Bifurcated stents: giving to Caesar what is Caesar’s

ABSTRACT

Since its earlier days, procedural and technical difficulties allied topoor immediate and long-term outcomes have turned the percutaneoustreatment of bifurcated coronary lesions into one of the mostchallenging scenarios of interventional cardiology1,2.In the mid 1980’s, when balloon angioplasty was the standardpercutaneous approach, the treatment of bifurcation lesions wasconsidered a procedure of exception for carrying a high risk of acuteischaemic complications (e.g. acute coronary thrombosis) andrestenosis. Usually, kissing-balloon was the preferred technique tominimise plaque shift to the side branch and improve immediateoutcomes3,4.In the early 1990’s, the use athero-ablative techniques (rotationaland directional atherectomy) decreased the need for repeat lesionrevascularisation but increased the procedural complications afterpercutaneous approach of bifurcations5-7.In the mid 1990’s, coronary stenting, through its scaffolding properties,became the treatment of choice for bifurcated lesions, mainlybecause of its impact in reducing acute complications. However, itwas yet to be determined which was the best technical approach toreduce restenosis and improve long term outcomes in that specificpopulation. Basically, the remaining issue was how to achieve thebest results in the main branch while preserving the side branch. Inthe bare metal stent era, several reports investigating the outcomeof stenting solely the main vessel versus stenting main vessel andside branches, reported dissimilar results; although both techniquesproved to be safe and feasible, substantial restenosis ratesof up to 40% were observed8,9. Of note, among those receivingstents in both branches, T-stenting was superior to Y-stenting inreducing adverse events (86.3% vs. 30.4%, p=0.004).