“Bailing Out” Side Branches: Technique Trumps Technology, Round 1

Bifurcation lesions remain a challenge for coronary interventionists. Planning for treatment of a bifurcation lesion not only includes addressing lesions with severe stenosis at the origin of the side branch before the procedure, but also consideration of “bailout” strategies for side branches that may be compromised due to a change in geometry or plaque shifting after main-vessel stenting. Dedicated specialty groups, such as the European Bifurcation Club, have brought serious clinicians together to discuss the technical challenges of bifurcation lesions, and these discussions have resulted in a number of innovative approaches to patients with bifurcation lesions. Randomized data evaluating one- and two-stent techniques show that “less is more,” and a single-stent technique is preferable to multiple stents.1 “Bailout” stenting is now recommended only for significant side-branch compromise (i.e., occlusion or reduced flow) following final kissing-balloon inflation. It is surprising that the dedicated bifurcation and side-branch access stents have, to date, been unable to provide superior outcomes to those achieved by careful attention to technique by skilled operators. In the current series, a very simple and intuitive approach to “bailout stenting” of the branch vessel is described, a technique that has admittedly struggled for a name for the past several years (a.k.a., “blocking-balloon” or “minicrush” techniques).2 The acronym “TAP” (“T And small Protrusion) is perfect. The “T” stent minimizes the amount of overlapped metal within the bifurcation and, potentially, stent thrombosis, and the “small protrusion” provides optimal coverage of the origin of the side branch at the carina, which has been a frequent site of restenosis. It was only used when needed to salvage a struggling side branch in 7.1% of lesions in this series. Early and late outcomes were comparable in this series to the single-stent approach. There are several very notable points to this study. First, by using the contemporary Medina Classification system,3 the authors provide an exact accounting of the distribution of the main vessel and side-branch disease. Approximately 40% of patients in this series had “true” bifurcation lesions, with disease in both the parent vessel and side branch. The Medina classification was useful in this series and has largely replaced prior classification systems. Its only limitation is that it does not completely describe the angulation of the parent vessel and the side branch, which may have had value in this study. The plexiglass model that is provided with this report is useful in delineating the sequential steps in the process, and shows that a minimal amount of duplicative stent remains at the level of the carina. The authors used the radial approach for the majority of cases, underscoring the fact that this method can be used with smaller (6 French) guiding catheters. Although we do not know the criteria for side-branch compromise in this series, only 7.1% of lesions required “bailout” stenting using this method. Finally, the 1-year accounting for major adverse cardiac events shows that there is no significant difference in outcomes with a single-stent technique in the event that there is need for a bailout stent. This is useful to know, as the bailout-stent method is sometimes a more prolonged procedure. The efforts to find the right technology for bifurcation lesions should proceed. Dedicated bifurcation stents may be useful when the main vessel proximal to the side branch is large and complete coverage of the carina is needed. Thus far, dedicated bifurcation stents have been hampered by higher profiles, issues relating to spatial orientation and wire crossing. Dedicated branch-vessel stents may be better for bifurcation lesions in preemptive rather than bailout situations. Clinical studies are ongoing with dedicated side-branch access using self-expanding nitinol, open-cell design and sleeves at the origin of the branch vessels. These important studies should continue, but it appears, based on the results of this series, that technique trumps technology — for this first round. From the Cardiovascular Division at the Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, Massachusetts. Disclosures: Dr. Popma discloses that he is a paid consultant to Abbott Vascular, Boston Scientific Corp., and Medtronic, Inc. He has also received research grants from Abbott Vascular, Boston Scientific Corp., Cordis Corp., and Medtronic, Inc. Dr. Yang has no disclosures to make regarding the content herein. Address for correspondence:Jeffrey J. Popma, MD, Senior Attending Physician, Beth Israel Deaconess Medical Center, Associate Professor of Medicine, Harvard Medical School, 185 Pilgrim Street, Palmer 4, Boston, MA 02215. E-mail: jpopma@bidmc.harvard.edu

1. Ferenc M, Michael G, Rolf-Peter K, et al. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J 2008;29:2859–2867.

2. Burzotta F, Sgueglia GA, Trani C, et al. Provisional TAP-stenting strategy to treat bifurcated lesions with drug-eluting stents: One-year clinical results of a prospective registry. J Invasive Cardiol 2009;21:532–537.

3. Medina A, Suarez de Lezo J, Pan M. A new classification of coronary bifurcation lesions. Rev Esp Cardiol 2006;59:183.