Treatment of coronary bifurcations: might less be more?

Abstract

Percutaneous coronary interventions (PCIs) on coronary arteries in which the lesion involves a clinically significant side branch, termed a bifurcation lesion, are among the most challenging lesions for intervention.1 Coronary occlusions are often cited as the most challenging type of lesion, but an unsuccessful PCI on a coronary occlusion is rarely associated with a clinically important event, and initial success is only rarely complicated by late adverse events. In contrast, PCI of bifurcation lesions is associated with an unusually high risk, perhaps the highest risk, for both early and late complications. For every bifurcation lesion on which a PCI is attempted, two major procedural questions must be answered: (i) should the side branch be treated in addition to the main branch; and, if the answer is yes, (ii) how should it be treated? Prior to beginning the percutaneous treatment of a bifurcation lesion, the decision about whether to treat a side branch lesion is usually based on whether there is a flow-limiting lesion in it before the procedure is initiated. When evaluating the functional significance of ostial side branch stenoses, it must be remembered that coronary angiography often leads to an overestimation (and less often an underestimation) of the functional significance of ostial branch lesions; more so than do lesions in other parts of the coronary circulation. This is in part due to difficulties in visualizing ostial lesions in multiple orthogonal views, and in part due to the fact that such lesions are often very short, reducing the likelihood that they limit blood flow. Measurement of the fractional flow reserve (FFR) can overcome the limitations of coronary angiography and should probably be considered the gold standard for assessing whether any lesions, let alone difficult to visualize lesions, are functionally significant.2 Guidewires that can measure the FFR, however, are … *Corresponding author. Email address: pbberger{at}geisinger.edu