Crossing a bifurcation coronary artery stenosis and successful treatment of the offending lesion can be one of the most challenging undertakings confronting the interventionist. There are several angiographic descriptors that influence procedural success. The angle at which the side branch arises from the main branch, the severity of the stenosis in both branches, as well as the degree of calcification and tortuosity surrounding the carina of the lesion may dampen the enthusiasm of even the most accomplished interventionist.

Two of the more commonly described procedural challenges are crossing the lesion with a dual-wire technique while preventing wire wrap and adequate coverage of the side branch ostium, the segment most susceptible to restenosis. Each case and each lesion is unique, reflecting the heterogeneity of bifurcation coronary disease. Irrespective of the treatment strategy undertaken (two-stent strategy versus provisional side-branch stenting), there are a few helpful tips and tricks that may facilitate successful treatment of bifurcation disease (Figure 1).

WIRE WRAP
Wire wrap is a common problem preventing the passage of balloons and stents beyond the carina of the lesion, whether attempting to negotiate a device into the main branch or side branch. One technique the operator may find extremely helpful is to approach bifurcations by first passing a wire into the main branch distally. Once the main branch has been successfully wired, prevention of wire wrap may be achieved by passage of a second wire through the main branch in the direction of the side branch, using an over-the-wire system. Specifically, the technique involves inching the wire forward and then trailing with the over-the-wire balloon close behind. In other words, as the operator makes small advances with the wire toward the side branch, this is followed by advancing the balloon close to the wire tip. This repetitive technique ensures that the wire is not freely moving circumferentially, entangling itself around the main branch wire. If wire wrap is suspected, the wire can simply be retracted back into the balloon to unwrap it. Using this technique may alleviate the time-consuming need to fully retract the wire proximally back into the guide catheter if wire wrap is encountered. Once the tip of the wire gains access into the side branch ostium, it is unlikely that wire wrap will occur, and advancing the balloon and wire distally can generally be accomplished without difficulty.

AVOIDING STENT GAP
A second challenge when treating bifurcations is the lack of consistency in adequately covering the side branch ostium when side branches are stented. Studies have shown that gaps in stent coverage beyond the lesion carina in the proximal 5 mm of the side branch ostium are a contributing factor in side branch restenosis. One trick that consistently aids in avoiding the all-too-commonly encountered stent gap necessitates using an inflated balloon in the main branch to align the proximal edge of the side branch stent at its ostium. The first step in this technique is to pass a stent into the side branch and a balloon into the main branch. With the main branch balloon inflated, gentle pulling force or retraction of the side branch stent is applied. When the stent being retracted in the daughter vessel meets the fully inflated balloon in the parent vessel, the stent can be inflated to achieve ostial placement. This maneuver also helps to prevent any significant degree of protrusion of the side branch stent into the main branch (ie, the balloon alignment technique). This can be followed by additional stenting of the main branch or side branch as needed. As always, it is recommended that final kissing balloon angioplasty be performed.

David G. Rizik, MD, FACC, FSCAI, is Director of Interventional Cardiology at Scottsdale Healthcare Hospital in Scottsdale, Arizona. He has disclosed that he is a paid consultant to Cordis, Abbott, and Boston Scientific. Dr. Rizik may be reached at (480) 860-1919; davidrizik@aol.com.