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SB/aSB occlusion
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MV stent oversized
No SB/aSB jailed wire
No SB/aSB predilatation in complex SB/aSB lesions:
a) SB/aSB stenosis >90%
b) Long SB/aSB lesion length >10 mm
c) Severe calcification
d) Bifurcation angle >75 degrees
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POT before SB/aSB rewiring attempt
Rewire the SB/aSB with a 3rd wire preferably assisted by a dual lumen microcatheter or another single lumen angulated or with deflectable tip microcatheter
Use of dedicated CTO wires
Pass a low-profile balloon on the jailed wire and dilate the SB/aSB (rescue balloon jailing technique)4
If a low-profile balloon cannot cross, the next step is trying to pass a Corsair Pro (Asahi Intecc) microcatheter and, if successful, retry the low-profile balloon
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MV stent sized to the dMV diameter
Jail wire into the SB/aSB
Modified jailed balloon technique33
Lesion preparation (NC balloons, cutting and scoring balloons, rotational and orbital atherectomy, IVL) in calcified CBL23
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dMV dissection
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MV stent oversized
Geographical miss
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Additional stent implantation in the dMV in case of significant stent edge dissection fulfilling specific criteria34
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MV stent sized to the dMV diameter
Avoid geographical miss
Intracoronary imaging (IVUS/OCT) provides valuable incremental information that can be used to avoid geographical miss
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Longitudinal stent deformation (especially in LM stenting)
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In LM stenting, the pull-back of a partially deflated balloon or the jailed wire may lead to forward movement of the guide catheter
In non-LM stenting, MV stent deformation is usually caused by the tip of a guide catheter extension (e.g., GuideLiner [Teleflex]) during the pull-back of a partially deflated balloon or of the jailed wire. Balloon tip or antegrade passage of a used device has a similar risk
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Imaging-guided detection by IVUS/OCT/stent enhancement techniques (stentviz, stent boost etc.) and correction by POT and, if required, additional stenting (stent-in stent)35
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In LM: backward traction (or sometimes near complete disengagement) of the guide catheter from the LM ostium36
Wait for full balloon deflation
Awareness of guide catheter extension interaction on device withdrawal, with retrograde traction of guide extension +/– guide catheter to minimise risk of deformation
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CBL: coronary bifurcation lesion; CTO: chronic total occlusion; dMV: distal main vessel; IVL: intravascular lithotripsy; IVUS: intravascular ultrasound; LM: left main; MV: main vessel; NC: non-compliant; OCT: optical coherence tomography; POT: proximal optimisation technique; PS: provisional stenting; SB/aSB: side branch/assigned side branch
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