Comment: The Balloon-Assisted Double-Kissing T-Stenting Technique: Concept, In Vitro Model, and Case Examples

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The Balloon-Assisted Double-Kissing T-Stenting Technique: Concept, In Vitro Model, and Case ExamplesJournal of the Society for Cardiovascular Angiography & InterventionsVol. 3Issue 7101928 We read with interest the article by Rinfret et al1Rinfret S. Verreault-Julien L. Croce K. The balloon-assisted double-kissing T-stenting technique: concept, in vitro model, and case examples.J Soc Cardiovasc Angiogr Interv. 2024; 101928https://doi.org/10.1016/j.jscai.2024.101928Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar about a novel technique called the balloon-assisted double-kissing T-stenting technique published in JSCAI; however, the article raises some issues that are worthy of being discussed. First of all, the technique itself appears to be, for the most part, the same as the nano-inverted T technique published years ago2Rigatelli G. Zuin M. Vassilev D. et al.Feasibility, safety and long-term outcomes of complex left main bifurcation treatment using the nano-inverted-t stenting: a multicentre prospective registry.Int J Cardiovasc Imaging. 2021; 37: 1107-1119https://doi.org/10.1007/s10554-020-02106-xCrossref PubMed Scopus (9) Google Scholar by our group as a modification of the nano-crush technique3Rigatelli G. Zuin M. Dell’Avvocata F. et al.Complex coronary bifurcation treatment by a novel stenting technique: bench test, fluid dynamic study and clinical outcomes.Catheter Cardiovasc Interv. 2018; 92: 907-914https://doi.org/10.1002/ccd.27494Crossref PubMed Scopus (15) Google Scholar and cited by the European Bifurcation Club consensus.4Lassen J.F. Albiero R. Johnson T.W. et al.Treatment of coronary bifurcation lesions, part II: implanting two stents. The 16th expert consensus document of the European Bifurcation Club.EuroIntervention. 2022; 18: 457-470https://doi.org/10.4244/EIJ-D-22-00166Crossref PubMed Scopus (53) Google Scholar That technique was conceived to minimize crushing of the side branch (SB) stent protrusion into the main vessel (MV) in order to offer a more physiologic profile compared with other double stenting techniques such as culotte stenting and double-kissing crush stenting5Rigatelli G. Zuin M. Marchese G. et al.Residence time in complex left main bifurcation disease after stenting.Cardiovasc Revasc Med. 2024; 61: 1-5https://doi.org/10.1016/j.carrev.2023.11.013Crossref PubMed Scopus (3) Google Scholar as assessed by bench studies and computational fluid dynamics. With our technique, the SB ostium has proven to be covered by both the SB stent itself and by the MV stent struts projecting into the SB. The nano-inverted T technique has been extensively applied to a wide range of bifurcation lesions, in particular the left main, showing very promising long-term outcomes.2Rigatelli G. Zuin M. Vassilev D. et al.Feasibility, safety and long-term outcomes of complex left main bifurcation treatment using the nano-inverted-t stenting: a multicentre prospective registry.Int J Cardiovasc Imaging. 2021; 37: 1107-1119https://doi.org/10.1007/s10554-020-02106-xCrossref PubMed Scopus (9) Google Scholar The technique outlined by Rinfret et al1Rinfret S. Verreault-Julien L. Croce K. The balloon-assisted double-kissing T-stenting technique: concept, in vitro model, and case examples.J Soc Cardiovasc Angiogr Interv. 2024; 101928https://doi.org/10.1016/j.jscai.2024.101928Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar proposes a similar approach with the difference being that the SB stent implantation is aided by the MV inflated balloon, as we usually do with the old T-stenting balloon technique. Unfortunately, using the T-stenting balloon technique causes the ostium of the SB to often be missed because the inflation of the MV balloon pushes the SB stent slightly away from the anatomic SB ostium, accounting for the poor results of T-stenting in real practice. Finally, the bench study associated with the clinical application of the Rinfret technique actually included very simple bifurcation angles, which do not appear challenging enough to prove that the technique effectively covered the ostium. This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.

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