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Final kissing balloon inflations after main vessel stenting in coronary bifurcations: not always, but sometimes
  1. David Hildick-Smith
  1. Correspondence to Dr David J R Hildick-Smith, Cardiology Department, Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton BN2 5BE, UK; david.hildick-smith{at}

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This is not a great time for bifurcation stenting trials. All manner of intellectually attractive bifurcation stent strategies have been studied, and all have demonstrated major weaknesses.1–5 Indeed, the simplest strategy of all, in which the side branch is essentially invited to look after itself, has proved the most durable and reproducible.6 This, presumably, is because any technique that takes a geometrically rigid stent design, and tries to deform and then reconfigure it within a coronary bifurcation, is likely to be found wanting in some respects.7 8

As with the branches of a tree, coronary bifurcations obey Murray's law (and some would say Murphy's too). That is to say, the diameter of the proximal parent vessel is two-thirds the sum of the diameters of the daughter vessels. It may therefore be surprising that the ‘super simple’ strategy, in which a single stent is placed in the main vessel before and beyond the bifurcation, is so successful, given that the relevant reference vessel diameters are different. Surely there should be significant stent strut failure of apposition in the proximal segment? The fact that the complication rate is so low using this unsophisticated technique is no doubt testament to the robustness of human physiology despite differential apposition of the stent proximal and distal to the bifurcation.

Systematic two-stent strategies have not proved superior as default treatment options.3 5 While there are some anatomies in which two-stent strategies may have advantages (eg, where the side branch merits stenting in …

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