The “mini‐crush” technique for managing bifurcation lesions

The ‘‘mini-crush’’ is one of various techniques used to treat atherosclerotic coronary bifurcation lesions. This method was designed primarily to treat complex bifurcation lesions in cases where atherosclerotic disease involves both the side branch (SB) and the main branch (MB) [1]. The ‘‘mini-crush’’ is a ‘‘two-stent’’ technique that represents an alternative to a provisional ‘‘single stent’’ approach to catheter-based management of bifurcation lesions [2]. The provisional technique involves single stent placement in the MB with the option to add another stent in the SB according to intra-procedural need (e.g., plaque shift, SB dissection and/or abrupt closure, flow limitation, etc.) [3]. In catheter-based bifurcation management, key goals are to optimize the angioplasty outcome and assure long-term bifurcation patency without making the procedure unduly complicated from a technical standpoint. These goals can be accomplished using either a provisional single-stent approach with an optional two-stent bailout strategy or an a priori planned two-stent technique with one of several stenting options, such as the T or Y techniques or using the ‘‘mini-crush’’ strategy. About one-third of patients will require a twostent strategy [4]. The ‘‘mini crush’’ technique was designed to provide complete coverage of the ostium of the SB while minimizing the length of the crushed segment [5]. In the ‘‘mini-crush’’ paradigm, both the MB and the SB are wired and pre-dilated using balloons. A 7 or even 8 French guiding catheter is recommended to allow a large space for catheter equipment delivery. Next, one stent each is delivered to the SB and the MB, in that sequence. The SB stent is brought to the midline crossing point of the MB stent, using the proximal marker of the SB stent as an indicator to assure a contact and even minimal overlap with the MB stent. This short overlapping segment will later become the SB ‘‘mini crushed’’ segment. When both of the stents have been appropriately positioned, the SB stent should be deployed at nominal or even supranominal pressure. Then, the delivery balloon of the SB stent is drawn backward and an additional act of ‘high pressure’ dilatation of the SB ostium is recommended. This maneuver should assure optimal apposition and even some flaring of the stent in the SB ostium, and prevent narrowing or separation of the stent during subsequent MB stent dilatation. Then, the SB wire is removed in order to prevent irreversible ‘‘jailing’’ of the wire, and the MB stent is dilated and deployed across the SB at a nominal or even higher pressure (i.e. pending the distal reference diameter). Next, the guide wire is reinserted into the SB ostium in order to introduce a low-profile balloon through the crushed segment. Recrossing of the SB ostium using a wire and/or balloon can be technically challenging. This step will allow for subsequent redilation of the bifurcation carina and the SB ostium. Initially, the SB and MB stents can be dilated separately at a relatively high-pressure followed by a final simultaneous ‘‘kissing’’ balloon dilatation of the treated bifurcation segment. Some operators may even use non-compliant balloons for this endeavor. This final kissing balloon dilatation step is mandatory in order to avoid stent distortion and improve shortand long-term angiographic, procedural, and clinical event-free outcomes at the treatment site [6]. Figure 1 shows a case example to highlight the key principles involved in the ‘‘minicrush’’ strategy for bifurcation lesion management. The ‘‘mini-crush’’ strategy for managing bifurcation lesions has both advantages and some potential limitations. The strategy is a fusion of the modified-T stenting technique in which no crush is allowed and a fully ‘‘crushed’’ stenting approach that involves a longer crushed segment. This ‘‘mini-crush’’ technique assures full coverage of the bifurcation carina between the proximal part of the MB stent edge and the origin of the SB ostium at any angle and without gap formation between the stented limbs. This technique has been shown to be associated with good shortand long-term angiographic