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Asad Shabbir
Cardiology Registrar, Oxford Deanery
Bifurcation PCI Techniques: A Practical Summary for Fellows
Percutaneous coronary intervention (PCI) of bifurcation lesions is a technically demanding field of interventional cardiology owing to plaque distribution, geometry, and flow dynamics, all of which introduce unique procedural challenges. This lesion subset is not infrequently encountered, with approximately 15–20% of all coronary interventions involving a bifurcation lesion.1,2
Despite advances in stent technology, imaging, and physiology, outcomes for bifurcation lesions remain less optimal compared with non-bifurcation lesions due to risks of branch occlusion, restenosis, and stent failure.3,4
A clear understanding of coronary bifurcation anatomy, lesion classification, and stepwise procedural strategies is essential for procedural success. This quick guide provides a practical summary of contemporary bifurcation PCI techniques and is intended to be a concise framework of reference for PCI fellows.
A bifurcation lesion involves a division of a main vessel (MV) into two branches, typically defined by a side branch ≥2.0 mm in diameter. The main branch (MB) extends from the proximal to distal segment across the bifurcation, while the side branch (SB) arises at an angle that may influence procedural planning. The bifurcation angle is the angle between the MB and SB. A large angle often makes wire manipulation and stent advancement more challenging.
The Medina system remains the simplest and most widely used method of describing bifurcation anatomy.5 It denotes the presence of disease in the MV, the MB, and the SB. Each segment is coded ‘1’ (diseased) or ‘0’ (not diseased) as follows; 1,1,1 = true bifurcation, 1,0,1 = proximal MB + SB involvement, and 1,1,0 = proximal and distal MB disease. This is shown in Figure 1. While practical, the Medina system lacks anatomical and geometrical detail, as it does not capture bifurcation angle, vessel size, lesion length, or calcification.
Figure 1. Medina classification of 0,1,1 bifurcation lesion. MV, MB, and SB are shown.
The general principals of bifurcation PCI are initially to identify the bifurcation anatomy, as described above. Following this, a decision needs to be made regarding whether or not, both branches need to be wired. The purpose of the side branch wire is to mark the ostium and course of the SB, rather than to ‘protect it’ and prevent SB vessel closure during MB PCI. The SB wire can also be used to pre-treat the SB with a balloon or drug-coated balloon, or stent, prior to treating the MV.
Generally, if the side branch is of reasonable calibre, and subtends a significant volume of myocardium, it should be wired (if you are in doubt about whether or not to wire it, you should probably wire it).
Workhorse wires should be used where possible, to reduce the risk of vessel dissection and/or distal wire perforation. At times, polymer jacketed wires are required in tortuous or calcified vessels, and if this is the case, the wire used to cross can be exchanged for a workhorse wire with a microcatheter or the parallel wire technique can be used once a polymer jacketed wire has been advanced.
In bifurcation PCI, angiography alone can underestimate key lesion features such as plaque morphology, vessel size, distribution of disease, or the precise location of side branches. Intravascular imaging (IVI) with intravascular ultrasound (IVUS) or optical coherence tomography (OCT) addresses these limitations by offering real-time cross-sectional and high-resolution assessment of the coronary vessel wall and plaque characteristics.
Contemporary evidence increasingly supports the routine use of IVI in bifurcation PCI to improve technical precision and clinical outcomes.6,7 IVI achieves this through the assessment of plaque distribution, plaque morphology, calcification, lipid content, reference vessel sizing, and the assessment of appropriate landing zones. Furthermore, IVI allows for the assessment of side-branch ostium anatomy and plaque burden, which may guide whether a 1- (provisional) or 2-stent strategy is preferable.
A determinant of clinical success after PCI is adequate stent expansion and apposition. Suboptimal stent expansion is a well-recognised risk factor for stent thrombosis, restenosis, and target lesion failure.8,9 IVI provides an accurate measurement of minimum stent area and visualisation of stent geometry relative to the vessel wall. IVI also enables precise identification of malapposition, edge dissections, and tissue prolapse. Imaging allows immediate correction of such issues during the index procedure, translating into improved long-term patency and fewer adverse events. For example, the OCTOBER trial demonstrated that systematic OCT guidance resulted in lower major adverse cardiac events (MACE) at 2 years in patients with complex bifurcation lesions compared with angiography guidance (10.1% vs. 14.1%; HR 0.70), particularly with a provisional one-stent strategy.10
IVI may assist with the detection of procedural complications such as edge dissections that may not be visible angiographically, under-expanded or asymmetrically expanded stent segments, and residual plaque protrusion or incomplete coverage. The ability to detect these issues allows the operator to correct them immediately, through further balloon dilation, additional stent placement, or more precise post-dilatation, before they lead to adverse events.
A recent systematic review and meta-analysis of randomised controlled trials comparing imaging-guided PCI with angiography guidance demonstrated that IVI significantly reduces target vessel failure (TVF) in bifurcation lesions (RR 0.70) and unprotected left main lesions (RR 0.55).11 Pooled analyses from trials like RENOVATE-COMPLEX PCI, ILUMIEN IV, and OCTOBER provide additional contemporary support that intravascular imaging leads to better procedural optimisation, lower rates of stent thrombosis, MACE, and adverse outcomes compared with angiography alone.12 A broader meta-analysis involving over 17,000 patients showed that IVUS significantly reduced MACE, cardiac death, revascularisation, and stent thrombosis versus angiography alone. OCT similarly reduced cardiac death and stent thrombosis.13 The ULTRA-BIFURCAT registry, a large multicentre propensity-matched cohort, found that IVUS-guided PCI was linked with lower composite MACE rates and reduced stent thrombosis compared with angiography guidance in patients with bifurcation lesions, especially in unprotected left main populations.14
The procedural strategy should be planned upfront. During the case, the operator should remain dynamic and may well be obligated to alter the strategy during the case, depending on how the anatomy behaves during PCI. The following should be considered; SB diameter and volume of subtended myocardium, lesion length in the SB, bifurcation angle, and plaque distribution. Generally, in 1,0,0 and 1,1,0 disease, the default strategy should be provisional stenting of the main branch. A planned 2-stent strategy may be used for large or significantly diseased SBs, or when the SB is ≥2.5 mm and extends >5–10 mm from the ostium, typically in 1,0,1 bifurcations or in true bifurcation 1,1,1 disease patterns.
5.1. The provisional (1-stent) strategy
The provisional approach is the default strategy for most bifurcations. The MV and MB are treated first, and the SB is only stented if necessary. Step-by-step technique described below and also shown in Figure 2:
Figure 2. Medina 1,1,0 bifurcation lesion treated with provisional (1-stent) technique. (A) Both MB and SB wired. (B) MB treated with balloon angioplasty. (C) MV and MB stented with a single stent. (D) Stent post-dilated. (E) POT to MV stented segment. (F) Final result with SB preserved.
5.2 Kissing balloon inflation (KBI)
5.3. 2-stent techniques
When the SB is large, supplies significant myocardium, or contains a long segment of disease, a planned 2-stent approach is preferred. Several configurations exist; the choice depends on anatomy, angle, and operator familiarity.
5.3.1 Culotte Stenting
Best for narrow bifurcation angle (<70°), similar vessel sizes, and both branches significantly diseased. Steps as below and shown in Figure 3:
Figure 3. Culotte stenting. (A) Medina 1,1,1 bifurcation lesion. (B) both MB and SB wired, and SB predilated. (C) further SB vessel preparation. (D) MB vessel preparation. (E) implantation of stent from SB to MV. (F) Post-dilatation of SB stent (not shown) and POT. (G) MB re-wired. (H) struts into MB opened using small balloon. (I) Implantation of stent from MB to MV. (J) SB wire removed, MB stent optimised (not shown), and POT. (K) SB re-wired. (L) struts into SB opened using small balloon. (M) KBI. (N) POT. (O) final result.
5.3.2 T-Stenting and TAP (T-and-protrusion)
Best for wide bifurcation angles (≥70°) and short ostial SB disease. Steps shown below and shown in Figure 4:
Figure 4. T-stenting. (A) Medina 1,1,1 bifurcation lesion. (B) SB pre-dilated. (C) SB ostium pre-dilated. (D) MB pre-dilated. (E) SB stented. (F) SB stent optimised. (G) MV and MB stented. (H) POT. (I) Recross into SB. (J) Open struts into SB with small balloon. (K) KBI. (L) final POT.
TAP modification:
5.3.3 Crush Techniques
Crush stenting ensures full ostial SB coverage, using intentional stent overlap. Variants include classic crush, mini-crush, nano-crush, and double kissing (DK) crush. Both vessels are wired and a balloon is advanced to the MV prior to stent deployment in the SB, in preparation to be pulled back and perform the crush. Shown in Figure 5. Classic crush steps:
Figure 5. Crush stenting. (A) Medina 1,1,1 bifurcation lesion. (B) SB pre-dilated. (C) SB ostium pre-dilated. (D) MB pre-dilated. (E) SB stented, with stent intentionally protruding into MV, balloon advanced in MB in preparation for pull-back and crush (F) SB stent crushed with MB-MV balloon. (G) MV stented. (H) POT. (I) Recross into SB and open struts into SB with small balloon. (J) KBI. (K) POT. (L) final result.
Mini-crush modification:
Double kissing (DK) crush modification:
5.3.4. V-Stenting and Simultaneous Kissing Stents (SKS)
Nowadays rarely performed. Steps:
POT is a cornerstone in bifurcation PCI. POT corrects malapposition in the larger proximal MV, facilitates accurate SB re-crossing through distal stent cells, and restores vessel geometry and reduces risk of stent thrombosis. It is important to remember to inflate short NC balloon (sized to proximal MV diameter) at high pressure (typically 14–18atm) and to deploy the balloon at carina level.
The left main coronary bifurcation (LMCA–LAD–LCx) presents additional complexity due to large vessel size and prognostic significance. Key principles:
Bifurcation PCI is a balance between anatomical understanding, procedural planning, and technical precision. The provisional stenting approach remains the mainstay for the majority of cases due to its simplicity and excellent outcomes. However, when anatomical or functional significance of the SB dictates, planned two-stent strategies—particularly DK-Crush or Culotte—provide durable results when executed with meticulous technique. Routine use of imaging (IVUS/OCT) and POT is essential for all bifurcation PCIs.
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