Left Main Bifurcation and Trifurcation PCI: Contemporary Principles and Strategies
Left Main Bifurcation and Trifurcation PCI: Contemporary Principles and Strategies
Review Article – Updated 2025 Insights. Techniques for LM Bifurcation PCI :
Takeaway :
1. Provisional Stenting
• Wire MV + SB. Predilate if needed.
• Stent MV first.
• If SB flow good → finish.
• If SB compromised → balloon angioplasty; stent only if severe stenosis/dissection.
2. DK-Crush
• Wire MV + SB. Predilate if needed.
• Stent SB with 2–3 mm protrusion → crush with MV non-compliant (NC) balloon, sized 1:1 to distal MV.
• Rewire SB via near-carina cell (DC) → first kissing balloon inflation.
• Stent MV.
• Rewire SB again via near-carina cell → final kissing.
• Final POT mandatory.
• Best evidence for complex LM bifurcations.
3. Culotte Technique
• Stent one branch (usually most diseased).
• Re-cross into the other branch (preferably near-carina cell).
• Stent second branch → “pants-leg” overlap configuration.
• Perform kissing balloon inflation and final POT.
• Useful when MV and SB are similar size.
4. TAP (T-and-Protrusion)
• Stent MV first.
• If SB compromised → implant short SB stent with minimal protrusion (≈1–2 mm).
• Final kissing balloon inflation only is required to flare/merge the protruded struts → no separate crushing step, unlike DK-Crush.
• Final POT.
• Serves as a rapid bailout option.
5. Proximal Optimization Technique (POT)
• Mandatory in all bifurcation PCI.
• Use short balloon sized to proximal MV.
• Inflate only in proximal stent (not across carina).
• Ensures proper expansion, facilitates SB access, prevents malapposition.
6. Kissing Balloon Inflation (KBI)
• Balloons in MV + SB inflated simultaneously at the carina.
• Balloon sizes:
• MV balloon: 1:1 with distal MV diameter.
• SB balloon: 1:1 with SB diameter.
• Inflation pressure: usually 10–12 atm, balanced inflations (some operators inflate MV first partially, then SB, then both).
• Restores carina shape and optimizes bifurcation geometry.
• Mandatory only if SB has been manipulated (ballooned or stented).
• Always followed by final POT.
Rule-of-Thumb
• POT mandatory in all bifurcations.
• Final kissing mandatory only if SB manipulated.
LM Trifurcation PCI – Step-by-Step
1. Preparation and Setup
• 7F–8F guide, consider guide extension; hemodynamic support if unstable.
• Anticoagulation with heparin (ACT monitoring).
• Antiplatelets: Cangrelor if CABG possible (bridging alternative); continue aspirin; avoid GP IIb/IIIa if CABG possible.
2. Two-/Three-Wire Strategy
• Always wire MV and all SBs.
• Do not remove wires before first stent.
• Jailing SB wires is intentional for access protection.
• After MV stent:
* If SB flow preserved → jailed wire may be removed gently.
* If SB compromised → keep wire for rewiring/balloon/stent.
• Safe removal: perform POT first, withdraw slowly; if resistance, advance balloon/microcatheter to release.
• Wire choice: workhorse in MV; soft-tip in SB to minimize fracture risk.
3. Initial Lesion Preparation
• Sequential predilatation (one branch at a time).
• Balloon size 1:1 with distal vessel.
• Start with low pressure in severe stenosis/thrombus, escalate as needed.
4. Strategy Selection
• If one branch small → treat as bifurcation.
• If all three large/important → complex multi-stent, most often Triple Kissing Crush (TKC).
• Always IVUS/OCT guided.
5. TKC (Triple Kissing Crush) Practical Sequence
• Wire MV + 3 SBs, predilate sequentially.
• Stent SB#1 → minimal protrusion → crush with NC MV balloon (1:1 distal MV).
• Rewire SB#1 via near-carina cell → kissing #1.
• Stent SB#2 → minimal protrusion → crush with NC MV balloon.
• Rewire SB#2 via near-carina cell → kissing #2.
• Stent MV across trifurcation.
• Final rewiring of SBs via near-carina cell.
• Final optimization: pairwise kissing ± triple kissing (“trissing”).
• Balloon sizes: each balloon 1:1 with the respective vessel (distal MV or each SB).
• Final POT mandatory.
• Confirm with IVUS/OCT.
6. Final Imaging and Checklist
• Confirm stent expansion, SB ostial opening, no malapposition, no edge dissection.
Do
• Wire all branches.
• Predilate sequentially.
• Re-cross via near-carina cell.
• Use IVUS/OCT before and after.
• Always finish with POT.
Don’t
• Don’t perform initial kissing predilatation.
• Don’t re-cross via outer-wall cell.
• Don’t use GP IIb/IIIa if CABG possible.
• Don’t skip final imaging.
Restenosis Management
• IVUS/OCT mandatory to identify mechanism (underexpansion, fracture, neoatherosclerosis).
• DCB: avoids new metal.
• KBI: for bifurcation restenosis.
• Trissing balloons: for trifurcation restenosis (each balloon sized 1:1 to vessel).
• Goal: restore flow, optimize geometry, reduce recurrence.