Editorial Comment

Bifurcation Lesions: AContinuing Challenge for theTreatment du Jour

David A. Clark, MD

Clinical Professor of Medicine (Cardiology),Stanford University School of Medicine,Stanford, California

Bifurcation lesions have long been one of the mostdifficult areas to solve with catheter-based techniques.Unique and clever twists have been tried on the treatmentof the day to solve the bifurcation problem. From bra-chial and femoral guiding catheter approaches with kiss-ing balloon angioplasty, through atherectomy, laser, rota-blator, and cutting balloon debulking as well as thevarious stenting styles to preserve the bifurcation—T-stenting, Y-stenting, reverse Y-stenting, Culotte stenting,D-stenting—the bifurcation lesion continues to tease,confound, and exasperate the interventional cardiologist.Immediate rebound narrowing at the origin of the smallervessel is not uncommon and higher rates of restenosis areseen in both vessels postinterventional procedures.

The present case [1], while on the surface disappoint-ing, offers a measure of hope for the bifurcationallychallenged vessel. The use of drug-eluting stents (seeabove: Treatment du Jour) was thought likely to solve therestenosis problem, a problem that will probably never becompletely eliminated. Drug-eluting stents should, how-ever, decrease the restenosis rates and lesions of allanatomic variations and in patients with all combinationsof risk factors. The case presented in this article empha-sizes the concept that the reduction in restenosis rateswith these new wunderkinder of Gruentzig is contingent

upon full expansion, even overexpansion of the stents toachieve the expected success of the procedure.

From this case, an argument could be made for post-dilitation intravascular ultrasound examination of the ar-tery (arteries) to ensure full expansion and optimal result.This postdilitation examination was attempted in thiscase, but passage of the intravascular ultrasound cathetercould not be accomplished. This may have been due tothe later-discovered stent underexpansion but is also acommonly encountered problem with intravascular ultra-sound catheters inherent to the design of the currentcatheters available. To aid in the ultrasound examinationof bifurcation lesions where the catheter has to passbetween stent struts as well as tortuous calcified arteries,catheter companies should be encouraged to design abetter intravascular ultrasound catheter with a longer railto aid in the success of the intravascular ultrasoundprocedure.

The fact that various factors resulted in restenosis instented bifurcation disease in this elegantly performedprocedure emphasizes the continuing difficulty with thebifurcation abnormality that has plagued interventional-ists through the years. I have no doubt that in future yearswhen athersclerotic Draino is developed and used toclean out arteries (a commonly requested procedure frompatients), the eddy currents produced at a bifurcationpoint will lessen the success of that futuristic techniqueas well.

REFERENCE1. Takebayashi H, Kobayashi Y, Dangas G, Fujii K, Mintz G, Stone

G, Moses J, Leon M. Restenosis due to underexpansion of siroli-mus stent in a bifurcation lesion. Catheter Cardiovasc Interv 2003;60:496–499.

DOI 10.1002/ccd.10717Published online in Wiley InterScience (www.interscience.wiley.com).

Catheterization and Cardiovascular Interventions 60:500 (2003)

© 2003 Wiley-Liss, Inc.