Emmanouil S. Brilakis, MD, PhD
Minneapolis Heart Institute and Minneapolis Heart Institute Foundation
Abbott Northwestern Hospital
Minneapolis, Minnesota
esbrilakis@gmail.com
Disclosures: Consulting/speaker honoraria from Abbott Vascular, American Heart Association (Associate Editor, Circulation), Boston Scientific Corporation, Cardiovascular Innovations Foundation (Board of Directors), Cordis, Elsevier, GE Healthcare, IMDS, Medtronic, SIS Medical, Teleflex, and Terumo; research support from Boston Scientific Corporation and GE Healthcare; owner, Hippocrates LLC; shareholder, Cleerly Health, LifeLens Technologies, Inc, MHI Ventures, Stallion Medical, and TrueVue Inc.

Yiannis S. Chatzizisis, MD, PhD
Division of Cardiovascular Medicine
Miller School of Medicine, University of Miami
Miami, Florida
ychatzizisis@icloud.com
Disclosures: Speaker honoraria, advisory board fees, and research grant from Boston Scientific Corporation; advisory board fees and research grant from Medtronic; issued United States patent (No. 11,026,749) and international patent pending (application No. PCT/US2020/057304) for the invention entitled “Computational simulation platform for the planning of interventional procedures”; Co-Founder, ComKardia, Inc.

Valeria Paradies, MD
Department of Cardiology
Maasstad Hospital
Rotterdam, the Netherlands
paradiesvaleria@gmail.com
Disclosures: None.

What are three keys for deciding between provisional or planned two-stent bifurcation percutaneous coronary intervention (PCI) in an individual case?

Dr. Brilakis: I use two key questions to decide on bifurcation strategy selection: (1) Is the side branch (SB) significant? And (2) is there high likelihood of SB occlusion, or does the SB have significant disease at baseline? If the answer is yes to both, then I proceed with an upfront two-stent strategy.

Dr. Chatzizisis: My three keys include:

  • Anatomic complexity of the bifurcation (ie, involvement of main vessel and SB) (Medina classification)
  • Size of the SB: This should be > 2.5 mm to consider a two-stent technique
  • Length of disease in SB: This should be > 10 mm to consider a two-stent technique
  • Optional point: If using a planned two-stent technique, the risk of compromising the SB after stenting the main vessel dictates the need to stent the SB first

Dr. Paradies: My three main keys to decision-making in bifurcation PCI are lesion complexity, clinical relevance of the SB and its ischemic territory, and the bifurcation angle. Together, these factors help determine whether a simpler provisional approach is appropriate or whether a planned two-stent strategy should be pursued.

What are the main factors that guide your patient/lesion selection? What are your protocols for risk stratification?

Dr. Chatzizisis: Patient-related features include comorbidities, such as diabetes, cardiomyopathy, and chronic kidney disease. Lesion-related features include bifurcation anatomic complexity (true vs nontrue bifurcation, left main involvement, bifurcation angle, disease burden), SB relevance diameter (≥ 2.5 mm), SB disease length (≥ 10 mm), myocardial area supplied, and calcification burden and distribution, as increased calcium burden can increase risk of SB loss and stent underexpansion.

For risk stratification, use clinical and physiologic assessment (fractional flow reserve [FFR]/instantaneous wave-free ratio [iFR]), anatomic assessment using quantitative coronary angiography and/or cardiac CTA, and intracoronary imaging (optical coherence tomography [OCT]/intravascular ultrasound [IVUS]) for lesion preparation and choosing the appropriate stent platform, sizing, and technique. Some rules of thumb:

  • Use intracoronary imaging to better understand the bifurcation anatomy
  • Keep the procedure simple and safe (start with provisional technique and escalate accordingly)
  • Use an upfront two-stent strategy in the case of an anatomically complex bifurcation
  • Size balloons/stents to distal reference vessels
  • Achieve adequate stent expansion (proximal optimization technique, kissing balloon inflation)

Dr. Paradies: Several factors guide patient and lesion selection. The diameter of the SB and the amount of myocardium at risk are critical considerations, as are the extent of ostial disease, lesion length within the SB, overall plaque burden, calcification, and bifurcation angle. Clinical context also plays a role: patients presenting with acute coronary syndrome (ACS), hemodynamic instability, or significant comorbidities such as bleeding risk or reduced life expectancy require tailored strategies.

For risk stratification, I use structured complexity scores such as the Medina or DEFINITION criteria to classify lesions as simple versus complex, which helps guide whether to plan for a systematic two-stent strategy or stick with provisional stenting.1 The global anatomic burden can be quantified with the SYNTAX score, and distal left main lesions are often discussed with the heart team. Intravascular imaging (IVUS or OCT) is used routinely in left main and complex bifurcations to assess vessel size, plaque distribution, and landing zones and optimize stent sizing and expansion.2

Dr. Brilakis: The indication on whether to revascularize and perform PCI or not is based on patient clinical presentation. Briefly, for patients with chronic coronary syndromes, it is symptom improvement. For ACS patients, it is culprit lesion treatment and achievement of complete revascularization. PCI (and bifurcation PCI) is performed when the anticipated benefits exceed the potential risks.

When do you use anatomy-guided versus physiology-guided planning? And, what tips do you have for identifying or avoiding misleading findings?

Dr. Paradies: True bifurcation lesions are complex by definition and should be managed under intravascular imaging guidance, in line with current guideline recommendations.3 Imaging is particularly valuable for defining plaque composition and extension, which informs lesion preparation, and for assessing outcomes after crossover stenting.4 This is especially relevant in situations such as ostial circumflex lesions, where angiographic interpretation can be ambiguous.4

Dr. Brilakis: Physiology is used frequently both before and after stenting a bifurcation. Before, it is used to determine the functional significance of lesions, especially in the SB. After stenting, it is usually done to assess whether additional treatment is needed, in both the main vessel and, more commonly, the SB. FFRangio may be particularly useful for post-stenting SB assessment given frequent challenges with rewiring.

Dr. Chatzizisis: Physiology guidance can help when there are borderline lesions or uncertainty about SB involvement and its clinical impact. Use of invasive FFR/iFR or noninvasive tools such as FFRCT can help the proceduralist choose the optimal technique and avoid unnecessary SB stenting. FFRCT platforms can also model outcomes of provisional versus two-stent “virtual stenting.”

Below are some tips to identify and avoid misleading findings, which can lead to stent undersizing, stent underexpansion, SB compromise, or unnecessary SB stenting:

  • Use intracoronary imaging (OCT/IVUS), as angiography alone frequently underestimates the true complexity of bifurcation lesions.
  • Use evidence-based criteria for stenting strategy. Provisional stenting remains the preferred approach for most bifurcation lesions, but two-stent techniques might be superior in selected complex lesions with long SB involvement.
  • Use tools for invasive physiologic lesion assessment
  • Use cardiac CTA (when available) for preprocedural planning and FFRCT for anatomic and physiologic assessment and preprocedural planning.

Are you following any particular data, guidelines, or classifications to shape your overall decision-making process?

Dr. Brilakis: The most valuable documents on bifurcation PCI are from the European Bifurcation Club. We are also doing independent research on bifurcation PCI in the PROGRESS-Bifurcation registry that currently has ≥ 3,000 patients enrolled.

Dr. Chatzizisis: Our decision-making is based on the consensus documents published by the European Bifurcation Club.

Dr. Paradies: Yes, European Bifurcation Club consensus documents are an important reference, as they provide both practical technical guidance and stepwise provisional algorithms.5 In addition, we recently published an expert consensus document specifically on left main provisional stenting, aimed at providing practical recommendations on angiographic and imaging features to guide left main revascularization with either one or two stents.4

And, if data or guidelines do not exist for any particular real-world scenario you encounter, what do you do?

Dr. Chatzizisis: Integrate intracoronary imaging, physiology, and clinical judgment. As a rule of thumb for bifurcations that are not anatomically complex, start with a provisional technique and escalate to a second stent only for clear SB ischemia/flow compromise.

Dr. Brilakis: Use best clinical judgment and discuss in detail with the patient and the referring physician.

Dr. Paradies: In such cases, consensus documents often still provide useful algorithms, even if they are based more on expert experience than on randomized evidence. Provisional strategy with careful protection of the SB—wiring, small ballooning, and being prepared for bailout is usually a winning strategy, unless predefined criteria clearly point toward a planned two-stent approach. Intravascular imaging and physiology are relied upon to reduce uncertainty. Finally, my suggestion is to prefer the technique that the operator has mastered with the highest level of expertise.

Looking at the bifurcation PCI landscape as a whole, what trends in care are you seeing? How and why have these decisions evolved over time?

Dr. Brilakis: Current trends include increasing use of physiology and imaging; increasing use of coronary CT, which may soon provide percent of myocardial mass supplied by each branch; virtual bifurcation PCI planning, such as using HeartFlow (Heartflow, Inc.) and other platforms; high use of provisional stenting; and increasing familiarity of operators with more complex bifurcation stenting strategies.

Dr. Paradies: Provisional stenting continues to be the default strategy for most bifurcations, particularly those that are not complex. However, systematic two-stent strategies are gaining stronger support for truly complex bifurcations, as defined by the DEFINITION criteria, and for certain true left main bifurcations.1,6 Another important trend is the more routine use of intravascular imaging to guide planning and optimization, which has improved accuracy in sizing, stent expansion, and ultimately, clinical outcomes.2 This shift is largely driven by supportive evidence from randomized and registry data, as well as by advances in education and operator training.

Dr. Chatzizisis: Decision-making has evolved due to robust randomized controlled trials, which showed provisional stenting and planned two-stent techniques yield similar outcomes in most cases. However, appropriately performed two-stent techniques are associated with lower rates of major adverse cardiac events, target lesion revascularization, and stent thrombosis in anatomically complex bifurcation lesions. There is growing evidence and momentum toward the routine use of intravascular imaging, and physiologic lesion assessment. Practice has shifted from a one-size-fits-all strategy to a tailored, anatomy-specific approach. In parallel, the integration of real-time artificial intelligence–enabled decision support systems, and advanced imaging is expected to enable more rigorous risk stratification and transform the practice of bifurcation PCI.7,8

1. Zhang JJ, Ye F, Xu K, et al. Multicentre, randomized comparison of two-stent and provisional stenting techniques in patients with complex coronary bifurcation lesions: the DEFINITION II trial. Eur Heart J. 2020;41:2523-2536. doi: 10.1093/eurheartj/ehaa543

2. Holm NR, Andreasen LN, Neghabat O, et al. OCT or angiography guidance for PCI in complex bifurcation lesions. N Engl J Med. 2023;389:1477-1487. doi: 10.1056/NEJMoa2307770

3. Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45:3415-3537. doi: 10.1093/eurheartj/ehae177

4. Paradies V, Banning A, Cao D, et al. Provisional strategy for left main stem bifurcation disease: a state-of-the-art review of technique and outcomes. JACC Cardiovasc Interv. 2023;16:743-758. doi: 10.1016/j.jcin.2022.12.022

5. Burzotta F, Louvard Y, Lassen JF, et al. Percutaneous coronary intervention for bifurcation coronary lesions using optimised angiographic guidance: the 18th consensus document from the European Bifurcation Club. EuroIntervention. 2024;20:e915-e926. doi: 10.4244/EIJ-D-24-00160

6. Chen SL, Zhang JJ, Han Y, et al. Double kissing crush versus provisional stenting for left main distal bifurcation lesions: DKCRUSH-V randomized trial. J Am Coll Cardiol. 2017;70:2605-2617. doi: 10.1016/j.jacc.2017.09.1066

7. Samant S, Bakhos JJ, Wu W, et al. Artificial intelligence, computational simulations, and extended reality in cardiovascular interventions. JACC Cardiovasc Interv. 2023;16:2479-2497. doi: 10.1016/j.jcin.2023.07.022

8. Chatzizisis YS, Makadia J, Zhao S, et al. First-in-human computational preprocedural planning of left main interventions using a new everolimus-eluting stent. JACC Case Rep. 2022;4:325-335. doi: 10.1016/j.jaccas.2022.02.001