Evolving strategies in provisional bifurcation percutaneous coronary intervention (PCI) now leverage precise bifurcation angle analysis and adjunctive revascularization techniques to confront the persistent challenge of side branch occlusion.
Interventional cardiologists frequently encounter the dilemma of preserving side branch flow while achieving robust main vessel scaffolding in bifurcation lesions. Despite advances in stent design and deployment, occlusion of the side branch remains a significant concern, occurring in approximately 8.4% of bifurcation lesions and being associated with increased risks of periprocedural myocardial infarction and adverse long-term outcomes.
According to real-world data from the PROGRESS-BIFURCATION registry, larger bifurcation angles correlate with a marked increase in side branch occlusion risk. In angles exceeding 70°, the incidence of side branch occlusion doubles compared to angles below 70%, underscoring the need for precise angle assessment to inform procedural planning and device selection.
Mastery of bifurcation geometry allows operators to anticipate flow dynamics and tailor their provisional strategy. In wide-angle lesions, preemptive side branch wiring, selective predilatation, and optimization of balloon sizing can mitigate the propensity for plaque shift. When angle-related risk remains high, early consideration of two-stent techniques may be warranted to safeguard the branch ostium.
A recent analysis comparing directional coronary atherectomy with drug-eluting stents demonstrates that targeted plaque debulking can significantly enlarge the lumen in left main bifurcation lesions, simplifying subsequent stent placement. By reducing plaque burden, directional coronary atherectomy (DCA) not only facilitates optimal stent expansion but also lessens the reliance on aggressive post-dilatation maneuvers that risk further branch compromise.
Earlier work on directional atherectomy underscores that post-debulking device selection must be personalized. In vessels with limited dissections and low bleeding risk, drug-eluting stents remain the backbone of durable revascularization; in scenarios favoring minimal scaffolding, drug-coated balloons offer a viable alternative to maintain patency without the long-term implant footprint.
As imaging modalities evolve toward real-time three-dimensional reconstructions, operators will gain instantaneous feedback on bifurcation angles and plaque distribution. Coupled with refined training programs, these advances have the potential to transform provisional bifurcation PCI from a one-size-fits-all approach into a precision intervention tailored to individual anatomy and lesion complexity, though further clinical validation is necessary before widespread adoption.
Key Takeaways:- Larger bifurcation angles in bifurcation PCI increase the risk of side branch occlusion, affecting outcomes.
- DCA aids in optimizing bifurcation lesion management by minimizing plaque burden.
- The choice between drug-coated balloons and drug-eluting stents should be personalized based on patient and lesion characteristics.