Bench Testing Analysis of Perforation Management in the Setting of Bifurcation Coronary Intervention

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BACKGROUND: Management of coronary perforation in bifurcation lesions with covered stents remains challenging. AIMS: We aimed to describe a proper practice and toolbox for "jailed-branch" management after covered stent deployment. METHODS: Using a bench model, we tested various wires with a 120° angulated microcatheter for their ability to penetrate covered stents to access jailed side branches (SB). Next, four PCI techniques were assessed: Test #1 (main branch [MB] rupture simulation): MB covered stent, graft penetration, and kissing balloon inflation (KBI) (n = 7). Test #2: Test #1 completed with Culotte using a drug-eluting stent (DES) (n = 3). Test #3: Culotte with two covered stents simulating MB and SB rupture (n = 3). Test #4: Test #3 plus final DES in MB (n = 3). RESULTS: High tip-load wires ( > 12 g) successfully penetrated covered stents within 14 s. All procedures were completed successfully. Test #1 showed lumen area reductions of -8% (MB) and -25% (SB), with graft overhang at the SB. Conversion to Culotte with DES (Test #2) improved SB lumen reduction to -8%. Test #3 showed reductions of -7% (MB) and -15% (SB), with graft overhang at MB, corrected in Test #4 by DES implantation, resulting in +9% lumen gain (MB) and improved SB lumen reduction (-11%). CONCLUSION: In this bifurcation perforation in-bench model, high tip-load wires effectively penetrated covered stents toward excluded branches after crossover covered stent implantation. Conversion to Culotte, using either a DES or a second covered stent, was feasible. Overhanging graft material following SB fenestration could be addressed by overstenting with a DES.

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