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Methods: Bench and in-vivo evaluations were performed. For the bench visualization bifurcated silicone mock vessel was used. The POKI technique5️⃣ was simulated using a 3.5 mm POT balloon. For the in-vivo evaluation patients with angiographic bifurcation lesions in a native5️⃣ coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm, SB diameter ≥ 2.0 mm, and percentage diameter stenosis5️⃣ (%DS) more than 50% in the main vessel (MV) were included. Provisional stenting was the default strategy.
In MV the distal5️⃣ balloon marker is exactly at the carina tip. SB balloon is positioned with proximal marker exactly at the stent struts5️⃣ borders. The proximal SB balloon marker and MV balloon distal marker could be in parallel or MV balloon marker could5️⃣ be a little bit distally in the direction to the carina tip (depending on the specific anatomy). Step IV: Simultaneous5️⃣ balloon inflation. During balloon inflation the stent is optimally deformed to achieve maximum apposition to the SB. A schematic representation5️⃣ of the POKI procedure is illustrated in Figure 1.
Figure 1. Schematic representation (above) and bench visualization (below) of each step5️⃣ of the proximal optimization with kissing balloon inflation (POKI) technique. I) The stent is implanted in main vessel (MV). Stent5️⃣ sizing is performed according to the distal reference diameter. II) Proximal optimization balloon is inflated in the proximal MV. The5️⃣ exact positioning is made by placing the distal balloon marker proximal from the carina tip. The proximal optimization technique (POT)5️⃣ balloon is inflated several times to ensure complete stent strut apposition in proximal region. III) The balloon positioning for POKI5️⃣ — in MV the distal balloon marker touches the carina tip, the side branch balloon is positioned with proximal marker5️⃣ exactly at the stent struts borders. The proximal SB balloon marker and MV balloon distal marker could be in parallel5️⃣ or MV balloon marker could be a little bit distally in the direction to the carina tip (depending on anatomy5️⃣ in practice). IV) During balloon inflation the stent is optimally deformed to achieve maximum apposition to the side branch ostium.5️⃣ V) Final result.
Discussion
Proximal optimization with KBI is a novel stent-optimization technique for bifurcation lesions. It showed excellent feasibility and success-rate5️⃣ both in bench and in-vivo evaluation.
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