Bifurcation Lesions

Abstract

Listening to dodecaphonic music requires patience and a willingness to be prepared to study the same piece over and over again. We experienced a similar feeling after reading 2 important studies about bifurcation lesions featured in this issue of Circulation: Cardiovascular Interventions . The first read gives a general impression; however, understanding and appreciation only comes after reading them a few times and devoting an effort to understand them. Bifurcation lesions historically have been associated with high restenosis rates1,2 and early atherogenesis,3,4 with the ostium of the side branch (SB) being the most common site of restenosis after stenting.1,5 Improvements in bifurcation stent techniques, the results from numerous randomized controlled trials,6–8 and registry data have led to the commonly held belief that provisional stenting should be our first-line strategy in the majority of lesions.9,10 However, the mechanism of SB neointimal hyperplasia and the implications of our choice of bifurcation stent technique still require further evaluation to ensure that we understand the long-term outcomes after percutaneous coronary intervention (PCI) in this complex lesion subgroup. The featured articles address a few of our ongoing queries with regard to bifurcation disease and provide some further information on the anatomy of these lesions and the relative significance of the SB. Articles see pp 105 and 113 Koo et al11 evaluated the mechanisms of changes in the geometry of the ostium of the SB after main branch (MB) stenting and investigated the predictors of a functionally significant SB stenosis using intravascular ultrasound (IVUS) and fractional flow reserve (FFR). The authors enrolled patients with a predetermined provisional SB strategy for de novo, proximal, or mid left anterior descending (LAD) artery lesions and went on to perform IVUS of the MB before and after MB stenting to measure the vessel volume …