Kissing balloon or sequential dilation of the side branch and main vessel for provisional stenting of bifurcations: lessons from micro-computed tomography and computational simulations.
OBJECTIVE
This study sought to evaluate post-dilation strategies in bifurcation stenting.


BACKGROUND
In bifurcation stenting practice, it is still controversial how post-dilation should be performed and whether the kissing balloon (KB) technique is mandatory when only the main vessel (MV) receives a stent.


METHODS
A series of drug-eluting stents (DES) (n = 26) were deployed in a coronary bifurcation model following a provisional approach. After the deployment of the stent in the MV, post-dilation with the KB technique was compared with a 2-step, sequential post-dilation of the side branch (SB) and MV without kissing.


RESULTS
The percentage of the SB lumen area free of stent struts was similar after KB (79.1 ± 8.7%) and after the 2-step sequence (74.4 ± 11.6%, p = 0.25), a considerable improvement compared with MV stenting only without dilation of the stent at the SB ostium (30.8 ± 7.8%, p < 0.0001). The rate of strut malapposition in the ostium was 21.3 ± 9.2% after KB and 24.9 ± 10.4% after the 2-step sequence, respectively, a significant reduction compared with a simple SB dilation (55.3 ± 16.8%, p < 0.0001) or MV stenting only (47.0 ± 8.5%, p < 0.0005). KB created a significant elliptical overexpansion of the MV lumen, inducing higher stress concentration proximal to the SB. KB also led to a higher risk of incomplete stent apposition at the proximal stent edge (30.7 ± 26.4% vs. 2.8 ± 9.6% for 2-step, p = 0.0016).


CONCLUSIONS
Sequential 2-step post-dilation of the SB and MV may offer a simpler and more efficient alternative to final KB technique for provisional stenting of bifurcations.
Department of Bioengineering, Imperial College London, London, United Kingdom. nicolas.foin@ic.ac.uk
Nicolas
N
Foin
Ryo
R
Torii
Peter
P
Mortier
Mathieu
M
De Beule
Nicola
N
Viceconte
Pak Hei
PH
Chan
Justin E
JE
Davies
Xiao Yun
XY
Xu
Rob
R
Krams
Carlo
C
Di Mario
D003198:Computer Simulation; D017023:Coronary Angiography / Q000295:instrumentation* / Q000379:methods; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000473:pathology / Q000628:therapy*; D003331:Coronary Vessels / Q000473:pathology*; D054855:Drug-Eluting Stents; D020342:Finite Element Analysis; D006801:Humans; D057446:Hydrodynamics; D018570:Risk Assessment; D013997:Time Factors; D014057:Tomography, X-Ray Computed / Q000295:instrumentation