina tip (depending on anatomy in practice). IV) During balloon inflation the🎅 stent is optimally deformed to achieve maximum apposition to the side branch ostium. V) Final result.
In-vivo evaluation
Figure 3. Changes in🎅 percentage diameter stenosis before and after percutaneous coronary intervention (PCI) in the main vessel ( A ), main branch (🎅 B ), and side branch ( C ) of the bifurcation lesion; %DS — percentage diameter stenosis.
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