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Archives of cardiovascular diseases
Sous presse. Epreuves corrigées par l'auteur. Disponible en ligne depuis le vendredi 31 janvier 2020
Doi : 10.1016/j.acvd.2019.11.003
Received : 23 September 2019 ;  accepted : 5 November 2019
Toward a sequential provisional coronary bifurcation stenting technique. From kissing balloon to re-POT sequence
Vers une nouvelle technique séquentielle de bifurcation: le re-POT
 

François Dérimay a, , Gilles Rioufol a, Adel Aminian b, Luc Maillard c, Gérard Finet a
a Department of Interventional Cardiology, Cardiovascular Hospital and Claude-Bernard University, INSERM Unit 1060 CARMEN, Lyon, France 
b Cardiology Department, CHU Charleroi, Charleroi, Belgium 
c GCS ES Axium Rambot, Aix-en-Provence, France 

Corresponding author. Fédération de Cardiologie Médicale, Hôpital Cardiologique Lyon, 69394 Lyon, France.Fédération de Cardiologie Médicale, Hôpital Cardiologique LyonLyon69394France
Summary

The specific anatomy of coronary bifurcations makes them prime sites of atherogenesis and complicates revascularization. Account must be taken of the systematic difference in diameter between the 3 constituent vessels so as to minimize final side-branch ostium obstruction and maintain the law of conservation of flow, while respecting the bifurcation angles. Kissing balloon inflation (KBI) was long recommended, but never clearly demonstrated clinical benefit in single-stent provisional stenting. The detrimental proximal overstretch induced by simultaneous inflation of balloons, observed clinically and confirmed experimentally, probably explains this inefficacy. Advances in knowledge of bifurcation pathophysiology and experimental bench studies gradually led to the development of a new purely sequential technique, re-POT, without balloon juxtaposition, comprising 3 successive steps: (1) initial “proximal optimization technique” (POT), (2) side-branch opening, and (3) final POT. In contrast to KBI, re-POT has been progressively assessed from bench to first clinical study. The aim of the present review is to present the pathophysiological specificities of coronary bifurcations, and some explanations for the failure of KBI which led to the development of a new purely sequential coronary bifurcation provisional stenting strategy, based on re-POT.

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Résumé

L’anatomie spécifique des bifurcations coronaires y favorise l’athérogenèse tout en en compliquant la revascularisation. Il est ainsi nécessaire de prendre en compte la différence systématique de diamètres entre les 3 vaisseaux afin de minimiser l’obstruction ostiale de la branche accessoire et de maintenir la loi de conservation du débit tout en respectant les angles de bifurcation. Le Kissing Balloon Inflation (KBI) a longtemps été recommandé, cependant sans jamais avoir clairement démontré de bénéfice clinique lors de la stratégie de première intention du provisional stenting (implantation d’un seul stent). La sur-dilatation proximale après inflation simultanée des ballons, observée cliniquement et confirmée expérimentalement, explique probablement cette absence de bénéfice. L’amélioration des connaissance de la pathophysiologie des bifurcations et l’expérimentation sur banc fractal ont progressivement permis le développement d’une nouvelle technique purement séquentielle, re-POT, sans juxtaposition de ballons, composée de 3 étapes distinctes: (1) « proximal optimization technique » (POT) initial, (2) ouverture de la branche accessoire, et (3) POT final. Au contraire du KBI, re-POT a été progressivement évalué, d’abord sur banc avant la réalisation d’une première étude expérimentale. Cette revue a pour but de présenter les spécificités physiopathologiques des bifurcations coronaires et les principales explications de l’échec de KBI qui ont conduit à la mise au point d’une nouvelle stratégie purement séquentielle de provisional stenting des bifurcations coronaires, basée sur le re-POT.

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Keywords : Bench experimentation, Proximal optimization technique.

Mots clés : Expérimentation sur banc d’essai, Technique d’optimisation proximale.

Abbreviations : CI, DES, DMB, DMoV, DSB, EBC, ESS, HK, IVUS, KBI, MB, MoV, OCT, OR, POT, SB, TIMI, TLR




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