Approach to complex bifurcation lesions in primary PCI

Coronary bifurcations are frequent and account for approximately 20% of all percutaneous coronary interventions. Nonetheless, they remain one of the most challenging lesion subsets in interventional cardiology in terms of a lower procedural success rate and increased rates of long-term adverse cardiac events. Provisional side branch stenting should be the default approach in the majority of cases and we propose easily applicable and reproducible stepwise techniques associated with low risk of failure and complications.Bifurcation lesion is seen in almost 25 percent of primary PCI cases and it doesn’t alter long term result of primary PCI. Drug-eluting stent (DES) implantation using the provisional approach is the gold standard for percutaneous treatment of patients with unselected bifurcated lesions. Nevertheless, many operators still consider the provisional approach unsuitable for coronary patients with complex bifurcation anatomies. Yet, the provisional approach may be so differently carried out that its procedural outcome is often unpredictable. Some technical renements may help to anticipate or manage procedural difculties, which may occur during the management of complex patients. We sought to overview the issues related with DES selection as well as some technical points, which may increase the effectiveness of provisional stenting. In particular, the DES characteristics inuencing bifurcation interventions and the technical renements, which may be considered during a provisional stenting procedure are discussed. Indeed, main vessel stent sizing, proximal optimisation, side branch protection modality, side branch rewiring, kissing balloon and side branch rescue techniques are all pivotal to increase the safety and efcacy of the provisional strategy especially in the setting of complex anatomies and patients.