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• Final kissing balloon inflation and proximal optimization technique should be performed in true bifurcation lesions with large side branch
  Mustafa Yurtdaş
  Published on: 17 May 2020

• Published on: 17 May 2020

  Final kissing balloon inflation and proximal optimization technique should be performed in true bifurcation lesions with large side branch

  • Mustafa Yurtdaş, Interventional Cardiologist Balıkesir Sevgi Hospital

  Dear editor,
  I have read with great interest the results of nordic baltic bifurcation study-4 by Kumsar et al (1), in which study clinical outcomes after treatment of lesions in large bifurcations by simple or complex stent implantation were compared. In the 6-month results of this study, compared to the provisional method, a decrease in major adverse cardiac event (MACE) was observed in the complex group, although it was not statistically significant. Again, in the comparison of the 2-year results, no difference was observed between the two groups. The fact that complex stenting is not found to be superior to simple stenting for true bifurcation lesions with such a wide side branch can be due to several reasons:
  1- All patients did not receive a final kissing balloon inflation (FKBI). It is well known that the FKBI should be performed in two-stenting techniques for full treatment of the true bifurcation lesion. In addition, why was the high rate of FKBI application required in simple stenting? It is well known that in simple stenting, POT should be used instead of FKBI unless the there is a TIMI flow <3, and / or a dissection in the side branch (2).
  2- Interestingly, no proximal optimization technique (POT) was used in any patient. In any complex two-stent technique without POT, the lesion is not considered to be truly treated (3,4). I think this is the most important limitation of the study. POT provides optimal positioning of the main vascular ste...

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  Dear editor,
  I have read with great interest the results of nordic baltic bifurcation study-4 by Kumsar et al (1), in which study clinical outcomes after treatment of lesions in large bifurcations by simple or complex stent implantation were compared. In the 6-month results of this study, compared to the provisional method, a decrease in major adverse cardiac event (MACE) was observed in the complex group, although it was not statistically significant. Again, in the comparison of the 2-year results, no difference was observed between the two groups. The fact that complex stenting is not found to be superior to simple stenting for true bifurcation lesions with such a wide side branch can be due to several reasons:
  1- All patients did not receive a final kissing balloon inflation (FKBI). It is well known that the FKBI should be performed in two-stenting techniques for full treatment of the true bifurcation lesion. In addition, why was the high rate of FKBI application required in simple stenting? It is well known that in simple stenting, POT should be used instead of FKBI unless the there is a TIMI flow <3, and / or a dissection in the side branch (2).
  2- Interestingly, no proximal optimization technique (POT) was used in any patient. In any complex two-stent technique without POT, the lesion is not considered to be truly treated (3,4). I think this is the most important limitation of the study. POT provides optimal positioning of the main vascular stent prior to carina and facilitates rewiring of the side branch. The superiority of this method has been demonstrated in the studies conducted. In the vast majority of cases of true bifurcation lesions involving large side branch, complex stenting without POT is resulted in malapposition and underexpansion, which are associated with coronary thrombosis and neo-atherosclerosis (closely related to stent restenosis and / or MACE) (3,4).
  For this reason, I think that the two-stent strategy is likey superior to the single-stent strategy in true bifurcation lesions with a wide side branch provided that POT - FKBI - POT sequence should be performed in all bifurcation lesions treated with the two-stent strategy.
  REFERENCES
  1- Kumsars I, Holm NR, Niemelä M On behalf of the Nordic Baltic bifurcation study group, et al. Randomised comparison of provisional side branch stenting versus a two-stent strategy for treatment of true coronary bifurcation lesions involving a large side branch: the Nordic-Baltic Bifurcation Study IV. Open Heart 2020;7:e000947. doi: 10.1136/openhrt-2018-000947.
  2- Sawaya FJ, Lefèvre T, Chevalier B, et al. Contemporary Approach to Coronary Bifurcation Lesion Treatment. JACC Cardiovasc Interv. 2016;9(18):1861‐1878. doi:10.1016/j.jcin.2016.06.056.
  3- Hoye A. The Proximal Optimisation Technique for Intervention of Coronary Bifurcations. Interv Cardiol. 2017;12(2):110‐115. doi:10.15420/icr.2017:11:2.
  4- Yurtdaş M, Asoğlu R, Özdemir M, Asoğlu E. An Upfront Two-Stent Strategy for True Coronary Bifurcation Lesions with A Large Side Branch in Acute Coronary Syndrome: A Two-Year Follow-Up Study. Medicina (Kaunas). 2020;56(3):102. doi:10.3390/medicina56030102.

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  Conflict of Interest:
  None declared.

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