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Chapter 38. Complex Lesion Intervention: Bifurcation, Left Main Coronary Artery, and Ostial Lesions

Which bifurcation stenting technique has a risk of incomplete side branch coverage?

A. Culotte technique

B. T-stenting technique

C. Crush technique

D. Simultaneous kissing stent technique

E. Double kissing crush technique

The correct answer is B

T-stenting technique is the most commonly used approach in the provisional stenting strategy, in which a single main vessel stent is deployed, with side branch stenting only used in cases of suboptimal angiographic results. A technical consideration with T-stenting is the angulation of the side branch relative to the main vessel. Lesions that more closely resemble a true “T” configuration with a side branch angulation >70° will enable better coverage of the entire side branch than lesions with less angulation, which may carry a risk of incomplete side branch ostium coverage. The side branch ostium is the most common site for angiographic restenosis following stenting of bifurcation lesions, which is why adequate coverage of this region is important.

Which anatomic feature of distal left main bifurcation would be favorable for a 2-stent strategy rather than single stenting?

A. Wide angle with left anterior descending artery

B. Left circumflex artery <2.5 mm in diameter

C. Medina classification 1,0,1

D. Right dominant coronary artery system

The correct answer is C

For distal left main bifurcation disease, the possibility of circulatory collapse after main vessel, attributable to the large myocardial volume supplied by the left circumflex artery in many patients, is always a concern. This is why 2-stent techniques are chosen relatively more frequently for left main bifurcation lesions than for non–left main lesions. In general, the provisional 1-stent approach would be preferred for left main bifurcations with insignificant stenosis at the ostial left circumflex artery or a nondominant left coronary system, whereas the elective 2-stent technique is preferred in patients with significant ostial stenosis of the left circumflex artery with a dominant left coronary arterial system. Medina class of 1,0,1 refers to a presence of significant stenosis at the side branch, a situation in which a 2-stent strategy should be considered.

What site is most common for restenosis after distal left main stenting, and what is the intravascular ultrasound minimal stent area criterion to predict restenosis at that site?

A. Left circumflex artery ostium, 5.0 mm2


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