Abstract
Stepwise provisional stenting is the default strategy for most coronary bifurcation lesions, yet side-branch (SB) occlusion after main-vessel (MV) stenting still occurs in about 6-18% of cases and is associated with periprocedural myocardial infarction and adverse cardiac events. This review synthesises the 17th European Bifurcation Club consensus, registries and randomised trials (COBIS II, RESOLVE, CIT-RESOLVE, SMART-STRATEGY, Nordic-Baltic III, DEFINITION II, OCTOBER, DCB-BIF, KISS, DKCRUSH VIII) into a practical approach. Three principles emerge. First, the clinical relevance of the SB (reference diameter ≥ 2.0 mm, > 10% of myocardium) and its risk of occlusion (RESOLVE score) should be established before MV stenting. Second, prevention is the first step of bailout: a jailed wire, stent sizing to the distal MV, correctly positioned proximal optimisation (POT), active protection with a jailed balloon in high-risk anatomy, and planned two-stent techniques for complex lesions. Third, when SB flow falls to TIMI 0-1, a stepwise sequence is advised: stabilise, keep the jailed wire, re-POT, rewire through a distal cell and dilate with a small balloon; if rewiring fails, a low-profile balloon or microcatheter is advanced over the jailed wire, and reverse crush is a last resort. Once TIMI 3 flow is restored without ischaemia or major dissection, further SB treatment can be withheld; SB stenting, preferably T and small protrusion (TAP), is reserved for persistent flow limitation, dissection or ischaemia. No randomised trial has yet defined the optimal bailout sequence, so the proposed algorithm should be individualised.
