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LATIB ET AL.
the SB, (iii) to dilate the MB with a balloon with the rationale that the plaque modification
and hopefully a favorable plaque shift will facilitate access toward the SB. Each of the three
options has its rationale and the specific anatomical condition, the operator’s experience, and
the clinical scenario may direct the selection of the best strategy.
one more frequentlyemployed and
should be “jailed” in the majority
most ofthe times effective.After the SBis wired,this SB wire
following deployment of the stent on the MB. This approach
Usually, the third option is the
is important in protecting the SB from closure due to plaque shift and/or stent struts during
MB stenting. The jailed SB wire also facilitates rewiring of the SB (if SB postdilatation/stenting
or FKI is needed, or if the SB occludes) by widening the angle between the MB and SB (33,35);
by acting as a marker for the SB ostium; and by changing the angle of SB take-off.
After Stenting the Main Branch
The next challenge is often in rewiring the SB after MB stenting. In our experience, recrossing
into the SBthrough theMB stentstruts isusually possible using the Rinato-Prowater wire(Asahi
Intecc Co Ltd, Nagoya, Japan/Abbott Vascular Devices, Redwood City, CA) and in extremely
difficult casesthe ACE fixed wire balloon (Boston Scientific). Indifficult situations, we have also
successfully used the Pilot 50 and 150 (Abbott Vascular Devices /Guidant Corporation, Santa
Clara, CA) or the Miracle 3 or 4.5 g (Asahi Intecc Co Ltd /Abbott Vascular Devices) wires. The
jailed wire in the SB should always be left in place as a marker until complete recrossing has
been done. We are very cautious about using hydrophilic guidewires when recrossing into the
SB due to
the risk of wire-induced dissection and perforation.
After having recrossed into the SB with a guidewire, there may subsequently be great
difficulty advancing a balloon through the struts in order to dilate them. We frequently try first
to cross through the stent struts into the SB with the smallest balloon we have on the table.
If this balloon fails, we then use a Maverick (Boston Scientific) 1.5 mm diameter balloon to
separate
struts and allow a larger balloon to pass into the SB. If the 1.5 mm balloon cannot
cross, weconsider recrossing witha second wire while thefirst wire remainsin place to traverse
stent struts in another spot. In cases of persistent failure, guidewires should be uncrossed
the
(by retrieving and re-inserting the MB wire). If balloon insertion through the strut still proves
impossible, the stent
coaxial balloon.
should be further dilated. Anotherattempt should be made with a 1.5-mm
If theproblem persists, we thentry a fixedwire balloon, suchas an ACE(Boston
Scientific). Another tip that sometimes works is to advance the balloon as close as is possible to
the stent struts, inflating the balloon, and while deflating the balloon to attempt advancing it
further. Repeating this maneuver can often result in the balloon being slowly advancedthrough
the stent struts. However, once the balloon is in the cell, it should not be inflated distal to the
strut to avoid “balloon jailing.” It is important to perform a final dilatation on the stent toward
the SB with a balloon appropriately sized to the diameter of this branch and inflated at high
pressure (12 atm or more).
PATIENT PREPARATION AND TECHNICAL PLANNING
Patient Preparation
Antithrombotic Therapy
The most important factor for us in regards to patient preparation is clopidogrel pretreatment.
We prefer to have all patients pretreated for at least five days before the procedure with aspirin
(at least100 mg/day) and clopidogrel 75 mg/day. If a patientis not pretreated,we give a600-mg
loading dose of clopidogrel after performing the diagnostic angiography and the patient has
consented toLMCA PCI. In our daily practiceand considering that international guidelinesgive
elective PCI for the LMCA a class IIb recommendation, we do not immediately perform LMCA
stenting. Instead, we take the patient off the cath table, and together with the patient, family
members, and cardiothoracic surgeon we discuss all revascularization options. In general, we
only proceed with unprotected LMCA stenting if the patient refuses CABG or if based on the
expertise of the surgeon the patient is considered to be excessively high risk for CABG. An
attractive strategy that we have commenced prior to left main PCI is to perform a point-of-care
assay such as the VerifyNow (Accumetrics Inc., San Diego, CA) for platelet responsiveness to
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clopidogrel. In patients who by VerifyNow are found to be low responders (i.e., PRU > 240)
(36), we reload them with 600 mg of clopidogrel and continue a double maintenance doseof 150
mg/day. In patients with unprotected LMCA disease treated with DES, hyporesponsiveness
to clopidogrel has been correlated with worse outcome (37). Although many operators give
elective glycoproteinIIb/IIIa inhibitors to allpatients undergoing double stenting of the LMCA
as intention-to-treat, there is no evidence to support this approach. In view of some reports
of intraprocedural and very early thrombosis when using two stents (31), we are not against
a more liberal usage of glycoprotein IIb/IIIa inhibitors, especially when the preparation with
clopidogrel is incomplete or there are uncertainties. Another approach, as an alternative to
glycoprotein IIb/IIIa inhibitors and heparin, is the usage of bivalirudin.
Hemodynamic Support
When dealing with unprotected LMCA lesions, the operator should take into account the 8%
risk ofacute hemodynamic instability, which almostalways will needurgent IABP support(38).
When performing double stenting, this risk may be even higher due to the complexity of the
disease and the interventional strategy being performed.
Thus, we would recommend that in
double stenting of an unprotected LMCA, to always electively position an intra-aortic balloon
pump (IABP) unless there is a specific contraindication. Indeed, Briguori et al. have demonstrated that elective IABP support seems to contribute to an uncomplicated and successful
outcome, particularly in patients with distal left main stenosis and Euroscore > 6 (38). In cases,
where the operatordecides not to electively placean IABP, we wouldadvise that vascular access
be secured at the beginning of the procedure in case urgent hemodynamic support becomes
necessary during the procedure. In general, if the PCI is completed without complication, we
remove the IABP at the end of the procedure. An alternate option for hemodynamic support in
high-risk patients istheImpella 2.5system (AbiomedInc., Danvers,Massachusetts). TheImpella
2.5 deviceis a miniaturized 12-F rotary blood pump,minimally invasive LV assistdevice, which
is placed retrogradely across theaortic valve via the femoral artery using conventional catheterization techniques. Using a miniaturized rotary pump, blood is drawn from the LV cavity and
expelled into the ascending aorta, providing up to 2.5 L/min forward flow at its maximum
rotation of 51,000 rpm. In the PROTECT I (A Prospective Feasibility Trial Investigating the Use
of the IMPELLA RECOVER LP 2.5 System in Patients Undergoing High Risk PCI) multicenter
trial, the Impella 2.5 was successfully implanted on 20 patients undergoing PCI of either an
unprotected LMCA or the last patent coronary conduit (39). No patients developed hemodynamic compromise during PCI. The study demonstrated that the use of the Impella 2.5 system
was safe and feasible during high-risk PCI, and based on these data a randomized clinical trial
is underway to compare the efficacy of prophylactic circulatory support during high-risk PCI
with the Impella 2.5 device versus conventional IABP counterpulsation (
PROTECT II).
Technical Planning
Guide Selection
When the operator knows a priori that two stents will be implanted, we recommend an 8-Fr
guiding catheter even if a 7-Fr is acceptable with some new generation DES. We think that
the 8-Fr guide will give better visualization, will decrease friction during advancement of the
stents, allow for all sizes of burr if rotablation required, and allow for IVUS to be performed in
the presence of multiple guidewires. In general, even if an initial provisional strategy is chosen
for the LMCA, we recommend utilizing an 8-Fr guide catheter, as this will give the operator
the largest variety of options if a second stent needs to be implanted in the other branch. If two
stents are needed and a 6-Fr guiding catheter is employed, some limitations need to be known.
The two stents can only be inserted and deployed sequentially. The standard crush technique
and the V or kissing stents technique cannot be performed unless a guiding catheter of 8-Fr
is utilized. Furthermore, if implanting Xience V (Abbott Vascular Devices), Promus (Boston
Scientific), or Endeavor and Endeavor Resolute stents (Medtronic), a 6-Fr guide will not allow
simultaneous insertion of the stent and an angioplasty balloon. Thus with these stents, a 6-Fr
guide catheter will prohibit the use of certain techniques such as the step crush technique,
T-balloon stenting, or V-balloon stenting.
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LATIB ET AL.
Lesion Preparation: Role of Debulking
Although lesion preparation should not be considered routine, it should be used when (a)
there are diffuse and severe calcifications (Fig. 18); (b) the predilating balloon does not cross
the lesion or fully expand; (c) it is difficult to cross the lesion with the stent. In these cases,
we usually perform rotational atherectomy with a 1.25 or 1.5 mm burr. However, if the IVUS
catheter crosses the lesion, we use information on the plaque morphology to determine our
lesion debulking strategy in the followingway: (i) superficial calciumextending more than 180
may demand lesion preparation with rotational atherectomy (Rotablator, Boston Scientific),
(ii) severe fibrosis or moderate calcifications may demand for cutting balloon (cutting balloon
Ultra and Flextome, Boston Scientific) or noncompliant balloons sized to the media-to-media
diameter; (iii) the presence of soft plaque may permit direct stenting.
◦
(A) (B)
Figure 18 (A and B) A severely calcified stenosis of the distal LMCA. This kind of severely calcified lesion
should always undergo debulking with rotational atherectomy to allow for optimal stent expansion. We performed
rotablation with a 1.5-mm burr and crush stenting with a 3.0 ×33 mm (LCX in panel C) and 3.5 × 18 mm (LAD in
panel D) Cypher sirolimus-eluting stents (Cordis Corp, Johnson & Johnson, Warren, NJ). Panel (E) demonstrates
the result after crush stenting and panel (F) demonstrates the result after FKI. At follow-up (G), there was no
evidence of angiographic restenosis.
(C)
(E)
(D)
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(F) (G)
183
Figure 18
(Continued
)
Rotational atherectomy (Fig. 18)
The role of rotablation is important to allow optimal stent expansion in lesions with severe
superficial calcifications or when the balloon does not cross the lesion or fully expand. Rotablation is performed with the intent of modifying the plaque to allow a
better stent expansion and
not with the goal of debulking the lesion, which means that a single small burr (1.25 or 1.5 mm)
is the most frequently utilized approach. Even if no published data are available regarding the
role of this technology with DES in the LMCA, we think it is intuitive to aim for optimal stent
expansion and symmetry. In a setting of a very calcific lesion, this goal can only be obtained
with adequate lesion preparation. The mainarea of discussion is howfrequently a calcificlesion
should be pretreated with rotational atherectomy and when, conversely, a high-pressure balloon is sufficient. Except for information obtained with IVUS or in circumstances where no
balloon would cross the lesion, we cannot provide additional objective guidelines to make a
scientific decision. The operator’s judgment remains the most frequent tool dictating the choice
of rotational atherectomy.
Cutting balloon (Fig. 19)
Bifurcation lesions witha fibrotic plaqueat the SBostium are anideal setting forthis device. The
REDUCE III (Restenosis reduction by Cutting balloon Evaluation) randomized trial evaluated
the role of cutting balloon dilatation before stenting versus standard balloon dilatation in a
variety of lesions (40). This trial reported a lower restenosis rate (11.8% vs. 18.8%, p = 0.04)
when lesions were predilated with the cutting balloon. The fact that the final postprocedure
lumen diameterwas larger in the cuttingballoon arm and thatthe late loss was0.74 mm for both
strategies may make us assume that the main advantage was toward better stent expansion.
As just discussed in the context of rotational atherectomy, it is difficult to demonstrate that
a niche device has an advantage in every lesion. Cutting balloon may be considered when a
noncompliant high-pressure balloon fails to fully expand. In some centers, cutting balloon is
used at high pressures with good clinical outcome (Eulogio Garcia, written communication,
March, 2009). Dr. Garcia reports that when treating very calcified lesions, he recommends
undersizing the cutting balloon by 0.5 to 0.75 mm according to the reference vessel diameter
obtained by IVUS and to inflate the cutting balloon at>14 atm (usually 16–18 atm). Whenusing
cutting balloons in noncalcified, high-plaque burden lesions, he suggests 12 atm.
Directional atherectomy (Fig. 20)
Directional coronary atherectomy (DCA) has been considered ideal for bifurcation lesions. The
rationale for plaque removal in this setting is various and there are a number of positive anecdotal experiences. Unfortunately, the AMIGO trial (Atherectomy before Multi-Link Improves
Lumen Gain and Clinical Outcomes) failed to support the original findings and hypothesis,
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LATIB ET AL.
even in the subgroup of lesions involving a bifurcation (41). However, it may be that such niche
technology only has a favorable cost–benefit ratio when used selectively and appropriately
as in the PERFECT (PrE Rapamycin-eluting stent FlExi-CuT) registry (42,43). In the PERFECT
prospective multicentre registry, 99 patients underwent IVUS-guided DCA of coronary bifurcation lesions prior to DES implantation. Eighty-one percent of the lesions were located in
the LMCA or at the ostium of the LAD or of the LCX. Atherectomy was performed mainly
in the MB, with only three lesions treated in the SB as well and no complications occurred
during the procedure. The primary endpoint, binary restenosis, occurred in one lesion on the
(A)
(C)
Figure 19 This patient presented with distal LMCA disease involving the ostium of the LCX (A and B). The
ostium of the LAD and LCX were not fully dilatable with conventional semicompliant and noncompliant balloons.
The result after balloon angioplasty was suboptimal (C), and thus cutting balloons wereutilized to dilate the ostium
of the LCX [3.5 × 6mmat14atm;(D)] and LAD (3.5 × 10 mm at 14 atm). The LMCA was then stented with
the culotte technique by implanting a 4.0 ×23 mm Biomatrix biolimus A9-eluting stent (Biosensors Interventional
Technologies Pte Ltd., Singapore) toward the LAD and a 3.5 × 18 mm Nobori biolimus A9-eluting stent (Terumo
Corporation, Tokyo, Japan) toward the LCX. FKI was implanted with two 4.0 × 15 mm noncompliant balloons at
18 atm. (E and F) The final angiographic result.
(B)
(D)
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(E) (F)
185
Figure 19
(Continued
)
MB andin three lesionsin the SBfor a total restenosis rate of4.5%. In the 63 patients with lesions
located in the LMCA, there were no cases of angiographic restenosis.
Stent Choice
We have no preference with respect to choice of DES. However, when performing double
stenting with large branches of ≥3.5 mm in diameter, we prefer using stents with an
open
cell design. The only randomized data comparing DES in LMCA is the ISAR-LEFT MAIN (A
Randomized Clinical Trial on Drug-Eluting Stents for Unprotected Left Main Lesions study),
which was recently reported in the Late Breaking Clinical Trial Session at TCT 2008 Study (44).
In the ISAR-LEFT MAIN, 607 patients were randomized to receive either a paclitaxel-eluting
stent (PES) or sirolimus-eluting stent (SES). Distal LMCA was present in 63% of the patients,
and Euroscore was 4.7 ± 3.5 and 4.4 ± 3.2 in the PES and SES groups, respectively. Two-stent
techniques were used in51% in PESversus 49% in SES (predominantly the “culotte”technique).
The primary endpoint of noninferiority wasmet at one year(MACE was 13.6% inPES vs. 15.8%
in SES; RR = 0.85; 95% CI = 0.56–1.29). Moreover, two-year results confirmed that MACE was
comparable between PES and SES (RR = 0.99; 95% CI = 0.69–1.42). Also, no differences were
observed in two-year mortality (RR = 1.14, 95% CI = 0.66–1.94, p = 0.64), ST rates (in PES
definite ST 0.3%, probable ST 0.0%, in SES definite ST 0.7%, probable ST 0.3%), and TLR (in
PES 9.2% vs. 10.7% in the SES; p =0.47). There are currently no adequate published data on the
outcomes of LMCA stenting with second-generation DES.
Stent Deployment Optimization: Role of IVUS
In our view, the most important part of LMCA PCI and where most attention needs to be
given is in the optimal performance of double stenting techniques, particularly in optimizing
stent implantation. Stent optimization in the era of DES is as important if not more so and the
part of the procedure that still remains most undervalued. Suboptimal stent implantation (in
particular stent underexpansion) has become recognized as an important risk factor not only
for DES failure (restenosis) but also for the more serious and rare event of stent thrombosis
(45,46). Indeed, one of the most important changes that have occurred in our practice during
LMCA PCI has been in the use of IVUS in determining and optimizing stent deployment with
noncompliant balloons at high pressure. We now
always perform
IVUS in LMCA intervention
not only at the beginning of the procedure to assess plaque morphology and burden but more
importantly afterstent implantation to determine theneed for postdilatation with appropriately
sized (i.e., based on average media-to-media diameters) noncompliant balloons.
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LATIB ET AL.
(A) (B)
(C) (D)
Figure 20 (A and B) The baseline angiogram of this lesion involving the distal LMCA, with a sharp angulation
of the LCX. The LAD is protected by a functioning left internal mammary artery graft. The first approach was to
try to wire both, the diagonal branch coming off the proximal LAD, the RI and LCX. Due to sharp angulation of
the LCX and despite numerous attempts with several different guidewires, we were not able to negotiate the wire
into the LCX. Thus we elected to perform directional atherectomy on the distal LMCA toward the LAD (C)witha
FlexiCut 3.0–3.5 mm (6 cuts). We felt that in this case some lesion debulking would not only allow better stent
expansion but also facilitate an easier passage of the wire into the LCX. The result following atherectomy is shown
in panel (D). Following atherectomy, we were able to advance a guidewire wire into the LCX and then dilated both
vessels as shown in panels (E and F) (using a 3.0 × 6 mm cutting balloon for the LCX). (G) The result following
lesion predilatation and cutting balloon. We then performed crush stenting on the distal LMCA with Taxus stent
paclitaxel-eluting stents (Boston Scientific, Natick, MA), followed by FKI (H–K). The final result with preservation
of all three major branches (L and M). We think that the approach to perform atherectomy to negotiate a wire into
a branch when the anatomy is not favorable is quite unusual and this is one of the first cases in which we used
this technique. Theoretically plaque removal in the MB may facilitate entry into the SB, as demonstrated in this
An alternative would have been to predilate the LMCA toward the LAD in order to modify the plaque at the
case.
ostium of the LCX and thus allow wiring of the branch. However, it should be noted that both of these techniques
may result in occlusion of the branch vessel.
(E)
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(F)
(H) (I)
(J) (K)
(G)
(L) (M)
Figure 20
(Continued
)
188
LATIB ET AL.
Current data on IVUS in bifurcation PCI is limited. In the crush technique, IVUS has
provided us with valuable insights in that it demonstrated that conventional crush stenting
was associated with incomplete crushing (i.e., incomplete apposition of the three layers of main
and SB stent struts) and ostial SB stent underexpansion are common and often not suspected
angiographically (47). As a result of this study and our own observations, we modified our
technique by
using noncompliant balloons to perform high-pressure SB inflation prior to FKI,
therebyperforming a two-step kiss (34). Theauthors have also undertaken aprospectiveregistry
(INSIDE
1) that enrolled 31 patients with 35 bifurcations in which IVUS-guided stenting was
performed on the MB and/or SB. This study found that an optimal IVUS result at the end of
the procedure was the main factor associated with the absence of restenosis on the MB or SB.
We also noticed that the need for two stents was mainly confined to lesions with a large plaque
burden at the baselineIVUS. An interesting finding from this early experiencewas that attaining
an optimal angiographic result in the SB was frequently not supported by IVUS evaluation. An
optimal IVUS result was finally obtained following dilation with a larger balloon and at higher
pressure.These observations remain preliminary due to thesmall number of patientsevaluated,
and only a prospective study with predefined criteria may be able to fully evaluate this issue.
The major obstacleto thewidespread adoptionof IVUS-guidedDES implantationhas been
the fact that it is more time-consuming, the added cost of IVUS and additional postdilatation
balloons, the lack of randomized data, as well as the lack of appropriate and easily applicable
criteria foroptimal stent deployment. Theroutine usage of IVUS inclinical practice is frequently
impeded by the time needed to perform a complete pullback and the need of additional staff to
control the IVUS console. We propose a clinical use of IVUS as if we are doing “fluoroscopy.”
The operator manually advances the IVUS catheter to the area of interest without necessarily
recording and then does the measurements online himself. Currentlyavailable integrated IVUS
systems with the use of electronic catheters facilitate the performance of this approach.
There are accumulating data, though not randomized, that suggest that IVUS mayimpact
long-term adverse events. In a large registry of IVUS-guided PCI with DES, the outcomesin 884
patients (1296lesions) whounderwent IVUS-guidedDES implantation toall treatedlesions were
compared with those in 884 propensity-score matched patients (1312 lesions) who underwent
DES implantation with angiographic guidance alone (48). At 30 days and 12 months, a higher
rate of definite stent thrombosiswas seenin theNo-IVUS comparedto IVUS-guidedgroup (1.4%
vs. 0.5%; p =0.046) and (2.0% vs. 0.7%; p =0.014, respectively).There were no major differences
in late stent thrombosis and MACE (14.5 vs. 16.2%; p = 0.33) at 12-month follow-up between
the groups. Rates of death and myocardial infarction were similar. A trend was seen in favor of
the IVUS group in TLR (5.1% vs. 7.2%; p =0.07). IVUS guidance was an independent predictor
of freedom from cumulative stent thrombosis at 12 months (adjusted hazard ratio = 0.5, 95%
CI = 0.1–0.8; p =0.02) (48).
Specifically looking at LMCA intervention, in the MAIN-COMPARE (Revascularization
for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary
Angioplasty versus Surgical Revascularization) registry, IVUS guidance was associated with
a significant tendency to a lower risk of three-year mortality compared with angiographyguidance (6.0% vs. 13.6%, log-rank p = 0.063; HR = 0.54, 95% CI = 0.28–1.03, p = 0.061) (49).
IVUS guidance, however, did not modify the risk of MI or repeat revascularization. Similarly,
in our multicentre registry evaluating 731 LMCA lesions (76.5% involving the distal left main)
undergoing DES implantation, IVUS guidance was associated with reduced cardiac death (OR
= 0.93, CI 95% =0.16–0.93; p = 0.03) at univariate exact logistic (unconditional) analysis (50).
Until now, thecriteria for IVUSoptimization used in different studies have reliedon distal
vessel reference or on the mean reference vessel size for stent or postdilatation balloon sizing.
This reduces the potential to optimally increase the lumen size in long lesions, overlapping
stents and in vessels with distal tapering. In addition, these criteria do not take advantage of
vessel remodeling, which may allow the operator to attain a larger final stent cross-sectional
area (CSA). We have recently proposed new IVUS criteria based on vessel remodeling which
is currently being utilized in an ongoing randomized study, the Angiographic Versus IVUS
Optimization (AVIO) trial (51). The AVIO study criteria for IVUS optimization are based on the
achievement of a CSA inside the stent corresponding to the area achieved in our preliminary
experience, called the achievable optimal result (AOR) in Table 1. The AOR depends on the
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Tab le 1 AVIO Study Criteria for Optimal DES Implantation Based on
Achievable Optimal Result (AOR), Which is the Target Minimum Stent
Cross-Sectional Area (CSA) According to the Noncompliant Balloon
Chosen for Postdilatation
Balloon size (mm) Achievable optimal result (mm2)
2.25 3.5
2.5 4
36
3.5 8
410
4.5 12
The diameter of the balloon is chosen on the basis of the average media-to-media
diameters of the vessel at different points of the stented area (proximal, mid-lesion,
distal, and any other points of interest such as the point of maximum underexpansion).
189
diameter of the optimal postdilatationballoon chosen on the basis of thevessel media-to-media
size at different points. These criteria take into account the varying vessel size in overlapping
stents andthat multiple postdilations withdifferent sizenoncompliant balloons maybe needed.
In Figure 10, we demonstrate a case of LMCA stent optimization utilizing the AVIO criteria.
Despite the lack of randomized data, we strongly believe that IVUS guidance utilizing modern
and feasible criteria should be utilized when implanting stents in bifurcation lesions involving
a large amount of myocardium at jeopardy such as the LMCA.
CONCLUSIONS
Current guidelines still indicate CABG as the optimal treatment for LMCA lesions. However,
data from worldwide registries and the left main subset of SYNTAX are encouraging toward a
noninferiority of PCI with DES versus CABG in regardsto MI,death, andcerebrovascular events
at medium-term follow-up. We are particularly optimistic by the randomized SYNTAX data,
which demonstrate
that you have to do 19 CABGs to prevent just one repeat revascularization
after leftmain PCI. Notwithstanding thesepositive results,we would stress that double stenting
of the distal
LMCA is more complex than provisional stenting and requires expertise and
performance of an optimal procedure including double antiplatelet pretreatment, testing for
clopidogrel hyporesponsiveness, elective hemodynamicsupport when needed,adequate lesion
preparation, and IVUS-guided DES implantation, and postdilatation in all cases. Moreover, we
would advise that this high-risk group should have good clinical follow-up assessing their
clinical condition and re-enforcing adherence todual antiplatelet therapy forat least 12 months.
We also recommend routine angiographic follow-up at six months.
TAKE HOME MESSAGE
1. The choice of stenting technique for LMCA bifurcations should be based on bifurcation
morphology and operator experience.
2. The bifurcation anatomy, size of the side branch, and distribution of disease are the most
important determinants of electively performing double stenting of the LMCA; that is, if
the side branch is of a sufficiently large diameter (at least ≥2.5 mm), with a large area of
distribution and the disease extends beyond the ostium, then elective implantation of two
stents should be considered.
Elective implantationof two stents to treat LMCA bifurcation disease isrequired inapprox-
3.
imately 50% of patients.
4. In complexbifurcations involvinglarge territories or inunstable patients, where it iscrucial
to maintain optimal patency of both branches, we recommend the V- or crush techniques.
5. Double stenting of the LMCA is more complex, time-consuming, and labor intensive;
optimal technique is mandatory to avoid complications and ensure favorable long-term
results.
6. Final kissing inflation with appropriately sized noncompliant balloons is mandatory with
all techniques of double stenting.
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