Side Branch Stenting Research Articles

Culotte stenting vs. TAP stenting for treatment of de-novo coronary bifurcation lesions with the need for side-branch stenting: the Bifurcations Bad Krozingen (BBK) II angiographic trial.

In percutaneous coronary intervention for de-novo coronary bifurcation lesions, the optimal technique for provisional side-branch stenting is still a matter of debate. We tested whether in this setting culotte stenting reduces the incidence of restenosis as compared with T-and-protrusion (TAP) stenting. This trial included 300 patients with a coronary bifurcation lesion requiring a side-branch stent. Patients were randomly assigned to culotte stenting or TAP stenting using drug-eluting stents in a 1:1 fashion. Primary endpoint was maximal per cent diameter stenosis of the bifurcation lesion at 9-month angiographic follow-up. As clinical endpoints we assessed target lesion re-intervention (TLR) and target lesion failure (composite of cardiac death, target vessel myocardial infarction, and TLR).Angiographic follow-up was available in 91% of the patients. After culotte stenting, the maximum per cent diameter stenosis in the treated bifurcation lesion was 21 ± 20% as compared with 27 ± 25% after TAP stenting (P = 0.038). The respective corresponding binary restenosis rates were 6.5 and 17% (P = 0.006). The 1-year incidence of TLR was 6.0% after culotte stenting vs. 12.0% after T-stenting (P = 0.069). Target lesion failure occurred in 6.7% of the culotte group and in 12.0% of the TAP group (P = 0.11). Only one patient of the culotte group incurred a definite stent thrombosis during 1-year follow-up. Compared with the TAP stenting, culotte stenting was associated with a significantly lower incidence of angiographic restenosis.

Anatomical and functional assessment of Tryton bifurcation stent before and after final kissing balloon dilatation: Evaluations by three-dimensional coronary angiography, optical coherence tomography imaging and fractional flow reserve.

To assess the anatomical and functional impact of final kissing balloon inflation (FKBI) after implantation of a dedicated bifurcation stent system. Current evidence suggests clinical benefit of FKBI in patients undergoing bifurcation dilatation using the Tryton side branch stent (Tryton-SBS). We hypothesized that FKBI improves anatomical reconstruction and functional results of bifurcation treated by Tryton-SBS. An unselected group of patients with complex bifurcation coronary lesions undergoing percutaneous coronary intervention (PCI) with Tryton-SBS underwent paired anatomical assessment with two- and three-dimensional quantitative coronary analysis (2D- and 3D-QCA), and optical coherence tomography (OCT), including 3D reconstruction before and after FKBI. Functional assessment by fractional flow reserve (FFR) was performed in the main branch (MB) and side branch (SB) before and after FKBI. Paired pre- and post-FKBI data were obtained in 10 patients. By OCT imaging, FKBI increased both the SB ostial area (4.93 ± 2.81 vs. 7.43 ± 2.87 mm2 , P < 0.001) and the SB maximum diameter (3.12 ± 0.98 vs. 3.82 ± 1.10 mm, P = 0.003). These findings were associated with a significant increase in FFR in the SB (0.90 ± 0.05 vs. 0.94 ± 0.03; P = 0.011), with no significant change in the MB (0.91 ± 0.05 vs. 0.92 ± 0.04; P = 0.470). In patients with complex bifurcation stenosis undergoing PCI with a dedicated bifurcation system, FKBI is associated with improved anatomical and functional results at the SB level, without compromising the result at the MB. © 2016 Wiley Periodicals, Inc.

A Pilot Study on Culottes versus Crossover Single Stenting for True Coronary Bifurcation Lesions.

The purpose of our study was to compare clinical and angiographic outcomes of planned culottes technique with that of provisional crossover single stenting in the treatment of true coronary bifurcation lesions (CBL) with drug-eluting stent (DES). True CBL patients (n = 104) were randomly assigned to either the provisional stenting of the side branch (crossover group) or the culottes group. Additional side branch (SB) stenting in the crossover group was required if there was thrombolysis in myocardial infarction flow ≤ 1 flow). The primary end point was the occurrence of major adverse cardiac events (MACE) at nine months, including cardiac death, myocardial infarction, target lesion/vessel revascularization and in-stent thrombosis. The secondary end point was angiographic in-segment restenosis at nine months. The rate of MACE at nine months was similar between the crossover and culottes groups (7.7% vs. 7.7%, p = 1.000). Additional SB stenting in the crossover group was required in 3.8% of patients. There was one procedural occlusion of SB in the crossover group. At nine months, the rate of in-segment restenosis was similar in the parent main vessel (0% vs. 1.9%, p = 1.000), main branch (1.9% vs. 7.7%, p = 0.363) and SB (17.3% vs. 9.6%, p = 0.250) between the crossover and culottes groups, respectively. This study demonstrated that there is no significant difference in cumulative MACE or in-segment restenosis between crossover and culottes groups. Larger randomized clinical trials are warranted to re-evaluate the outcomes of the provisional crossover stenting versus the culottes stenting techniques utilizing DES for true CBL.

Predictors for Side Branch Failure During Provisional Strategy of Coronary Intervention for Bifurcation Lesions (from the Korean Bifurcation Registry)

The most favored strategy for bifurcation lesion is stenting main vessel with provisional side branch (SB) stenting. This study was performed to elucidate predictors for SB failure during this provisional strategy. The study population was patients from 16 centers in Korea who underwent drug-eluting stent implantation for bifurcation lesions with provisional strategy (1,219 patients and 1,236 lesions). On multivariate analysis, the independent predictors for SB jailing after main vessel stenting were SB calcification, large SB reference diameter, severe stenosis of SB, and not taking clopidogrel. Regarding SB compromise, however, the independent predictors were true bifurcation lesion and small SB reference diameter, whereas possible predictors were parent vessel thrombus and parent vessel total occlusion. In addition, SB predilation helps us to get favorable SB outcome. The diameter of SB ostium after main vessel stenting became similar between severe SB lesions treated with predilation and mild SB lesions not treated with predilation. In conclusion, SB calcification, less clopidogrel use, large SB reference diameter, and high SB diameter stenosis are independent predictors for SB jailing, and true bifurcation and small SB reference diameter are independent predictors for SB compromise after main vessel stenting.

Results From the International Drug Coated Balloon Registry for the Treatment of Bifurcations. Can a Bifurcation Be Treated Without Stents?

This observational study assessed the 9-month clinical outcomes in patients with coronary bifurcation lesions suitable for drug-coated balloon (DCB) angioplasty. It was the intention to use DCB's without additional stenting (DCB-only strategy) in selected patients for this chosen strategy. Bail-out main branch (MB) and/or side branch (SB) stenting, however, were permissible when flow limiting dissections or excessive recoil occurred. A multitude of interventional strategies have been studied to treat bifurcation lesions. With the availability of DCB angioplasty, investigators have been using this interventional tool with the optional implantation of bare metal stents (BMS). This study is an international, prospective, multicenter registry enrolling patients with coronary bifurcation lesions including a side branch ≥2 mm in diameter. Patients with stable angina and documented ischemia or selected forms of unstable angina due to a culprit bifurcation lesion of any Medina classification type were recruited. The primary endpoint was clinically driven target-lesion revascularization (TLR) at 9 months. Secondary endpoints included 9-month major adverse cardiac events (death, myocardial infarction, or TLR), technical success, in-hospital outcomes and vessel thrombosis rates. A total 127 patients 66.1 ± 10.1 years of age were enrolled. Demographic characteristics were 80.3% (102/127) male gender, 31.5% (40/127) diabetes, 91.3% (116/127) hypertension, 7.1% (9/127) ST-elevation myocardial infarction (STEMI), and 9.4% (12/127) non ST-elevation myocardial infarction (NSTEMI). The 130 lesions were treated with 184 DCB's and 64 BMS. In 53.8% (70/130) of all lesions the DCB-only strategy could be used while 34.6% (45/130) of lesions had at least 1 stent (BMS) in the main branch, 8.5% (11/130) had at least 1 stent in the side branch and 3.1% (4/130) needed at least 1 stent in the main and side branch. 94.5% patients (121/127) were available for follow-up after 9.8 ± 2.0 months. The TLR rate was 4.6% in the absence of any thrombotic events in the treated vessels whereas the 9-month MACE rate was 6.2%. This observational study suggests that the DCB-only strategy is safe and effective to treat selected bifurcations while benefiting from a shortened dual antiplatelet therapy (DAPT).

Optimal Strategy for Provisional Side Branch Intervention in Coronary Bifurcation Lesions

This study compared the long-term follow-up results of conservative versus aggressive strategies for provisional side branch (SB) intervention in coronary bifurcation lesions. The appropriate criteria for provisional SB ballooning or stenting have not been established. A total of 258 patients with a large bifurcation lesion were randomized to a conservative or aggressive SB intervention strategy. Different criteria applied for the initiation of SB intervention after main vessel stenting in the conservative and aggressive groups were Thrombolysis In Myocardial Infarction flow grade lower than 3 versus a stenosis diameter >75% for non-left main bifurcations, and a stenosis diameter >75% versus a stenosis diameter >50% for left main bifurcations. The primary endpoint was target vessel failure (TVF), defined as a composite of cardiac death, spontaneous myocardial infarction, or target vessel revascularization at 3 years. At 3 years, TVF occurred in 11.7% of the conservative group versus 20.8% of the aggressive group (p = 0.049). Although no significant differences were observed in the incidence of TVF between groups at 1 year (9.4% vs. 9.2%; p = 0.97), landmark analysis between 1 and 3 years showed significantly less TVF in patients assigned to the conservative strategy (2.6% vs. 12.7%; p = 0.004). The crossover to the 2-stent technique was an independent predictor of TVF (hazard ratio: 5.42, 95% confidence interval: 2.03 to 14.5; p < 0.001). There was no interaction between left main bifurcation and treatment effects for TVF (p for interaction = 0.8). A conservative strategy compared with an aggressive strategy for provisional SB intervention is associated with long-term benefits for patients with a large bifurcation lesion. (Optimal Strategy for Side Branch Stenting in Coronary Bifurcation Lesion; NCT00794014).

Update on Provisional Technique for Bifurcation Interventions.

A series of scientific evidence supports the concept that provisional side-branch stenting should be the preferred strategy for percutaneous coronary intervention of bifurcation coronary lesions. However, to date, many interventional cardiologists still consider this technique unsuitable for complex bifurcation lesions. This is mainly due to the fact that provisional stenting may be performed in different ways and several technical refinements may influence the procedural outcome. We here systematically overviewed the arguments which should be considered during the following steps of the provisional strategy: branch wiring, side-branch predilation, "crossover" stenting, proximal optimization, kissing balloon and the side-branch rescue techniques. We suggest that provisional stenting should be regarded as a highly flexible technique which, with specific technical tricks, may allow us to safely treat patients with wide spectrum of bifurcated lesion complexity.

Drug eluting balloons as stand alone procedure for coronary bifurcational lesions: results of the randomized multicenter PEPCAD-BIF trial.

We set out to investigate the benefit of distal main or side branch treatment with a DCB compared to POBA in coronary bifurcation lesions. The standard treatment of bifurcation lesions is application of a DES to the main branch with provisional side branch stenting. While this resulted in considerable improvement in overall MACE rate suboptimal side branch results remained a problem. The study was performed from 2011 to 2013 in six German centers. Native bifurcation lesions were included if side branch vessel diameter was ≥2 and ≤3.5mm and no proximal main branch lesions was found. After successful predilatation randomization was performed to either DCB application or no further treatment. Follow-up angiograms for QCA analysis were done after 9months. Primary endpoint was late lumen loss (LLL). 64 patients were successfully randomized. Minimal lumen diameter and grade of stenosis were equal in both groups. Only five stents were used as bail out. Angiographic follow-up was achieved in 75% of patients. No patient died. There was one NSTEMI in the POBA group. Restenosis rate was 6% in the DCB group vs 26% in the POBA group (p=0.045). TLR was necessary in one patient of the DCB group vs three patients of the POBA. The primary endpoint LLL was 0.13mm in the DCB vs 0.51mm in the POBA group (p=0.013). In bifurcation lesions that show only class A or B dissection and recoil not beyond 30% the use of DCBs is a sound strategy.

Impact of side branch stenting on five-year long-term clinical outcome with the bifurcation-dedicated Axxess Biolimus A9-eluting stent system.

Our aim was to evaluate the five-year clinical impact of side branch (SB) stenting with a drug-eluting stent (DES) following Axxess stent implantation in coronary bifurcation lesions. Four hundred patients treated with Axxess were pooled from the AXXESS Plus and DIVERGE five-year follow-up studies. We compared unadjusted and propensity-adjusted major adverse clinical events (MACE) between Axxess with no SB stenting ("Axxess provisional") versus Axxess with SB stenting ("Axxess additional"). "Axxess additional" had no impact on the MACE rate, with unadjusted and adjusted HR 1.59 (95% CI: 0.95-2.64) and 1.37 (95% CI: 0.88-2.13), respectively. No differences were seen in the individual components of death, myocardial infarction and ischaemia-driven target lesion revascularisation, respectively, both in unadjusted (HR 0.92 [95% CI: 0.38-2.19]; HR 1.73 [95% CI: 0.78-3.82]; HR 1.65 [95% CI: 0.84-3.26]) and adjusted analysis (HR 0.92 [95% CI: 0.41-2.09]; HR 1.13 [95% CI: 0.59-2.17]; HR 1.31 [95% CI: 0.74-2.31]). No differences in definite stent thrombosis were seen with unadjusted HR 2.1 (95% CI: 0.45-9.88) and adjusted HR 1.0 (95% CI: 0.32-3.1). Stenting the SB following Axxess implantation does not impact on long-term clinical outcomes compared to MV stenting only. The Axxess stent system offers a safe and tailored alternative for the treatment of coronary bifurcation lesions.

Outcomes of a dedicated stent in coronary bifurcations with large side branches: A subanalysis of the randomized TRYTON bifurcation study

To examine the benefit of the Tryton dedicated side branch (SB) stent compared with provisional stenting in the treatment of complex bifurcation lesions involving large SBs. The TRYTON Trial was designed to evaluate the utility of a dedicated SB stent to treat true bifurcation lesions involving large (≥2.5 mm by visual estimation) SBs. Patient enrolled in the trial had smaller SB diameters than intended (59% SB ≤2.25 mm by Core Lab QCA). The TRYTON Trial did not meet its primary endpoint due to an increased rate of peri-procedural myocardial infarctions (MIs). The TRYTON Trial randomized 704 patients to the Tryton SB stent with main vessel DES versus provisional SB treatment with main vessel DES. The rates of the primary end point of target vessel failure and the secondary powered end point of angiographic percent diameter stenosis in the SB at 9 months were assessed and compared between the two treatment strategies among patients with a SB ≥2.25 mm diameter at baseline determined by Core Lab QCA. Among the 704 patients enrolled in the TRYTON Trial, 289 patients (143 provisional and 146 Tryton stent; 41% of entire cohort) had a SB ≥2.25 mm. The primary end point of TVF was numerically lower in the Tryton group compared with the provisional group (11.3% vs. 15.6%, P = 0.38), and was within the non-inferiority margin. No difference among the rates of clinically driven target vessel revascularization (3.5% vs. 4.3% P = 0.77) or cardiac death (0% both groups) were seen. In-segment percent diameter stenosis of the SB was significantly lower in the Tryton group compared with the provisional group (30.4% vs. 40.6%, P = 0.004). Analysis of the TRYTON Trial cohort of SB ≥2.25 mm supports the safety and efficacy of the Tryton SB stent compared with a provisional stenting strategy in the treatment of bifurcation lesions involving large SBs. © 2015 Wiley Periodicals, Inc.

7 Initial experience of bioabsorbable polymer everolimus-eluting stents in high risk patients

Aims As progressively more elderly and comorbid patients are being considered for revascularisation the need for one year of dual anti-platelets becomes of increasing concern. SYNERGY Everolimus-eluting platinum chromium coronary stents allow for early cessation of dual antiplatelet therapy (DAPT) due to complete polymer absorption and drug elution by three months. The aim of this study was to retrospectively assess those in our unit who have underwent PCI with a SYNERGY stent to look for adverse outcomes post-discontinuation of DAPT. Methods All patients in our unit who underwent clinically indicated PCI with a SYNERGY stent from August 2013–December 2014 were retrospectively analysed. Baseline and procedural characteristics were recorded. Follow-up was by review of medical records or telephone contact for post-procedural complications or adverse events. Results In total 100 patients underwent PCI with a SYNERGY during the one-year study period. The mean age was 72.3 years (10.0; range 41–92 years), 37% of the cohort was defined as elderly (age >75 years) and 8% defined as very elderly (age >85 years). Mean EuroSCORE was 11.37 (11.13, range 0.88–70.23). The indication for SYNERGY stent use was as follows; frail or elderly (16%), concurrent anticoagulation (28%) need for a non-cardiac procedure (10%), increased bleeding risk (31%), or other (15%). NSTEMI/STEMI was the presenting complaint in 32% of patients. The coronary disease was complex. Left main stem was involved in (13%), multi-vessel disease (36%), bifurcation disease requiring side-branch stenting (9%), and 37% required CTO intervention. Mean Syntax score was 22.7 (12.1, range 6–53). The mean stent length/ patient was 75.3 mm (41.5) with 1.44 (0.64) lesions treated and 2.67 (1.33) stents implanted per patient. DAPT discontinuation by 3 months has occurred in 52% to date (planned in 77%). Despite the patient and lesion complexity, there were no thrombotic events after discontinuation of anti-platelets (acute, sub-acute or late stent thrombosis). Eight patients were able to undergo non-cardiac surgery after three months DAPT. By a maximum of six months four patients died from non-cardiac causes (one from cancer, one sepsis and multi-organ failure, one ruptured abdominal aortic aneurysm and one vascular complication post-TAVI). There was one target vessel revascularisation by the same time-point. Full outcome data will be available for presentation at the conference. Conclusion The use of SYNERGY stents allows early discontinuation of DAPT, reducing the risk of bleeding complications and facilitating non-cardiac procedures, without an increase in the incidence of sub-acute thrombosis in complex coronary disease and a high-risk population.

Impact of bifurcation dual stenting on endothelial shear stress.

Despite advances in percutaneous coronary interventions and the introduction of drug eluding stents, in-stent restenosis and stent thrombosis remain a clinically significant problem for bifurcations. The aim of this study is to determine the effect of dual bifurcation stenting on hemodynamic parameters known to influence restenosis and thrombosis. We hypothesized that double stenting, especially with a longer side branch (SB) stent, likely has a negative effect on wall shear stress (WSS), WSS gradient (WSSG), and oscillatory shear index (OSI). To test this hypothesis, we developed computational models of dual stents at bifurcations and non-Newtonian blood simulations. The models were then interfaced, meshed, and solved in a validated finite-element package. Longer and shorter stents at the SB and provisional stenting were compared. It was found that stents placed in the SB at a bifurcation lowered WSS, but elevated WSSG and OSI. Dual stenting with longer SB stent had the most adverse impact on SB endothelial WSS, WSSG, and OSI, with low WSS region up to 50% more than the case with shorter SB stent. The simulations also demonstrated flow disturbances resulting from SB stent struts protruding into the main flow field near the carina, which may have implications on stent thrombosis. The simulations predict a negative hemodynamic role for SB stenting, which is exaggerated with a longer stent, consistent with clinical trial findings that dual-stenting is comparable or inferior to provisional stenting.

Procedural Predictors of Angiographic Restenosis After Bifurcation Coronary Stenting (from the Choice of Optimal Strategy for Bifurcation Lesions With Normal Side Branch and Optimal Stenting Strategy for True Bifurcation Lesions Studies)

Most subordinate techniques accompanying bifurcation stenting have not been supported by relevant clinical trials. The aim of this study was to investigate the impact of technical specifications involved in bifurcation stenting on angiographic outcomes. We analyzed patients enrolled in a cohort consisting of the patients in 2 randomized studies: one comparing routine final kissing inflation (FKI) versus leave-alone strategy after the 1-stent technique for bifurcations without side branch (SB) stenosis (<50%) and the other comparing crush versus the 1-stent technique for lesions with SB stenosis (≥50%). The effects of subordinate techniques and devices on 8-month angiographic restenosis were studied using multivariate models. Of 514 patients whose 8-month angiograms were available, 58 (11.3%) were found to have restenosis involving, in total, 35 main branches (MBs) and 27 SBs. Using multivariate models, we identified FKI as the only independent predictor of MB restenosis in the technically modifiable variables. The effect of FKI was significantly different across subgroups defined by bifurcation lesion type and stenting technique (test for homogeneity, p= 0.003): FKI was unrelated to MB restenosis in the 1-stent for diseased SB (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.10 to 1.72; p= 0.22) and the 2-stent groups (OR 0.14, 95% CI 0.01 to 1.36; p= 0.09) but predictive of MB restenosis in the 1-stent for normal SB group (OR 4.90, 95% CI 1.58 to 15.16; p= 0.006).

Technical aspects of the provisional side branch stenting strategy.

Provisional side branch (SB) stenting is the recommended treatment strategy in the vast majority of bifurcation lesions. Over the past 10 years, advances in fundamental knowledge have led to a better understanding and to improvements of this technical approach. This strategy has reached maturity, and long-term clinical results are now comparable to those of non-bifurcation lesions. This paper describes in detail simple rules and tips and tricks which may help physicians in daily practice to use provisional side branch (SB) stenting as the gold standard treatment for the majority of bifurcation lesions.

Technical aspects of the T And small Protrusion (TAP) technique.

The T and small protrusion (TAP) technique is a modification of provisional T-stenting aimed at optimising "bail-out" SB stent implantation in bifurcated coronary lesions treated using the "provisional" approach. The main strengths of the TAP stenting technique are: compatibility with 6 Fr guiding catheters, full coverage of the side branch ostium, and facilitation of final kissing balloon inflation. The main drawback of TAP is related to the creation of a single layer stent strut neocarina of variable length. In this paper, we review the technical aspects which should be considered in order to achieve TAP stenting successfully in the case of "bail-out" need for side branch stenting. Furthermore, we report the technical details which may help in the practice of TAP stenting in complex bifurcated lesions with the anticipated high probability of requiring double stenting. Although no large trial has investigated this technique, the clinical results reported so far look promising.

Lessons from the GHOST-EU registry.

Bifurcations are increasingly being treated with bioresorbable vascular scaffolds (BVS) and accounted for about 25% of patients treated in the large multicentre GHOST-EU registry. This registry, along with bench testing, has provided a glimpse of the techniques and limitations of treating bifurcations with BVS. The provisional strategy remains the default approach to bifurcation treatment with BVS. If correctly performed, SB dilatation, T-kissing inflation, crossover to side branch stenting and elective double stenting are feasible without causing scaffold disruption. Theoretically, when the scaffolds are resorbed, the normal bifurcation anatomy, flow and vascular function will be restored, while jailed SBs will be liberated. However, data from the GHOST-EU registry are awaited to confirm the long-term safety and efficacy of BVS in coronary bifurcations.

The Tryton Side Branch Stent.

The Tryton Side Branch Stent (Tryton Medical, Durham, NC, USA) is a dedicated bare metal stent developed to enhance the safety and efficacy of the two stent technique for the treatment of bifurcation lesions. The stenting technique, a "reverse culotte", secures the side branch (SB) with the placement of this dedicated stent in the proximal main vessel, across to the side branch while it facilitates the positioning of a conventional stent in the proximal to distal main vessel. The First-In-Man trial showed minimal SB late loss (0.17±0.35 mm) at six months while real world registry data reported target vessel revascularisation rates as low as 4% at the same time points and no stent thrombosis. The simplicity of the technique as well as the promising results have led to its widespread utilisation in Europe while in the US, a randomised trial is imminent and will serve for the device approval by the Food and Drug Administration.

Lessons from the real bench: non-BRS.

Bench testing of stents used in bifurcations can provide information on the general properties that influence performance including crossing profile, radial strength, recoil, flexibility and radiopacity. Problems with device delivery can be clarified. Bench testing identified that side branch dilatation caused stent distortion and elucidated correction strategies. Bench testing led to a stent design change adding connectors between hoops to help overcome the clinical problem of longitudinal distortion. Testing on the bench can determine best deployment strategies and showed that a two-step post-dilatation strategy produced the best deployment with "crush" stenting. Scanning electron microscopy showed that withdrawal of a coronary guidewire trapped between a stent (or scaffold) and a mock arterial wall during a provisional side branch stenting strategy caused only mild linear polymer coating damage. Stent fracture can cause adverse clinical events and our repetitive bend test identified the stents most resistant to fracture. Causes of obstruction of the passage of a balloon over a wire through the side of a stent include damage to the catheter tip, complex cell geometry and inadvertent passage of a wire behind a strut. Bench testing plays a major role in validation of computer modelling of bifurcation treatments and flow alterations.

Classic crush and DK crush stenting techniques.

Clinical data have supported the advantages of the double kissing (DK) crush technique, which consists of stenting the side branch (SB), balloon crush, first kissing, stenting the main vessel (MV) and final kissing balloon inflation, for complex coronary bifurcation lesions compared to other stenting techniques. Careful rewiring from the proximal cell of the MV stent to make sure the wire is in the true lumen of the SB stent is key to acquiring optimal angiographic results. Balloon anchoring from the MV, alternative inflation and each kissing inflation using large enough non-compliant balloons at high pressure, and the proximal optimisation technique are mandatory to improve both angiographic and clinical outcomes. Stratification of a given bifurcation lesion is recommended before decision making.

TCTAP C-057 Stent Thrombosis Following Side Branch Stenting for Medina 0,0,1 Coronary Bifurcation Lesion Caused by Metal Carina

### Patient initials or identifier number 00230841 ### Relevant clinical history and physical exam 78-year-old man with paroxysmal atrial fibrillation, hypertension, dyslipidemia presented chest pain on exertion. His height and weight were 166 cm and 67kg, respectively. On physical examination,