Virtual stenting analyses for the assessment of side branch compromise after provisional stenting in coronary bifurcations

The treatment of coronary bifurcation lesions, which account for approximately 15-20% of total coronary lesions, represent a challenge for interventional cardiologists due to technical difficulties and associated high event rates [1]. The provisional side branch (PSB) stenting technique, which involves stent placement in the main branch (MB) with optional treatment of the side branch (SB), is nowadays the routine procedure to treat bifurcation lesions. Despite the high success rate of this technique, MB stent implantation can aggravate SB ostial stenosis, inducing SB compromise (Fig. 1), which is considered one of the main procedural complications of percutaneous coronary intervention in bifurcations [2].The severity of SB compromise can be difficult to assess with conventional angiography, which is routinely used in interventional cardiology. Angiographic images can show a significant lumen compromise, which cannot be accompanied by a hemodynamically significant compromise, as demonstrated by post-implantation fractional flow reserve measurements of the SB [3]. Several potential predictors of SB ostium occlusion after PSB stenting, such as MB calcified plaque and distal bifurcation angle, have been identified [4,5]. However, the exact contribution of bifurcation and lesion characteristics to SB occlusion has not been fully clarified and the results are contradictory. The aim of this study is to investigate the impact of plaque composition and distal angle on SB compromise after PSB stenting using a virtual implantation environment.