Managing Non-left Main Bifurcation Lesions

By Amit Goyal, MD - August 18, 2023

An article written by Calik et al, “An Approach to Non-left Main Bifurcation Lesions: A Contemporary Review,” was recently published in US Cardiology Review, the official journal of The CardioNerds.1

In it, the authors examine the current evidence and guidelines on the management of non-left main bifurcation lesions, which are commonly occurring and challenging coronary lesions that may require percutaneous coronary intervention (PCI). The authors discuss the anatomy, classification, and assessment of bifurcation lesions, as well as the different techniques, devices, and strategies for optimal PCI outcomes. They also provide practical recommendations based on the latest trials and expert consensus. Their analysis offers several key takeaways.

Coronary bifurcation lesions (CBLs) are among the most challenging complex coronary interventions, with diverse anatomical and pathological features that require dynamic alterations during the procedure. The optimal treatment strategy for CBLs depends on several factors, including the lesion characteristics, the side branch (SB) significance, the operator’s experience and preference, and information gained from intracoronary imaging and physiological assessment.

The main stenting techniques for CBLs are provisional SB stenting and upfront 2-stent strategies. Provisional SB stenting is recommended as the primary approach in most cases. It involves stenting the main branch (MB) first and then performing SB intervention only if needed. The advantages of this technique are its simplicity, lower cost, lower risk of stent thrombosis and restenosis, and generally better long-term outcomes compared with 2-stent strategies.

The main challenges of provisional SB stenting are the risk of SB occlusion or compromise during MB stenting, the difficulty of SB rewiring and recrossing after MB stenting, and the suboptimal results of SB balloon angioplasty or kissing balloon inflation (KBI).

Two-stent strategies are typically reserved for complex bifurcations with a significantly diseased SB that supplies a crucial myocardial territory. Upfront 2-stent strategies involve an initial plan to stent both branches. The advantages of this technique are the preservation of SB patency and flow, the avoidance of SB rewiring and recrossing, and the improved acute angiographic results compared with provisional SB stenting.

The main challenges of upfront 2-stent strategies are the complexity of the procedure, the higher cost, the higher risk of stent thrombosis and restenosis, and the lack of clear evidence of superiority over provisional SB stenting in terms of clinical outcomes.

The most commonly used 2-stent strategies are T-stenting, T-and-protrusion stenting, crush stenting, culotte stenting, V-stenting, simultaneous kissing stents, and double-kissing crush stenting. Each strategy has its own advantages and disadvantages, and no single strategy has been proven to be superior to others in all scenarios.

Intracoronary imaging, such as intravascular ultrasound or optical coherence tomography can provide valuable information for CBL treatment, such as lesion assessment, optimal stent sizing and expansion, optimal stent apposition and alignment, optimal KBI results, and detection of complications.

The optimal treatment strategy for CBLs should be individualized based on a comprehensive evaluation of all relevant factors and careful consideration of the risks and benefits of each technique. A stepwise approach that starts with provisional SB stenting and progresses to 2-stent strategies, if needed, may be preferable in most cases.

Future studies are needed to compare different stenting techniques for CBLs using standardized definitions and classifications, large sample sizes, long-term follow-up, hard clinical end points, and intracoronary imaging guidance.

US Cardiology Review is the official journal of The CardioNerds. It’s mission is to democratize cardiovascular publishing, and publication fees are waived for a limited time. Submit your articles online here.


  1. Calik AN, Cader FA, Rafflenbeul E, et al. An approach to non-left main bifurcation lesions: a contemporary review. US Cardiol Rev. 2023. doi:10.15420/usc.2022.25
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