Division of Cardiology, St. Mary's General Hospital, Kitchener, Ontario, Canada.
Division of Cardiology.
Curr Opin Cardiol. 2020 Sep;35(5):574-582. doi: 10.1097/HCO.0000000000000775.
Coronary artery disease affecting bifurcations poses a challenge for percutaneous intervention. Several techniques and strategies for percutaneous management of bifurcation lesions have been described in the literature with variable data available for outcomes. In this review, we provide an overview of the strategies and techniques used for percutaneous intervention of bifurcation lesions with an update of recent technical developments and clinical evidence.
The coronary bifurcation lesions of both left main and other coronary segments are best treated with a provisional stenting strategy where main branch is treated with a stent placement and side branch intervention reserved for angiographically or physiologically determined hemodynamically significant residual stenosis despite application of a proximal stent optimization technique. When a provisional stent strategy is not likely to be successful due to anatomic or morphologic lesion characteristics and a large side branch or distal left main bifurcation is involved, an upfront bifurcation stenting strategy with double kissing crush technique may provide the optimum results. Coronary imaging and fractional flow determination may guide lesion specific management, facilitate device selection and improve clinical outcomes for percutaneous therapy for bifurcation lesions.
Despite advances in technology and procedural techniques, percutaneous intervention of coronary bifurcation lesions remains challenging and associated with higher adverse outcomes compared to non bifurcation lesions. Among the several bifurcation strategies, a provisional stenting approach is preferred for technical simplicity and better long term outcomes. Double kissing crush technique provides superior clinical results and should be preferred when a two stent strategy is indicated. Use of coronary imaging and physiology assessment should be incorporated in the algorithm of bifurcation interventions for greater technical and clinical success.
影响分叉的冠状动脉疾病给经皮介入治疗带来了挑战。文献中已经描述了几种经皮处理分叉病变的技术和策略，但对于结果，可用的数据各不相同。在这篇综述中，我们概述了用于经皮介入分叉病变的策略和技术，并更新了最近的技术发展和临床证据。
左主干和其他冠状动脉节段的分叉病变最好采用临时支架策略进行治疗，其中主支采用支架置入，侧支干预保留用于血管造影或生理学确定的血流动力学意义上的残余狭窄，尽管应用了近端支架优化技术。如果由于解剖或形态病变特征以及大的侧支或远端左主干分叉而不太可能成功采用临时支架策略，则采用双吻压术的 upfront 分叉支架策略可能提供最佳结果。冠状动脉成像和分数流量测定可指导病变特异性管理，促进器械选择，并改善经皮治疗分叉病变的临床结果。
尽管技术和程序技术有所进步，但与非分叉病变相比，经皮介入治疗冠状动脉分叉病变仍然具有挑战性，并且相关的不良结局更高。在几种分叉策略中，临时支架方法因其技术简单性和更好的长期结果而受到青睐。当需要采用双支架策略时，双吻压术提供了更好的临床结果，应优先考虑。在分叉干预的算法中应纳入冠状动脉成像和生理学评估，以提高技术和临床成功率。
