Perforation Management in Bifurcations: Bench Testing of Bailout with Covered Stents

Coronary perforations during PCI are one of the most dreaded complications in interventional cardiology, especially in bifurcations. Though rate, this critical situation requires an immediate response and the use of covered stents has been shown effective and safe for rupture sealing. 

However, when there is a perforation at bifurcation level with relevant side branch jailing, there are additional technical challenges. There is limited data available, with isolated case reports and no systematized, clearly defined strategy. 

The study presented by Hemetsberger et al. addresses this gap by bench testing the viability of different side branch recanalization and reconstruction techniques after covered stent implantation. 

Using silicone models with standard 70° bifurcations, four perforation and bailout scenarios were simulated:

• Main branch covered stent crossover with side branch exclusion
• Side branch ostium optimization with culotte technique using a DES
• Covered stent implantation both in main and side branches
• Final optimization with DES after implantation of two covered stents

Read also: EMERALD II: Non-Invasive Coronary Anatomy and Physiology (CCTA) in ACS Prediction.

To cross the stent membrane, tip load wires were used (≥12 g) and an angulated micro-catheter (Supercross 120°). Post intervention morphologic assessment was done using optical coherence tomography and angioscopy.

These techniques were successfully implemented in all experimental models. High tip-load wires allowed effective cover penetration in less than 60 seconds (Confianza Pro 12 and Infiltrac Plus 14). Simple fenestration generated overhang material towards side branch ostium, with approximately 25% lumen reduction, a situation effectively corrected with additional DES implantation using the Culotte technique, improving lumen area by at least 8%. Similar results were observed in the main branch after DES optimization following dual covered stent implantation.

Conclusions

This bench test has shown that when managing coronary perforations in bifurcations with side branch exclusion, flow restitution is technically feasible using tip-load wires and optimizing outcomes with drug eluting stent techniques, such as culotte. Even though these are lab scenarios, the observed technical feasibility suggests potential clinical application in emergency contexts. 

Original Title: Bench Testing Analysis of Perforation Management in the Setting of Bifurcation Coronary Intervention.

Reference: Hemetsberger R, Maaroufi A, Hamzaraj K, Andreka J, Abdelghani M, Farhan S, Lootz D, Gollmer J, Mankerious N, Hengstenberg C, Johnson TW, Toth GG. Bench Testing Analysis of Perforation Management in the Setting of Bifurcation Coronary Intervention. Catheter Cardiovasc Interv. 2025 Dec 12. doi: 10.1002/ccd.70406. Epub ahead of print. PMID: 41387216.