Proximal Side-Branch Optimization in Crush Stenting: A Step-by-Step Technical Approach in a Silicone Phantom Model

Provisional single drug-eluting stent (DES) strategy remains the standard of care in simple bifurcation lesions which comprise the vast majority of coronary bifurcations. Nevertheless, the presence of complex bifurcations which are defined based on the 1) Side Branch (SB) lesion length of >10 mm and 2) SB ostial diameter stenosis of >70% are approached with a 2-DES strategy upfront. The bifurcation angle will further define the most appropriate technique, with T-stenting more suitable in angulations close to 90°, Culotte and the family of Crush techniques more appropriate for acute angles of <75°. The Crush techniques which are composed of the classic Crush, mini-Crush and double kissing Crush (DK-Crush) share the core principle of protruding the SB DES within the Main Branch (MB) to minimize the risk of ostial SB restenosis, which remains the most prevalent etiology of stent failure during 2-stent approach in bifurcations. Proximal Side Optimization (PSO) is an additional technical consideration to further optimize the protruding SB struts enabling 1) optimal SB strut accommodation to the larger MB vessel diameter, 2) strut enlargement that will further facilitate effortless rewiring for kissing balloon inflation (KBI) avoiding unfavorable guide wire advancement in the peri-ostial SB area.