Balloon crush: New tool in bifurcation treatment armamentarium

The first consideration when dealing with a bifurcational lesion is whether to use one or two stents. An appropriate and timely taken decision will affect the result and help save time and cost and lower the risk of complications. When we decide to stent only the main branch, there is a possibility to place a second stent on the side branch in case of suboptimal result in the side branch (provisional stenting). Using this approach, Lefevre et al. [1] reported stenting the branch in approximately 30% of cases when final kissing balloon inflation was systematically performed. However, this approach has inherent limitations; it does not allow performance of some techniques, such as the V-stenting, and sometimes may make recrossing into the side branch difficult, if not an impossible, task. When decision is made to stent both vessels at the beginning of the procedure, several implantation techniques have been proposed, but with bare metal stents, long-term clinical outcome was regularly affected by the higher risk of restenosis [2–4]. The use of drug-eluting stents significantly reduced the incidence of angiographic restenosis in the Bifurcations Study (Randomized Study to Evaluate Sirolimus-Eluting Stents Implanted at Coronary Bifurcation Lesions), but also revealed the prevailing occurrence of restenosis at the ostium of the side branch [5]. In that study, the technique utilized to perform double stenting was the T-technique. The frequent recurrence of stenosis at the ostium of the side branch and known limitation of the T-stenting technique to leave a small gap between the main branch and the ostium of the side branch was considered a contributing factor for restenosis. To overcome that problem, we designed a new technique for stenting bifurcation lesions: modified T-stenting with crush [6]. The main advantage of this technique, except for the better coverage of the side branch ostium, is its simplicity and immediate patency of both branches. However, our early experience without side branch stent postdilatation and final kissing inflation showed restenosis at the ostium of the side branch in about one-third of the patients [7]. Gaining experience with this technique resulted in development of several modifications of the crush stenting for specific anatomical and clinical settings (reverse, inverted, and step crushing). For example, in some instances, the operator may decide to defer stenting the side branch following an evaluation of the final result after main branch stenting and balloon angioplasty of the side branch (after final kissing inflation). If the final result at the ostium of the side branch is considered unsatisfactory, it is still possible to perform a crushing technique toward the side branch (reverse or provisional crushing). The operator will advance a stent into the side branch and then a balloon in the main branch. The stent in the side branch will be positioned to protrude slightly into the main branch and deployed. The balloon and the wire will be removed from the side branch and the balloon in the main branch will be fully inflated to crush against the wall of the main branch the protruding struts of the side branch stent. A final step will be recrossing toward the side branch to perform high-pressure balloon inflation in the side branch and then a final kissing inflation. The availability of the Taxus stents mounted on the Maverick balloon (Boston Scientific, Natick, MA) allows performing the reverse crushing technique with a 6 Fr guiding catheter. In this issue, Lim and Dzavik [8] present the balloon stent crush technique as another modification of the crush stenting for use in a 6 Fr guiding catheter suitable for radial approach. Traditional crush stenting has been adapted by initially placing a stent in the side branch and a balloon in the main branch. Following deployment of the side branch stent, protruding struts are crushed with the balloon inflated in the main vessel. The main branch is then stented and the side branch recrossed for kissing balloon inflation. The technique was used in seven patients without problems of side branch recrossing and kissing balloon inflation in cases where it was attempted and without major procedure-related complications. To enhance successful side branch recrossing, as potential advantage of this approach, authors propose variation to recross the side branch immediately after the balloon