The outcomes of bifurcation percutaneous coronary intervention (PCI) in patients aged ≥80 and ≥90 years have received limited study. We compared the procedural characteristics and outcomes of bifurcation PCIs in patients aged ≥80 years and those aged <80 years in a multicenter registry. Of 1,253 patients who underwent 1,262 bifurcation PCIs between 2014 and 2024 at 6 centers, 194 (15%) were aged ≥80 and ≥90 years. These patients were more likely to have atrial fibrillation (30 vs 12%, p <0.001) and heart failure (39 vs 19%, p <0.001) than were younger patients. They were more likely to have bifurcation lesions with greater angiographic complexity, including severe calcification (38% vs 14%, p <0.001) and left main coronary artery (30% vs 0%, p <0.001) and left anterior descending artery (80% vs 70%, p <0.001) stenoses. Patients aged ≥80 years had lower procedural success (87% vs 92%, p = 0.026) and greater incidence of in-hospital major adverse cardiovascular events (MACE, 8.3% vs 3.4%, p = 0.002) and death (3.1% vs 1%, p = 0.035). During a median follow-up of 903 days, patients aged ≥80 years had greater follow-up MACE (47.3% vs 28.1%, p <0.001), mortality (38.4% vs 10.9%, p <0.001), and stroke (6.8% vs 2.9%, p = 0.018) than did younger patients. In multivariable analysis, follow-up MACE was independently associated with age ≥80 years (hazard ratio 1.46, 95% confidence intervals 1.05 to 2.04, p = 0.026). In conclusion, success rates were lower than those in younger patients and the risk of complications greater in patients aged ≥80 years who underwent bifurcation PCI.

The outcomes and characteristics of patients with side branch occlusion (SBO) after bifurcation percutaneous coronary intervention (PCI) have received limited study.

We compared the procedural characteristics and outcomes of patients with and without SBO among 933 provisional bifurcation PCIs performed in 803 patients at six centers between 2014 and 2024.

The prevalence of SBO was 13% (n = 121). SBO patients had lower rates of hypertension, prior coronary artery bypass graft surgery (CABG), and prior PCI but higher angiographic complexity, with higher prevalence of left anterior descending artery stenoses, smaller side branch diameter and more severe side branch diameter stenoses. SBO patients were more likely to convert from provisional to two-stent strategies (24.8% vs 6.0%, p < 0.001), and to require plaque modification (39.7% vs 17.5%, p < 0.001) and side branch percutaneous transluminal coronary angioplasty (PTCA) (25.6% vs 12.9%, p < 0.001). SBO patients had lower technical (78.5% vs 96.2%, p < 0.001) and procedural (73.5% vs 92.2%, p < 0.001) success and similar in-hospital major adverse cardiovascular events (MACE), but higher dissection rates (7.1% vs 2.0%, p = 0.007). Patients with untreated SBO had similar in-hospital MACE with untreated SBO patients. During a median follow-up of 1,095 days patients with treated SBO (83.9%, n = 94) had lower follow-up MACE (hazard ratio [HR]: 0.29, 95% confidence intervals [CI]: 0.10, 0.84, p = 0.023) and mortality (HR: 0.22, CI: 0.065, 0.755, p = 0.016) compared with patients with untreated SBO.

SBO occurs in 13% of provisional PCIs. SBO patients had more complex coronary lesions and worse follow-up clinical outcomes if the SBO was left untreated.

Coronary bifurcation lesions (CBLs) present significant challenges in interventional cardiology, especially in low and middle-income countries like Vietnam. While the double-kissing (DK) crush technique is gaining attention for its potential benefits, its efficacy and safety compared with provisional stenting (PS) in the Vietnamese population remain underexplored. This study aimed to assess the effectiveness of the DK crush technique in reducing major adverse cardiovascular events (MACE) compared with those of PS, providing essential data to inform clinical decision-making in settings with limited resources.

This prospective cohort study included 58 patients with CBL, 33 patients undergoing the DK crush technique and 25 receiving PS. Clinical follow-up at 1, 3, 9, and 12 months assessed MACE, including cardiovascular disease-related death, acute myocardial infarction, hospitalization for heart failure, and stroke.

Post-percutaneous coronary intervention side branch diameter stenosis in the DK crush group was 5.64% ± 5.80%, significantly lower than the PS group (48.2% ± 28.5%; P < .001). One-year follow-up data revealed greater MACE reduction in the DK crush group (91% MACE-free vs 72% in the PS group; P = .03; hazard ratio [HR], 3.689; 95% CI, 1.034-13.160). However, the DK crush technique had longer procedural times (91.1 vs 54.6 minutes) and required higher contrast and radiation doses (P < .01).

Although DK crush requires longer procedure times and greater radiation exposure, it results in greater MACE reduction than does PS in patients with CBL. Clinicians should weigh the benefits and limitations of both techniques, particularly in resource-limited settings.

This study aimed to detail the technical management of Medina 0.0.1 lesions, assess their outcomes, and identify predictors of Major Adverse Cardiovascular Events (MACE).

Medina 0.0.1 bifurcations are rare and under-researched, with their optimal treatment strategy still debated and poorly described in daily practice.

A multicenter international registry enrolled 273 patients (277 lesions) undergoing PCI for de novo Medina 0,0,1 lesions (2017-2022). Data were systematically collected, and clinical follow-up was performed. The primary endpoint was 3-year MACE (cardiovascular death, myocardial infarction, and target vessel revascularization). Target lesion revascularization and stent thrombosis were secondary endpoints.

Median follow-up was 1180 days. Most cases were treated with planned one-stent PCI (84.1 %), mainly inverted provisional and ostial stenting (53.6 % and 45.9 %, respectively). The incidence of MACE and TLR was 16.9 % and 13.4 %, respectively. Univariate analysis identified dyslipidemia, diabetes, prior PCI, and left main bifurcation as predictors of MACE. Proximal optimization technique significantly reduced 3-year MACE (HR 0.28, 95 % CI 0.10-0.80, p = 0.03). Multivariate analysis identified diabetes as the only independent predictor of 3-year MACE (adjusted HR 2.35, 95 % CI 1.23-4.49, p = 0.01). No significant difference in 3-year MACE was found between inverted provisional and ostial stenting (17.2 % vs. 12.1 %).

Medina 0.0.1 bifurcations show high levels of MACE and TLR in the long-term. Diabetes emerged as the only independent 3-year MACE predictor. While current recommendations are widely adhered to in left main bifurcation angioplasty, they are less frequently applied in smaller bifurcations and acute settings.

The impact of diabetes mellitus (DM) on the outcomes of bifurcation percutaneous coronary intervention (PCI) has received limited study. We compared the procedural characteristics and outcomes of patients with and without DM in 1,302 bifurcation PCIs (1,147 patients) performed at 5 centers between 2013 and 2024. The prevalence of DM was 33.8% (n = 388). Patients with diabetes were younger and had more cardiovascular risk factors and greater angiographic complexity, including more main vessel calcification and more frequent stenoses in the left main, proximal left anterior descending, and right coronary artery. There was no difference in technical (95.5% vs 94.9%, p = 0.613) or procedural success (90.2% vs 91.3%, p = 0.540); provisional stenting was used less frequently in patients with diabetes (64.5% vs 71.1%, p = 0.015). Patients with diabetes had higher rates of repeat in-hospital PCI and acute kidney injury. Other in-hospital outcomes were similar after adjusting for confounders. During a median follow-up of 1,095 days, diabetes was independently associated with greater incidence of major adverse cardiovascular events (hazard ratio [HR] 2.04, 95% confidence intervals [CI] 1.52 to 2.72, p <0.001), myocardial infarction (HR 1.94, 95% CI 1.05 to 3.25, p = 0.033), death (HR 2.26, 95% CI 1.46 to 3.51, p <0.001), and target (HR 1.6, 95% CI 1.01 to 2.66, p = 0.045) and nontarget (HR 2.00, CI 1.06 to 3.78, p = 0.032) vessel revascularization. Patients with DM who underwent bifurcation PCI had greater risk of in-hospital repeat-PCI and major adverse cardiac events during follow-up than did those without diabetes.

Objectives. This study investigated the influence of higher pressure protection with a small diameter balloon of side branch (SB) on bifurcation lesions. Background. Of the different coronary stent implantation techniques, the modified jailed balloon technique has become a viable option for bifurcation lesions. However, there was no detailed study on the relationship between the balloon inflation pressure of the main vessel (MV) and SB. Methods. In this study, we collected information of patients who underwent percutaneous coronary intervention (PCI) for bifurcated lesions between March 2019 and December 2022. They were divided into two groups according to the operation way: active jailed balloon technique (A-JBT) group and jailed wire technique (JWT) group. Results. A total of 216 patients were enrolled. The A-JBT group had a larger SB stenosis diameter (1.53 ± 0.69 vs. 0.95 ± 0.52, p < .001), the lower degree of stenosis (44.34 ± 18.30 vs. 63.69 ± 17.34, p < .001) compared to the JWT group. However, the JWT group had a higher incidence of SB occlusion (18.0% vs. 1.9%, p < .001) compared to the A-JBT group. Nevertheless, the success rate for both groups was 100%. Conclusions. This novel high inflation pressure and small diameter balloon approach we propose has significant advantages. There is a lower rate of SB occlusion and SB dissection, which is more cost-effective and provides better clinical outcomes for the patient. This method should be considered in the future for treating bifurcation lesions.

Traditionally, coronary angiography was restricted to visual estimation of contrast-filled lumen in coronary obstructive diseases. Over the previous decades, considerable development has been made in quantitatively analyzing coronary angiography, significantly improving its accuracy and reproducibility.  Notably, the integration of artificial intelligence (AI) and machine learning into quantitative coronary angiography (QCA) holds promise for further enhancing diagnostic accuracy and predictive capabilities. In addition, non-invasive fractional flow reserve (FFR) indices, including computed tomography-FFR, have emerged as valuable tools, offering precise physiological assessment of coronary artery disease without the need for invasive procedures. These innovations allow for a more comprehensive evaluation of disease severity and aid in guiding revascularization decisions. This review traces the development of QCA technologies over the years, highlighting key milestones and current advancements. It also explores prospects that could revolutionize the field, such as AI integration and improved imaging techniques. By addressing both historical context and future directions, the article underscores the ongoing evolution of QCA and its critical role in the accurate assessment and management of coronary artery diseases. Through continuous innovation, QCA is poised to remain at the forefront of cardiovascular diagnostics, offering clinicians invaluable tools for improving patient care.

Coronary artery bifurcation lesion is an epicardial stenosis that, when compared to non-bifurcation lesions, poses a greater risk of adverse events and can compromise prognosis. This study aims to investigate the clinical efficacy of different stenting techniques, particularly in terms of their immediate, short-term, intermediate, and long-term outcomes in patients with true bifurcation lesions.

This retrospective observational cohort study was conducted in a tertiary cardiac hospital in Islamabad, from February 1, 2015, to February 28, 2021. A total of 172 patients who met the inclusion criteria and underwent percutaneous coronary intervention were selected using a consecutive sampling technique. Follow-up was maintained for three years to assess procedural outcomes.

Of the 172 participants, the majority were males (69%) and only 4% were above 75 years of age. A significant relation between major adverse cardiac events (MACEs) with acute coronary syndrome (ACS) and previous percutaneous coronary intervention (PCI) (p < 0.000) was observed. Procedural success was good in all patients using the drug-eluting stent. The MAC rate was 6.9% and the final kissing balloon inflation, stenting technique, and bifurcation involvement were significantly associated with MACE occurrence (p < 0.01), and mortality was reported in two patients (1.16%). MACEs were associated with mortality; previous PCI and hypertension increased the risk of mortality.

The two-stent strategy can be used with good long-term outcomes and low complication rates.

Bifurcation involvement close to or within the occluded segment poses increasing difficulties for chronic total occlusion (CTO)-percutaneous coronary intervention (PCI). However, this variable is not considered in the angiography-based CTO scoring systems nor has been extensively investigated in large multicenter series. Accordingly, we analyzed a CTO-PCI registry involving 92 European centers to explore the incidence, angiographic and procedural characteristics, and outcomes specific to CTO-PCIs with bifurcation involvement. A total of 3,948 procedures performed between January and November 2023 were examined (33% with bifurcation involvement). Among bifurcation lesions, 38% and 37% were located within 5 mm of the proximal and distal cap, respectively, 16% within the CTO body, and in 9% of cases proximal and distal bifurcations coexisted. When compared with lesions without bifurcation involvement, CTO bifurcation lesions had higher complexity (J-CTO 2.33 ± 1.21 vs 2.11 ± 1.27, p <0.001) and were associated with higher use of additional devices (dual-lumen microcatheter in 27.6% vs 8.4%, p <0.001, and intravascular ultrasound in 32.2% vs 21.7%, p <0.001). Radiation dose (1,544 [836 to 2,819] vs 1,298.5 [699.1 to 2,386.6] mGy, p <0.001) and contrast volume (230 [160 to 300] vs 190 [130 to 250] ml, p <0.001) were also higher. Technical success was similar (91.5% with bifurcation involvement vs 90.4% without bifurcation involvement, p = 0.271). However, the bifurcation lesions within the CTO segment (intralesion) were associated with lower technical success than the other bifurcation-location subgroups (83.7% vs 93.3% proximal, 93.4% distal, and 89.0% proximal and distal, p <0.001). On multivariable analysis, the presence of an intralesion bifurcation was independently associated with technical failure (odds ratio 2.04, 95% confidence interval 1.24 to 3.35, p = 0.005). In conclusion, bifurcations are present in approximately one-third of CTOs who underwent PCI. PCI of CTOs with bifurcation can be achieved with high success rates except for bifurcations within the occluded segment, which were associated with higher technical failure.

Severely calcified coronary bifurcations complicate percutaneous coronary interventions (PCI) and often necessitate dedicated lesion preparation. We compared the outcomes of single- versus two-stent techniques for treating heavily calcified true bifurcation lesions following rotational atherectomy (RA).

Among patients receiving RA for severely calcified true bifurcations at a single center, 59 were treated with a single stent, and another 59 received two stents. We analyzed in-hospital adverse outcomes and 1-year rates of the bifurcation-oriented composite endpoint (BOCE), defined as cardiac death, target bifurcation myocardial infarction (TB-MI), or target bifurcation revascularization (TBR).

The single-stent arm was associated with more in-hospital adverse outcomes (adj. OR, 6.13; 95% CI, 1.34-28.0; p = 0.019), driven by higher peri-procedural MI rates (18.6% vs. 5.1%, p = 0.043) and more side branch compromise (13.6% vs. 0%, p = 0.006). After 1 year, both techniques had comparable 1-year BOCE (adj. HR, 0.38; 95% CI, 0.12-1.23; p = 0.106). We observed a significant interaction between the treatment technique and the presence of LM bifurcation (p interaction = 0.012), favoring single-stent technique in patients with non-LM bifurcations (HR 0.14, 95% CI 0.03-0.68; p = 0.015). Notably, the single-stent technique had lower rates of TBR (2% vs. 15%, p log-rank = 0.026) after 1 year.

Patients with severely calcified true bifurcation lesions, treated with RA followed by a single stent implantation, had more in-hospital adverse outcomes compared to those treated with two stents. However, the superior outcomes of the two-stent technique did not translate into improved long-term results. In fact, the two-stent technique was even associated with higher rates of revascularization after 1 year.

The benefits of transradial access (TRA) over transfemoral access (TFA) for bifurcation percutaneous coronary intervention (PCI) are uncertain because of the limited availability of device selection. This study aimed to compare the procedural differences and the in-hospital and long-term outcomes of TRA and TFA for bifurcation PCI using second-generation drug-eluting stents (DESs).

Based on data from the Coronary Bifurcation Stenting Registry III, a retrospective registry of 2,648 patients undergoing bifurcation PCI with second-generation DES from 21 centers in South Korea, patients were categorized into the TRA group (n = 1,507) or the TFA group (n = 1,141). After propensity score matching (PSM), procedural differences, in-hospital outcomes, and device-oriented composite outcomes (DOCOs; a composite of cardiac death, target vessel-related myocardial infarction, and target lesion revascularization) were compared between the two groups (772 matched patients each group).

Despite well-balanced baseline clinical and lesion characteristics after PSM, the use of the two-stent strategy (14.2% vs. 23.7%, P = 0.001) and the incidence of in-hospital adverse outcomes, primarily driven by access site complications (2.2% vs. 4.4%, P = 0.015), were significantly lower in the TRA group than in the TFA group. At the 5-year follow-up, the incidence of DOCOs was similar between the groups (6.3% vs. 7.1%, P = 0.639).

The findings suggested that TRA may be safer than TFA for bifurcation PCI using second-generation DESs. Despite differences in treatment strategy, TRA was associated with similar long-term clinical outcomes as those of TFA. Therefore, TRA might be the preferred access for bifurcation PCI using second-generation DES.

ClinicalTrials.gov Identifier: NCT03068494.

Quantitative flow ratio derived from computed tomography angiography (CT-QFR) and invasive coronary angiography (Murray law-based quantitative flow ratio [μQFR]) are novel approaches enabling rapid computation of fractional flow reserve without the use of pressure guidewires and vasodilators. However, the feasibility and diagnostic performance of both CT-QFR and μQFR in evaluating complex coronary lesions remain unclear.

Between September 2014 and September 2021, 240 patients with 30% to 90% coronary diameter stenosis who underwent both coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve within 60 days were retrospectively enrolled. The diagnostic performance of CT-QFR and μQFR in detecting functional ischemia among all lesions, especially complex coronary lesions, was analyzed using fractional flow reserve as the reference standard.

CT-QFR and μQFR analyses were performed on 309 and 289 vessels, respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for CT-QFR in all lesions at the per-vessel level were 91% (with a 95% CI of 84%-96%), 92% (95% CI, 88%-95%), 83% (95% CI, 75%-90%), 96% (95% CI, 93%-98%), and 92% (95% CI, 88%-95%), with values for μQFR of 90% (95% CI, 81%-95%), 97% (95% CI, 93%-99%), 92% (95% CI, 84%-97%), 96% (95% CI, 92%-98%), and 94% (95% CI, 91%-97%), respectively. Among bifurcation, tandem, and moderate-to-severe calcified lesions, the diagnostic values of CT-QFR and μQFR showed great correlation and agreement with those of invasive fractional flow reserve, achieving an area under the receiver operating characteristic curve exceeding 0.9 for each complex lesion at the vessel level. Furthermore, the accuracies of CT-QFR and μQFR in the gray zone were 85% and 84%, respectively.

Angiography-derived quantitative flow ratio (CT-QFR and μQFR) demonstrated remarkable diagnostic performance in complex coronary lesions, indicating its pivotal role in the management of patients with coronary artery disease.

The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

Complex percutaneous cardiac intervention (PCI) is a growing procedure in modern day cath labs. The treated population is often older, with multiple comorbidities, complex coronary anatomy, left ventricular dysfunction, and possibly concomitant valvular heart disease and/or cardiogenic shock. As such, PCI of bifurcations, chronic total occlusions, and atherectomy coronary interventions are becoming more common. The outcomes in terms of acute procedural success, procedure-related complications, and long-term mortality or heart failure hospitalizations are important to consider. Unfortunately, to date there is a paucity of data identifying sex and gender disparities following such interventions. With respect to bifurcation lesions, women usually have more comorbidities with less complex coronary anatomy. However, despite less complex anatomy, women have a significantly increased risk of MI. These differences are also noted with left main stem and multivessel disease, during which women appear to have a trend towards worse outcomes following PCI compared with coronary artery bypass grafting. Randomized trials have revealed that women present with increased cardiovascular risk factors, which may contribute to adverse longer-term outcomes. Revascularization of women with concomitant valvular heart disease is particularly challenging because the existing data are conflicted on not only the indication, but also the timing of revascularization. Similarly, women undergoing PCI of calcified lesions with drug-eluting stents have a worse clinical profile and remain at increased ischemic risk. The lower incidence of coronary calcification in women, combined with the under-representation of women in randomized trials, poses a real challenge when attempting to address safety and survival benefit in women undergoing complex interventions. This warrants dedicated trials exploring the safety and efficacy of complex interventions in women.

It is rare to use the one-stage model without segmentation for the automatic detection of coronary lesions. This study sequentially enrolled 200 patients with significant stenoses and occlusions of the right coronary and categorized their angiography images into two angle views: The CRA (cranial) view of 98 patients with 2453 images and the LAO (left anterior oblique) view of 176 patients with 3338 images. Randomization was performed at the patient level to the training set and test set using a 7:3 ratio. YOLOv5 was adopted as the key model for direct detection. Four types of lesions were studied: Local Stenosis (LS), Diffuse Stenosis (DS), Bifurcation Stenosis (BS), and Chronic Total Occlusion (CTO). At the image level, the precision, recall, mAP@0.1, and mAP@0.5 predicted by the model were 0.64, 0.68, 0.66, and 0.49 in the CRA view and 0.68, 0.73, 0.70, and 0.56 in the LAO view, respectively. At the patient level, the precision, recall, and F1scores predicted by the model were 0.52, 0.91, and 0.65 in the CRA view and 0.50, 0.94, and 0.64 in the LAO view, respectively. YOLOv5 performed the best for lesions of CTO and LS at both the image level and the patient level. In conclusion, the one-stage model without segmentation as YOLOv5 is feasible to be used in automatic coronary lesion detection, with the most suitable types of lesions as LS and CTO.

In patients with complex coronary bifurcation lesions undergoing percutaneous coronary intervention (PCI), various 2-stent techniques might be utilised. The Visible Heart Laboratories (VHL) offer an experimental environment where PCI results can be assessed by multimodality imaging.

We aimed to assess the post-PCI stent configuration achieved by 2-stent techniques in the VHL and to evaluate the procedural factors associated with suboptimal results.

Bifurcation PCI with 2-stent techniques, performed by expert operators in the VHL on explanted beating swine hearts, was studied. The adopted bifurcation PCI strategy and the specific procedural steps applied in each procedure were classified according to Main, Across, Distal, Side (MADS)-2 and to their adherence to the European Bifurcation Club (EBC) recommendations. Microcomputed tomography (micro-CT) was used to assess the post-PCI stent configuration. The primary endpoint was "suboptimal stent implantation", defined as a composite of stent underexpansion (<90%), side branch ostial area stenosis >50% and the gap between stents.

A total of 82 PCI with bifurcation stenting were assessed, comprised of 29 crush, 25 culotte, 28 T/T and small protrusion (TAP) techniques. Suboptimal stent implantation was observed in as many as 53.7% of the cases, regardless of baseline anatomy or the stenting strategy. However, less frequent use of the proximal optimisation technique (POT; p=0.015) and kissing balloon inflations (KBI; p=0.027) and no adherence to EBC recommendations (p=0.004, p multivariate=0.006) were significantly associated with the primary endpoint.

Commonly practised bifurcation 2-stent techniques may result in imperfect stent configurations. More frequent use of POT/KBI and adherence to expert recommendations might reduce the occurrence of post-PCI suboptimal stent configurations.

A case of stent thrombosis as a complication of coronary bifurcation stenting is described. We review potential complications of bifurcation stenting and established guidelines.

A 64-year-old man presented with a non-ST segment elevation myocardial infarction. High-sensitivity troponin I peaked at 99 000 ng/L (normal <5). He previously had coronary stenting for stable angina when residing in another country 2 years previously. Coronary angiography revealed no significant stenosis with TIMI 3 flow in all vessels. Cardiac magnetic resonance imaging demonstrated a left anterior descending artery (LAD) territory regional motion abnormality, late gadolinium enhancement consistent with recent infarction, and a left ventricular apical thrombus. Repeat angiography and intravascular ultrasound (IVUS) confirmed bifurcation stenting at the junction of the LAD and second diagonal (D2) with protrusion of several millimetres of the uncrushed proximal segment of the D2 stent in the LAD vessel lumen. There was under-expansion of the LAD stent in the mid-vessel and stent malapposition in the proximal LAD, extending into the distal left main stem coronary artery and involving the ostium of the left circumflex coronary artery. Percutaneous balloon angioplasty was performed along the length of the stent, including an internal crush of the D2 stent. Coronary angiography confirmed a uniform expansion of the stented segments and TIMI 3 flow. Final IVUS confirmed full stent expansion and apposition.

This case highlights the importance of provisional stenting as a default strategy and familiarity with procedural steps in bifurcation stenting. Furthermore, it emphasizes the benefit of intravascular imaging for lesion characterization and stent optimization.

Aim: Bifurcation-PCI is performed frequently, although without extensive evidence to back up a definitive solution for its complexity. We set out to identify factors associated with 1- and 12-month mortality after bifurcation-PCI between 2017 and 2021 in our tertiary center in Wales, UK. Results: Of 732 bifurcation PCI cases (mean age 69; 25% female), 67% were in ACS, 42% were left main PCI and 25.3% involved two-stent strategy. 30-day and 12-month mortality were 1.9 and 8.2%, respectively. Age, diabetes, smoking and renal failure are associated with mortality after bifurcation-PCI, while the choice between provisional and 2-stent strategies did not impact mortality/TLR. Conclusion: Awareness of 'real-world' outcomes of bifurcation-PCI should be used for appropriate patient selection, technique planning and procedural consent.

Percutaneous coronary intervention using drug-eluting stents for coronary bifurcation lesions is associated with higher rates of in-stent restenosis, myocardial infarction, and revascularisation as compared with non-coronary bifurcation lesions. The increased percentage of suboptimal results after stenting bifurcation lesions is largely, if not always, due to the extreme complexity of the anatomy. Obviously, one weapon (stenting technique) does not suit all enemies (bifurcation lesions with different anatomies), and it underscores the importance of establishing a stratification system.

V-stenting (VS) and simultaneously kissing stents (SKS) upfront 2-stent strategies for treating large diameter bifurcations and especially distal left main coronary artery (LMCA) disease. Former teaching suggests that the minimal requirements for VS and SKS requires 8F guiding catheters or 7.5F sheathless guide. Presented is the "2-Step refinement" of SKS and VS that can be executed via conventional 6F guide without any additional equipment. In view of the simplicity and suitability for unstable subjects with acute coronary syndromes; "2 Step SKS and VS" should be in the armamentarium of all advanced interventionalists.

Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) for the treatment of coronary bifurcation lesions (CBLs) is still technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. Although provisional stenting (PS) is considered as the preferred strategy for most of the CBLs, a systematic two-stent technique (double kissing [DK] crush) should be considered in patients with complex left main (LM)-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation should be used to optimize CBLs intervention. PCI with DES for the treatment of CBLs is technically demanding, mainly because of higher rates of both acute and chronic complication as compared with non-CBLs. PS is a default strategy for most of the CBLs. Double kissing (DK) crush is associated with better clinical outcomes compared with PS in patients with complex LM-CBLs or non-LM-CBLs stratified by the DEFINITION criteria. Intracoronary imaging and/or physiologic evaluation are useful tools to guide the treatment of CBLs. The use of drug-coated balloons in CBLs needs further data to support the clinical benefits.

Previous studies have not compared outcomes between different percutaneous coronary intervention (PCI) strategies and lesion locations in non-left main (LM) bifurcation lesions. We enrolled 2044 patients from a multicenter registry with an LAD bifurcation lesion (n = 1551) or non-LAD bifurcation lesion (n = 493). The primary outcome was target lesion failure (TLF), a composite of cardiac death, myocardial infarction, and target lesion revascularization (TLR). During a median follow-up period of 38 months, non-LAD bifurcation lesions treated with the two-stent strategy, compared with the one-stent strategy, were associated with more frequent TLF (20.7% vs. 6.3%, p < 0.01), TLR (16.7% vs. 4.7%, p < 0.01), and target vessel revascularization (TVR; 18.2% vs. 6.3%, p < 0.01). There was no significant difference in outcome among LAD bifurcation lesions treated with different PCI strategies. The two-stent strategy was associated with a higher risk of TLF (adjusted HR 4.34, CI 1.93−9.76, p < 0.01), TLR (adjusted HR 4.30, CI 1.64−11.27, p < 0.01), and TVR (adjusted HR 5.07, CI 1.69−9.74, p < 0.01) in the non-LAD bifurcation lesions. The planned one-stent strategy is preferable to the two-stent strategy for the treatment of non-LAD bifurcation lesions.

A coronary bifurcation stenting is still a challenging issue due to frequent restenosis and stent thrombosis even with drug-eluting stents. The bifurcation angle (BA) between a main vessel and a side branch is one of the crucial determinants of coronary flow and shear stress that affect the plaque distribution. Previous bench and clinical studies have evaluated the impact of the BA between the proximal main vessel and the side branch (Angle A) and the BA between the distal main vessel and the side branch (Angle B) on the clinical outcomes of bifurcation stenting. However, the impact has not yet been fully elucidated due to a lack of statistical power or different manner of the assessment of BA.

To analyze the published studies on coronary artery BA, the modalities used for assessment, and the impact of BA on interventions and attempt to define the pre-procedural protocols.

A scoping review was performed using the Joanna Briggs Institute Methodology. A total of 52 relevant references were selected from PubMed, Cochrane Library, and CINAHL databases and categorized into three topic areas.

A wider Angle A is associated with the increased likelihood of carina shift and a wider Angle B, with that of side branch occlusion. A wider Angle B promotes stent malapposition and deformation in the side branch ostium and has been reported as an independent predictor of major adverse cardiac events after bifurcation stenting; however, improvement of the drug-eluting stent, refinement of the stenting technique, and accurate 3-dimensional assessment may attenuate the adverse clinical impact of a wider BA.

Assessment of the BA is necessary to predict the effect of bifurcation intervention procedure on the stent configuration and coronary flow at the bifurcated vessels. This will help to optimize stent selection and the stenting technique.

Bifurcation coronary artery disease is common as the development of atherosclerosis is facilitated by altered endothelial shear stress. Multiple anatomical and physiological factors need to be considered when treating bifurcation lesions. To achieve optimal results, various stenting techniques have been developed, each with benefits and limitations. In this state-of-the-art review we describe technically important characteristics of bifurcation lesions and summarise the evidence supporting contemporary bifurcation techniques.

The Bifurcation Academic Research Consortium (Bif-ARC) project originated from the need to overcome the paucity of standardization and comparability between studies involving bifurcation coronary lesions. This document is the result of a collaborative effort between academic research organizations and the most renowned interventional cardiology societies focused on bifurcation lesions in Europe, the United States, and Asia. This consensus provides standardized definitions for bifurcation lesions; the criteria to judge the side branch relevance; the procedural, mechanistic, and clinical endpoints for every type of bifurcation study; and the follow-up methods. Considering the complexity of bifurcation lesions and their evaluation, detailed instructions and technical aspects for site and core laboratory analysis of bifurcation lesions are also reported. The recommendations included within this consensus will facilitate pooled analyses and the effective comparison of data in the future, improving the clinical relevance of trials in bifurcation lesions, and the quality of care in this subset of patients.

There is a paucity of data comparing functional difference between active jailed balloon technique (A-JBT) and conventional jailed balloon technique (C-JBT) in treating non-left main coronary bifurcation lesions (CBLs).

In this retrospective cohort study, we consecutively enrolled 232 patients with non-left main CBLs who underwent percutaneous coronary intervention (PCI) using JBTs between January 2018 and March 2019. Among them, 191 patients entered the final analysis with 12-months angiographic follow-up. We stratified patients into A-JBT group (130 patients) and C-JBT group (61 patients). The functional analysis by Murray law-based quantitative flow ratio (μQFR) and Seattleanginaquestionnaire (SAQ) were performed to compare the two techniques.

Compared with C-JBT group, A-JBT group observed a lower abrupt (0.8% vs. 11.1%, p = 0.002) and final SB occlusion (0 vs. 7.9%, p = 0.005). Meanwhile, A-JBT group had a significantly higher μQFR of side branch (SB) both post-PCI and 12-months follow-up (median [interquartile range (IQR)]: 0.91 (0.86-0.96) vs. 0.82 (0.69-0.92), p < 0.001; median [IQR]: 0.95 (0.89-0.98) vs. 0.85 (0.74-0.93), p < 0.001) than C-JBT group. Besides, A-JBT group gained a μQFR improvement at follow-up period compared with post-PCI data (median [IQR]: 0.95 [0.89-0.98] vs. 0.91[0.86-0.96] of SB, p < 0.001) and a higher SAQ scores at 12-months follow-up compared with C-JBT group (p < 0.001).

Compared with C-JBT, A-JBT provided excellent SB protection during MV stenting and improved the SB functional blood flow as well as the angina relief even after 12 months.

Coronary bifurcation lesions (CBLs) account for 15%-20% of all percutaneous coronary interventions. The complex nature of these lesions is responsible for poorer procedural, early and late outcomes. This complex lesion subset has received great attention in the interventional cardiac community, and multiple stenting techniques have been developed. Of these, the provisional stenting technique is most often the default strategy; however, the elective double stenting (EDS) technique is preferred in certain subsets of complex CBLs. The double kissing crush technique may be the preferred EDS technique because of its efficacy and safety in comparative trials; however, this technique consists of many steps and requires training. Many new methods have recently been added to the EDS techniques to provide better stent scaffolding and to reduce early and late adverse outcomes. Intravascular imaging is necessary to determine the interventional strategy and postinterventional results. This review discusses the basic concepts, contemporary percutaneous interventional technical approaches, new methods, and controversial treatment issues of CBLs.

The ability to customize the size and shape of angioplasty balloons may be useful in many clinical and research applications of coronary and endovascular intervention. Fully customizable balloons are outside the reach of most researchers due to their prohibitive cost. A small-scale balloon-forming machine was developed to produce fully customizable balloons. This study describes the creation of this customizable balloon-forming machine and identifies the key components of manufacturing a patient-specific balloon. Using a standard balloon-shaped mold created with a novel application of 3D stereolithography-printed resin, 104 PET balloon formation tests were conducted. A statistical study was conducted in which molding temperature and inflation air pressure were independent variables ranging from 100 to 130 °C and from 3.7 to 6.8 atm, respectively. The criteria for balloon-forming success were defined; pressure and temperature combined were found to have a significant impact on the success (p = 0.011), with 120 °C and 4.76 atm resulting in the highest chance for success based on a regression model.

There have been mixed results regarding the efficacy and safety of various percutaneous coronary intervention bifurcation techniques. An electronic search of Medline, Scopus, and Cochrane databases was performed for randomized controlled trials that compared the outcomes of any bifurcation techniques. We conducted a pairwise meta-analysis comparing the 1-stent versus 2-stent bifurcation approach, and a network meta-analysis comparing the different bifurcation techniques. The primary outcome was major adverse cardiac events (MACEs). The analysis included 22 randomized trials with 6,359 patients. At a weighted follow-up of 25.9 months, there was no difference in MACE between 1-stent versus 2-stent approaches (risk ratio [RR] 1.20, 95% confidence interval [CI] 0.92 to 1.56). Exploratory analysis suggested a higher risk of MACE with a 1-stent approach in studies using second-generation drug-eluting stents, if side branch lesion length ≥10 mm, and when final kissing balloon was used. There was no difference between 1-stent versus 2-stent approaches in all-cause mortality (RR 0.95, 95% CI 0.69 to 1.30), cardiovascular mortality (RR 1.07, 95% CI 0.68 to 1.68), target vessel revascularization (TVR) (RR 1.22, 95% CI 0.90 to 1.65), myocardial infarction (MI) (RR 1.04, 95% CI 0.69 to 1.56) or stent thrombosis (RR 1.10, 95% CI 0.68 to 1.78). Network meta-analysis demonstrated that double kissing crush technique was associated with lower MACE, MI, TVR, and target lesion revascularization, whereas culotte technique was associated with higher rates of stent thrombosis. In this meta-analysis of randomized trials, we found no difference between 1-stent versus 2-stent bifurcation percutaneous coronary intervention approaches in the risk of MACE during long-term follow-up. Among the various bifurcation techniques, double kissing crush technique was associated with lower rates of MACE, target lesion revascularization, TVR, and MI.

Optimal deployment of coronary stents in a bifurcation lesion remains a matter of debate.

We sought to capture the daily practice of bifurcation stenting by means of a worldwide registry and to investigate how post-implantation deployment techniques influence clinical outcomes.

Data from the e-ULTIMASTER registry were used to perform an analysis of 4,395 patients undergoing percutaneous coronary intervention for bifurcation lesions. Inverse probability of treatment weights (IPTW) propensity score methodology was used to adjust for any baseline differences. The primary outcome of interest was target lesion failure (TLF) at one year (follow-up rate 96.2%).

The global one-year TLF rate was low (5.1%). The proximal optimisation technique (POT) was used in 33.9% of cases and was associated with a reduction in the adjusted TLF rate (4.0% [95% confidence interval: 3.0-5.1%] vs 6.0% [5.1-6.9%], p<0.01) due to a reduction of all components of this composite endpoint, except for cardiac death. Stent thrombosis was also positively impacted (0.4% [0.04-0.7%] vs 1.3% [0.8-1.7%], p<0.01). POT benefit was uniform across subgroups. Conversely, the use of the kissing balloon technique (36.5%) did not influence the adjusted TLF rate.

Despite a low one-year failure rate in this large bifurcation stenting cohort, POT was associated with a further reduction in the event rate and a uniform benefit across subgroups, suggesting systematic use of this deployment technique regardless of the bifurcation anatomy and stenting technique.

Coronary bifurcations are prone to atherosclerotic plaque growth, experiencing regions of reduced wall shear stress (WSS) and increased platelet adhesion. This study compares effects across different rheological approaches on hemodynamics, combined with a shear stress exposure history model of platelets within a stenosed porcine bifurcation. Simulations used both single/multiphase blood models to determine which approach best predicts phenomena associated with atherosclerosis and atherothrombosis. A novel Lagrangian platelet tracking model was used to evaluate residence time and shear history of platelets indicating likely regions of thrombus formation. Results show a decrease in area of regions with pathologically low time-averaged WSS with the use of multiphase models, particularly in a stenotic bifurcation. Significant non-Newtonian effects were observed due to low-shear and varying hematocrit levels found on the outer walls of the bifurcation and distal to the stenosis. Platelet residence time increased 11% in the stenosed artery, with exposure times to low-shear sufficient for red blood cell aggregation (>1.5 s). increasing the risk of thrombosis. This shows stenotic artery hemodynamics are inherently non-Newtonian and multiphase, with variations in hematocrit (0.163-0.617) and elevated vorticity distal to stenosis (+15%) impairing the function of the endothelium via reduced time-averaged WSS regions, rheological properties and platelet activation/adhesion.

Calcified coronary artery bifurcation lesions (CBL) remain a challenge for the interventional cardiologist. Evidence regarding treatment of CBL is minimal. Optimal plaque modification is the most important step prior to stent deployment. Provisional stenting is the preferred strategy for most bifurcation lesions. However, two-stent strategy should be considered for BL with compromised large SB (>2.5 mm) supplying a large territory, >70% SB stenosis and lesions more than 5 mm long. In this contemporary review article, we present a simplified approach to treating CBL and demonstrate the approach to specific case examples using our newly developed mobile application, BifurcAID.