Percutaneous coronary intervention (PCI) for coronary bifurcation disease remains one of the most challenging situations in interventional cardiology in terms of procedural success rates and long-term cardiac events. Optical coherence tomography (OCT), with a higher signal-to-noise ratio and the ability to distinguish plaque components, can display the true condition of bifurcation lesions without overlapping or shortening and achieve detailed visualization of vascular structures, which is superior to those of other imaging modalities. Three-dimensional (3D) reconstruction of OCT images (3D-OCT) helps to gain a more informed understanding of the geometry and morphology of bifurcation lesions and provide additive information on plaque distribution. Following stent implantation, 3D-OCT can also guide the re-crossing of guide wires through stent struts jailing the side branch (SB) ostium and more clearly display the jailing strut configuration, as well as the ideal position of the guidewire recrossing point and stent struct link connection, to confirm the optimal guidewire position and understand interactions between stents and vessel walls, which may improve clinical results after PCI. The present review provides an up-to-date overview of the clinical use of 3D-OCT for accurate assessment of bifurcation anatomy, guiding the optimal guidewire rewiring into SB during bifurcation stenting, and evaluation of post-PCI results, offering novel information about atherosclerotic disease or stenting process.

Percutaneous coronary interventions (PCI) of bifurcation lesions poses a technical challenge with a high complication rate. Kissing balloon inflation (KBI) and proximal optimization technique (POT) are used to correct bifurcation carina after stenting. However, both may still lead to uncomplete strut apposition to the side branch (SB) lateral wall. Proposed herein, is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and KBI called proximal optimization with kissing balloon inflation (POKI).

Bench and in-vivo evaluations were performed. For the bench visualization bifurcated silicone mock vessel was used. The POKI technique was simulated using a 3.5 mm POT balloon. For the in-vivo evaluation patients with angiographic bifurcation lesions in a native coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm, SB diameter ≥ 2.0 mm, and percentage diameter stenosis (%DS) more than 50% in the main vessel (MV) were included. Provisional stenting was the default strategy.

In total 41 vessels were evaluated. The target vessel was left main in 9 (22.0%) patients, left anterior descending artery - in 26 (63.4%), left circumflex artery - in 4 (9.8%) and right coronary artery - in 2 (4.9%). The predominant type of bifurcation was Medina 1-1-1 (61.8%). Baseline proximal MV DS% was 60.0 ± 23.7%, distal MV DS% - 58.8 ± 28.9% and SB DS% 53.0 ± 32.0%. The application of POKI was feasible in 41 (100%) of the vessels. Post-PCI residual DS at proximal MV was 11.5 ± 15.4%, distal MV - 6.6 ± 9.3%, and SB - 22.9 ± 28.5%. Both procedural and angiographic success was 100%.

POKI is a novel stent-optimization technique for bifurcation lesions. It showed excellent feasibility and success rate both in bench and in-vivo evaluation.

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.