{"id":8682,"date":"2025-09-20T19:33:19","date_gmt":"2025-09-20T16:33:19","guid":{"rendered":"https:\/\/jordan-cardiac.org\/?p=8682"},"modified":"2025-09-20T19:33:19","modified_gmt":"2025-09-20T16:33:19","slug":"left-main-bifurcation-and-trifurcation-pci-contemporary-principles-and-strategies","status":"publish","type":"post","link":"https:\/\/jordan-cardiac.org\/en\/left-main-bifurcation-and-trifurcation-pci-contemporary-principles-and-strategies\/","title":{"rendered":"Left Main Bifurcation and Trifurcation PCI: Contemporary Principles and Strategies"},"content":{"rendered":"
Left Main Bifurcation and Trifurcation PCI: Contemporary Principles and Strategies<\/div>\n
<\/div>\n
Review Article \u2013 Updated 2025 Insights. Techniques for LM Bifurcation PCI :<\/div>\n
<\/div>\n
Takeaway :<\/div>\n
1. Provisional Stenting<\/div>\n
\u2022 Wire MV + SB. Predilate if needed.<\/span><\/div>\n
\u2022 Stent MV first.<\/span><\/div>\n
\u2022 If SB flow good \u2192 finish.<\/span><\/div>\n
\u2022 If SB compromised \u2192 balloon angioplasty; stent only if severe stenosis\/dissection.<\/span><\/div>\n
<\/div>\n
2. DK-Crush<\/div>\n
\u2022 Wire MV + SB. Predilate if needed.<\/span><\/div>\n
\u2022 Stent SB with 2\u20133 mm protrusion \u2192 crush with MV non-compliant (NC) balloon, sized 1:1 to distal MV.<\/span><\/div>\n
\u2022 Rewire SB via near-carina cell (DC) \u2192 first kissing balloon inflation.<\/span><\/div>\n
\u2022 Stent MV.<\/span><\/div>\n
\u2022 Rewire SB again via near-carina cell \u2192 final kissing.<\/span><\/div>\n
\u2022 Final POT mandatory.<\/span><\/div>\n
\u2022 Best evidence for complex LM bifurcations.<\/span><\/div>\n
<\/div>\n
3. Culotte Technique<\/div>\n
\u2022 Stent one branch (usually most diseased).<\/span><\/div>\n
\u2022 Re-cross into the other branch (preferably near-carina cell).<\/span><\/div>\n
\u2022 Stent second branch \u2192 \u201cpants-leg\u201d overlap configuration.<\/span><\/div>\n
\u2022 Perform kissing balloon inflation and final POT.<\/span><\/div>\n
\u2022 Useful when MV and SB are similar size.<\/span><\/div>\n
<\/div>\n
4. TAP (T-and-Protrusion)<\/div>\n
\u2022 Stent MV first.<\/span><\/div>\n
\u2022 If SB compromised \u2192 implant short SB stent with minimal protrusion (\u22481\u20132 mm).<\/span><\/div>\n
\u2022 Final kissing balloon inflation only is required to flare\/merge the protruded struts \u2192 no separate crushing step, unlike DK-Crush.<\/span><\/div>\n
\u2022 Final POT.<\/span><\/div>\n
\u2022 Serves as a rapid bailout option.<\/span><\/div>\n
<\/div>\n
5. Proximal Optimization Technique (POT)<\/div>\n
\u2022 Mandatory in all bifurcation PCI.<\/span><\/div>\n
\u2022 Use short balloon sized to proximal MV.<\/span><\/div>\n
\u2022 Inflate only in proximal stent (not across carina).<\/span><\/div>\n
\u2022 Ensures proper expansion, facilitates SB access, prevents malapposition.<\/span><\/div>\n
<\/div>\n
6. Kissing Balloon Inflation (KBI)<\/div>\n
\u2022 Balloons in MV + SB inflated simultaneously at the carina.<\/span><\/div>\n
\u2022 Balloon sizes:<\/span><\/div>\n
\u2022 MV balloon: 1:1 with distal MV diameter.<\/span><\/div>\n
\u2022 SB balloon: 1:1 with SB diameter.<\/span><\/div>\n
\u2022 Inflation pressure: usually 10\u201312 atm, balanced inflations (some operators inflate MV first partially, then SB, then both).<\/span><\/div>\n
\u2022 Restores carina shape and optimizes bifurcation geometry.<\/span><\/div>\n
\u2022 Mandatory only if SB has been manipulated (ballooned or stented).<\/span><\/div>\n
\u2022 Always followed by final POT.<\/span><\/div>\n
<\/div>\n
Rule-of-Thumb<\/div>\n
\u2022 POT mandatory in all bifurcations.<\/span><\/div>\n
\u2022 Final kissing mandatory only if SB manipulated.<\/span><\/div>\n
<\/div>\n
LM Trifurcation PCI \u2013 Step-by-Step<\/div>\n
<\/div>\n
1. Preparation and Setup<\/div>\n
\u2022 7F\u20138F guide, consider guide extension; hemodynamic support if unstable.<\/span><\/div>\n
\u2022 Anticoagulation with heparin (ACT monitoring).<\/span><\/div>\n
\u2022 Antiplatelets: Cangrelor if CABG possible (bridging alternative); continue aspirin; avoid GP IIb\/IIIa if CABG possible.<\/span><\/div>\n
<\/div>\n
2. Two-\/Three-Wire Strategy<\/div>\n
\u2022 Always wire MV and all SBs.<\/span><\/div>\n
\u2022 Do not remove wires before first stent.<\/span><\/div>\n
\u2022 Jailing SB wires is intentional for access protection.<\/span><\/div>\n
\u2022 After MV stent:<\/span><\/div>\n
* If SB flow preserved \u2192 jailed wire may be removed gently.<\/div>\n
* If SB compromised \u2192 keep wire for rewiring\/balloon\/stent.<\/div>\n
\u2022 Safe removal: perform POT first, withdraw slowly; if resistance, advance balloon\/microcatheter to release.<\/span><\/div>\n
\u2022 Wire choice: workhorse in MV; soft-tip in SB to minimize fracture risk.<\/span><\/div>\n
<\/div>\n
3. Initial Lesion Preparation<\/div>\n
\u2022 Sequential predilatation (one branch at a time).<\/span><\/div>\n
\u2022 Balloon size 1:1 with distal vessel.<\/span><\/div>\n
\u2022 Start with low pressure in severe stenosis\/thrombus, escalate as needed.<\/span><\/div>\n
<\/div>\n
4. Strategy Selection<\/div>\n
\u2022 If one branch small \u2192 treat as bifurcation.<\/span><\/div>\n
\u2022 If all three large\/important \u2192 complex multi-stent, most often Triple Kissing Crush (TKC).<\/span><\/div>\n
\u2022 Always IVUS\/OCT guided.<\/span><\/div>\n
<\/div>\n
5. TKC (Triple Kissing Crush) Practical Sequence<\/div>\n
\u2022 Wire MV + 3 SBs, predilate sequentially.<\/span><\/div>\n
\u2022 Stent SB#1 \u2192 minimal protrusion \u2192 crush with NC MV balloon (1:1 distal MV).<\/span><\/div>\n
\u2022 Rewire SB#1 via near-carina cell \u2192 kissing #1.<\/span><\/div>\n
\u2022 Stent SB#2 \u2192 minimal protrusion \u2192 crush with NC MV balloon.<\/span><\/div>\n
\u2022 Rewire SB#2 via near-carina cell \u2192 kissing #2.<\/span><\/div>\n
\u2022 Stent MV across trifurcation.<\/span><\/div>\n
\u2022 Final rewiring of SBs via near-carina cell.<\/span><\/div>\n
\u2022 Final optimization: pairwise kissing \u00b1 triple kissing (\u201ctrissing\u201d).<\/span><\/div>\n
\u2022 Balloon sizes: each balloon 1:1 with the respective vessel (distal MV or each SB).<\/span><\/div>\n
\u2022 Final POT mandatory.<\/span><\/div>\n
\u2022 Confirm with IVUS\/OCT.<\/span><\/div>\n
<\/div>\n
6. Final Imaging and Checklist<\/div>\n
\u2022 Confirm stent expansion, SB ostial opening, no malapposition, no edge dissection.<\/span><\/div>\n
<\/div>\n
Do<\/div>\n
\u2022 Wire all branches.<\/span><\/div>\n
\u2022 Predilate sequentially.<\/span><\/div>\n
\u2022 Re-cross via near-carina cell.<\/span><\/div>\n
\u2022 Use IVUS\/OCT before and after.<\/span><\/div>\n
\u2022 Always finish with POT.<\/span><\/div>\n
<\/div>\n
Don\u2019t<\/div>\n
\u2022 Don\u2019t perform initial kissing predilatation.<\/span><\/div>\n
\u2022 Don\u2019t re-cross via outer-wall cell.<\/span><\/div>\n
\u2022 Don\u2019t use GP IIb\/IIIa if CABG possible.<\/span><\/div>\n
\u2022 Don\u2019t skip final imaging.\u00a0<\/span><\/div>\n
<\/div>\n
Restenosis Management<\/div>\n
\u2022 IVUS\/OCT mandatory to identify mechanism (underexpansion, fracture, neoatherosclerosis).<\/span><\/div>\n
\u2022 DCB: avoids new metal.<\/span><\/div>\n
\u2022 KBI: for bifurcation restenosis.<\/span><\/div>\n
\u2022 Trissing balloons: for trifurcation restenosis (each balloon sized 1:1 to vessel).<\/span><\/div>\n
\u2022 Goal: restore flow, optimize geometry, reduce recurrence.<\/span><\/div>\n
<\/div>\n
https:\/\/pmc.ncbi.nlm.nih.gov\/articles\/PMC11909422\/?utm_source=chatgpt.com<\/a><\/div>\n
<\/div>\n
https:\/\/pubmed.ncbi.nlm.nih.gov\/40436434\/?utm_source=chatgpt.com<\/a><\/div>\n","protected":false},"excerpt":{"rendered":"

Left Main Bifurcation and Trifurcation PCI: Contemporary Principles and Strategies Review Article \u2013 Updated 2025 Insights. Techniques for LM Bifurcation PCI : Takeaway : 1. Provisional Stenting \u2022 Wire MV + SB. Predilate if needed. \u2022 Stent MV first. \u2022 If SB flow good \u2192 finish. \u2022 If SB compromised \u2192 balloon angioplasty; stent only […]<\/p>\n","protected":false},"author":145,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-8682","post","type-post","status-publish","format-standard","hentry","category-uncategorized"],"_links":{"self":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/8682","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/users\/145"}],"replies":[{"embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/comments?post=8682"}],"version-history":[{"count":1,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/8682\/revisions"}],"predecessor-version":[{"id":8683,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/posts\/8682\/revisions\/8683"}],"wp:attachment":[{"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/media?parent=8682"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/categories?post=8682"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/jordan-cardiac.org\/en\/wp-json\/wp\/v2\/tags?post=8682"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}