Tips and Tricks in Interventional Therapy of Coronary Bifurcation Lesions PDF

Preface

Themark ofmediocrity inwrittenmaterial,whether it is literature, politics, or medicine, is to rely heavily on precedents; so whatever is previouslywritten about a topic is written again and again propagating the same narratives. This statement may seem irrelevant to the topic of coronary bifurcation lesions, and to medical writing in general, because we are in the era of "evidencebased medicine" and written medical literature need to be supported by "evidence" and not merely reflect opinions and anecdotal experience. In reality, however, what is occasionally offered as "evidence" does not qualify as an undisputable guide for clinical or technical decision making.

There is no topic in Interventional Cardiovascular Medicine where this "disconnect" is more relevant than that of interventional treatment of coronary bifurcation lesions. The narrative that has been propagated in the literature is that provisional stenting (stenting the main vessel, with additional stenting of the side branch only in the case of an unsatisfactory result) is better than elective double stenting of both branches. This narrative states no exceptions to the rule, as it applies to all patients with coronary bifurcation lesions irrespective of bifurcation anatomy. Advocates of this narrative base their supposition on the results of several prospective randomized controlled trials. This narrative, however, overlooks fundamental problems in the design of these clinical trials, which makes its generalizability to all patients with coronary bifurcation lesions problematic.

The goal of this book is to present the reader with a patient-centered approach to technical decision making in the interventional treatment of coronary bifurcation lesions. In doing so, we relied on evidence when it was of high quality and relevant, and we relied on experts' opinion and judgment when high-quality evidence was lacking. The first section of the book is devoted to the fundamentals of decision making with regard to interpretation of the existing evidence (chapter 1) and understanding the role of bifurcation anatomy in impacting technique choice and outcomes (chapter 2). The subsequent chapters are devoted to technical decision making with regard to tailoring technical approaches to bifurcation anatomy for patients with left main and non–left main coronary bifurcation lesions. A particular emphasis is placed on providing practical tips and tricks to optimize the results and deal with complications, all in the context of actual case presentations. The last section of the book is devoted to the role of in vitro bifurcation modeling and the current state of dedicated bifurcation stent systems.

Ultimately,we hope that this book will be a useful resource for interventional cardiologists who thrive to treat their patients as unique individuals whomay not fit the profile represented in a given randomized clinical trial. Technical decision making in these patients requires individualized judgment, utilizing pragmatic interpretation of the evidence and applying techniques tailored to the individual patient.