Coronary Bifurcation Lesion PCI

Coronary bifurcation lesions involve a parent vessel and side branch, accounting for 15-20% of percutaneous coronary intervention (PCI) cases and associated with higher procedural complexity, peri-procedural myocardial infarction risk, in-stent restenosis, and stent thrombosis. Lesions are classified using the Medina system based on involvement of proximal main vessel, distal main vessel and side branch (e.g., 1,1,1 = true bifurcation lesion).

Strategy selection follows the DEFINITION criteria distinguishing simple bifurcations (most cases) treated with provisional one-stent strategy (main vessel stenting with side branch protection wire and proximal optimization technique, POT), versus complex bifurcations (left main, large side branch with diffuse disease, severe angulation, calcification) requiring planned two-stent techniques. Two-stent options include T-stenting and small protrusion (TAP), culotte, and double kissing crush (DK crush) — the most studied, effective for complex left main and angulated bifurcations.

Pre-procedural intracoronary imaging (IVUS or OCT) optimizes lesion preparation, stent sizing, and detection of stent malapposition. Post-procedural intravascular imaging confirms adequate stent expansion, ostial coverage, and absence of edge dissection or jailing wire malposition. Final kissing balloon inflation (FKBI) is critical to optimize side branch ostium in two-stent strategies. Dual antiplatelet therapy duration is typically 6-12 months in stable disease, longer in ACS and complex anatomy. Long-term outcomes show 1-year MACE of 5-10% in expert centers.