[Renal denervation by trans-radial access for resistant hypertension]. / Dénervation rénale par voie radiale pour le traitement d'une hypertension artérielle résistante.

Renal denervation which consists in the ablation of the sympathetic fibers located in the adventitia of renal arteries is a therapeutic strategy allowing improved arterial hypertension control in patients who do not respond to medical treatment. This technique is currently performed using the femoral approach in the majority of cases. The diameter and the length of the ablation catheters limit their use via the radial route. The most frequent peri-procedural complications are vascular problems. We report here two cases of renal denervation via the trans-humeral and trans-radial routes respectively.

[Renal denervation a treatment for resistant hypertension: a French experience]. / La dénervation rénale un traitement pour l'hypertension artérielle résistante : expérience française.

Arterial hypertension is the largest single contributor to global mortality, and is poorly controlled in approximately 50% of patients despite lifestyle and pharmacologic interventions. Randomized clinical trials have demonstrated that catheter-based renal sympathetic denervation reduces blood pressure (BP) in patients with resistant hypertension. We sought to evaluate the efficacy of this novel therapy in "Real World" clinical practice. Consecutive patients with treatment-resistant primary hypertension, as defined as home BP>160 mmHg despite treatment with ≥3 antihypertensive drugs, were selected for denervation following renal artery screening. Ambulatory and home BP monitoring was performed in all patients prior to and following percutaneous renal sympathetic denervation. In total, 35 patients were selected for catheter-based renal sympathetic denervation. The mean age was 63.6 ± 11.7 years, 37.1% were women, 37.1% were diabetic, and 11.4% had renal impairment (GFR<45 mL/min). The basal BP (home or ambulatory) was 179.1 ± 20.75/99.66 ± 19.76 mmHg, despite an average of 4.91 ± 0.98 medications per patient. Successful bilateral sympathetic denervation was performed in 33/35 patients (1 renal artery stenosis on angiography [not ablated], 1 patient with renal artery spasm [unilateral denervation]), with an average 5.9 ± 1.6 ablations per renal artery. No procedural complications occurred. At 6 months, blood pressure was 15.5 ± 22.37/87.76 ± 13.97 mmHg (P<0.01). At 2 years follow-up, systolic blood pressure (ABPM or Home BP) was 143.8 ± 15.30 mmHg (P<0.0001) and diastolic 83.42 ± 12.80 mmHg (P=0.0004). There were no adverse events during follow-up, and no deterioration in renal function was observed. Catheter-based renal denervation is safe and efficacious treatment, which results in significant reductions in blood pressure in patients with treatment-resistant hypertension, stable at 2 years follow-up. These results are applicable to real-world patient populations.

[The use of the Five-in-Six System for stent delivery in challenging coronary lesions: a multi-center experience]. / L'utilisation du cathéter Heartrail II « 5-in-6 ¼ dans l'angioplastie coronaire complexe : expérience multicentrique.

BACKGROUND: The mother and child "5-in-6" technique using the Heartrail II catheter is a novel tool allowing stent delivery in challenging lesions, when conventional techniques have failed. METHODS: A total of 147 consecutive patients underwent percutaneous coronary intervention (PCI) using the "5-in-6" Heartrail II catheter was restrospectively identified in the Institut Cardiovasculaire Paris Sud, (Jacques-cartier hospital), Institut hospitalier Claude-Galien (Claude-Galien hospital) and European hospital of Paris between July 2009 and September 2012. RESULTS: Ten interventional cardiologists treated 147 patients with the new device. The patients mean age was 68.5 ± 21.5 years, 78% were men. Radial access was used in 128 cases (87.9%). The treated vessels were the right coronary artery in 82%, left anterior descending in 22%, left circumflex in 18%, marginal branch in 9%, the posterior descending artery in three patients, retroventricular artery in one patient and a saphenous graft in two patients. Most lesions (70%) had American Heart Association/American College of Cardiology (AHA/ACC) type B2 or C, and greater than 50% were located in distal vessel segments. Mean lesion length was 16 ± 4 mm, which is indicative of long lesion. Most (62%) lesions were moderately to heavily calcified and 22 (14%) were chronic total occlusions. Problems with stent delivery were due to poor guide catheter support or excessive calcification. Introduction of the "Heartrail II" catheter allowed successful stent delivery in 139 cases (94%). CONCLUSION: The "5 in 6" Heartrail II catheter is a simple and easy-to-use device that can improve the success of stent delivery in challenging coronary interventions.

[Multicentric experience with the use of Sheathless 6.5 French-size catheter in coronary angioplasty for bifurcation lesions: feasibility and safety]. / Expérience multicentrique de l'utilisation du Sheathless 6.5 French dans l'angioplastie coronaire des lésions de bifurcation : faisabilité et sécurité

BACKGROUND: Transradial intervention of coronary lesion is increasing in frequency and is associated with lower major vascular access site complications. However, the small size of the radial artery is a major limitation of this technique, especially for bifurcation lesions, because 6-French guiding catheters are necessary to optimize the technique. A Sheathless guiding catheter has recently been introduced, optimizing a large lumen with a small size. OBJECTIVES: The aim of this study is to report our preliminary experience performing bifurcated transradial interventions using a 6.5 French Sheathless guide catheter. PATIENTS AND METHODS: From March 2009 to February 2012 in three hospitals, 46 consecutive patients were enrolled in this study who underwent transradial approach (TRA) for percutaneous bifurcation coronary interventions using the 6.5 French Sheathless Eaucath guiding catheter system because of small radial artery caliber. RESULTS: In this study, 46 patients were enrolled with mean age of 72.13 ± 16.41 years. The majority of patients were females with sex-ratio 0.53. Procedural success using the 6.5 French Sheathless guide catheter system was 100 % with no cases requiring conversion to a conventional guide and catheter system. During procedures, adjunctive devices used in this cohort included IVUS (2 patients), 35 bifurcated lesions were treated with a kissing-balloon technique in the group of 46 patients undergoing bifurcation PCIs, one patient required rotational atherectomy, thrombus-aspiration catheters had used in four patients, FFR-guided angiography in four patients. We report one case of chronic total occlusion bifurcated lesion successfully treated using this hydrophilic catheter. There were no radial artery site complications. CONCLUSION: The treatment of coronary bifurcation lesions with 6.5 French Sheathless guiding catheter by transradial approach is feasible and appears safe in this multicenter study.

[Renal artery denervation for treating refractory hypertension]. / La dénervation rénale un traitement pour l'hypertension artérielle résistante.

Arterial hypertension is a major healthcare issue affecting between 30 and 40% of the adult population in industrialized countries. Despite the availability of numerous pharmaceutical treatments, arterial hypertension often remains uncontrolled. A non-negligible percentage of patients are refractory to multiple-drug therapy, which exposes them to an increased risk of cardiovascular events. Percutaneous, renal denervation using a catheter connected to a low energy radiofrequency generator has proven effective in decreasing arterial pressure in patients resistant to medical therapy, by reducing afferent nerve activity. In order to be eligible for this therapeutic approach, patients must have uncontrolled essential hypertension despite treatment with a combination of three anti-hypertensive drugs including a diuretic agent, and ≥ 45mL/min glomerular filtration rate. The initial registry study demonstrated that catheter-based sympathetic renal denervation was a simple and safe procedure resulting in a significant and durable reduction in arterial pressure. Subsequently, a randomized controlled trial (the Symplicity HTN-2 trial) showed a mean 32/12 mmHg decrease in blood pressure measurements in the group of patients who underwent renal denervation whereas no difference was observed in the control group. The reduction in blood pressure was still present at 24-month follow-up. No procedure-related complications were reported and no instances of renal artery stenosis or aneurysmal dilatation were evidenced during the follow-up period. No cases of renal function impairment or deterioration were recorded. This technique seems to be a promising strategy in patients suffering from this serious condition. In order to demonstrate the actual benefit of this technique, we report the case of two patients who underwent renal denervation in our institution.

[Percentage of transradial approach for interventional cardiology in the world and learning the technique]. / Pénétration de l'approche radiale dans le monde et apprentissage de la technique.

The transradial approach has been used for the first non selective coronary angiographies but was quickly replaced by the femoral approach until a new birth in 1989 for coronary angiography in 1989 and coronary angioplasty in 1992. Transradial approach use is extremely heterogeneous in the world, dominated by some countries in Europe, Canada, and eastern Asia (India, Taiwan, China, Japan). Risk factors of failure have been well described, allowing two kinds of learning: systematic attempt in all kind of patients when working with a proctor; patient selection when beginning the technique alone in order to get a high and stable success rate from the beginning. Systematic radial approach for coronary angiography is a must to learn the technique.

[Why perform PCI of coronary chronic occlusion and how?]. / Pourquoi faire des angioplasties d'occlusions coronaires chroniques et comment?

Angioplasty of coronary chronic total occlusion (CTO), defined by complete occlusion of coronary vessel with TIMI 0 flow greater than 3 months, has been avoided for many years, single vessel diseases being medically treated and multivessel diseases sent to surgeons mainly because a low success and high restenosis rates. Major improvements in devices and techniques mainly coming from Japan created a new concern about when and how to perform PCI of CTO. Clearly CTO are stable lesions but during the last years it was demonstrated that while comparing success and failure of recanalization, success improved symptoms, ischemia, left ventricular function, and even survival. Reopening CTOs can also decrease the risk of death and cardiogenic shock associated with a future acute coronary event. Selection of cases for PCI is based on well-known predictors of failure (calcifications, tortuosities, length of occluded segment and age of occlusion), on operator's experience and on a proof of viability and ischemia of the myocardium depending from occluded vessel (MRI). Many specific devices (powerful wires, microcatheters and coaxial balloons, specific guiding catheters, Tornus) and techniques (anterogrades and retrogrades through trans-septal collateral vessels) have been developed to increase success rate (70 to 90% in high volume operator hands). Outside of coronary perforations which are no more frequent in CTO lesions, some specific problems are important limitations: X-Ray exposure, contrast medium volume, and cost. With the success rate these complications are good reasons to have these procedures (or the most complex) performed by specialists.

[Assessment of myocardial function and perfusion by MRI two days and four months after acute myocardial infarction revascularised by primary angioplasty]. / Evaluation par IRM de la fonction et de la perfusion myocardique à deux jours et quatre mois de l'infarctus aigu du myocarde revascularisé par angioplastie primaire.

The extent of gadolinium enhancement assessed by cardiac MRI is an accepted marker of myocardial necrosis. The correlation between late enhancement and other parameters of infarct size after myocardial infarction have previously been described. However, the prognostic value of the extent of late enhancement in terms of myocardial recovery remains controversial especially in revascularised infarcts analysed by early MRI. In order to clarify this question the authors compared the results of MRI at two days and four months after myocardial infarction benefiting from early revascularisation. Between July 2002 and November 2004, the authors included patients with myocardial infarction treated by primary angioplasty and examined by MRI (Siemens Symphony 1.5 T) at two days and three to five months after myocardial infarction. The left ventricular ejection fraction, volume, mass and wall thickness were measured. Perfusion at first passage (PP) and late enhancement were analysed after injection of 20 cc of gadolinium. An eight segment short axis model was used for PP and analysis of late enhancement. Each segment was assessed for transmural or subendocardial hypoperfusion for PP assessment and the wall thickness with late enhancement (1-25%, 26-50%, 51-75%, and 76-100%) was measured to calculate the percentage of myocardial mass showing late enhancement. Thirty-nine patients (thirty three men) were included. The average age was 59 +/- 10 years. TIMI III flow was obtained in all but one (TIMI II) patient. Cardiac MRI was performed 2.1 +/- 1.5 days and 4.6 +/- 1.7 months after myocardial infarction. The ejection fraction increased from 48.7 +/- 12.6% to 54.2 +/- 11.1%, p<0.05, and was related to infarct size (p<0.01). Forty-eight per cent of dysfunctional segments at the initial MRI improved their contractility and the extent of transmural late enhancement was inversely correlated with wall thickening at initial (p<0.01) and four month MRI (p<0.01). The PP improved significantly (regression from 9.5 +/- 8.2% to 2.8 +/- 4.1% of segments with abnormal myocardial perfusion, p<0.01). The late enhancement with respect to total myocardial mass decreased from 20.0 +/- 10.7% to 13.0 +/- 8.1%, p<0.01). Despite restoring TIMI III flow, early myocardial reperfusion is incomplete and improves in the medium term. The authors also observed a reduction in late enhancement at four months, indicating that the results immediately after myocardial infarction may overestimate the infarct size and that this sign does not represent necrotic tissue alone but also viable myocardium with a potential for recovery.

[Results of the French register of renal stenting: the Esternal study]. / Résultats du registre français du stenting rénal: étude Esternal.

Renal artery angioplasty using the same techniques employed for coronary arteries has developed considerably. A register was set up in France to evaluate the efficacy of this treatment for improving renal function and lowering blood pressure in cardiac patients. Between 2001 and 2005, 205 patients (234 lesions) were treated in 14 centres (mean age: 69.2 +/- 10.4 years, 59% male). All of the patients had hypertension and the majority of them (171) had renal failure (creatinine clearance<90 ml/min). Direct implantation of a stent was performed in 75.2% of the cases, successfully in 196 patients (96%) with 220 lesions (95.2%). The complications encountered were segmental renal infarction in two patients (0.9%), and four cases of minor vascular complications at the puncture site (2%). The mean value for pre-implantation creatinine clearance was 54.6 +/- 32.8 ml/min and 58.1 +/- 36.0 post- implantations. The duration of follow up was 5.9 +/- 2.7 months. Mortality was 3.5% (seven patients, of whom two died from renal causes). The mean systolic and diastolic blood pressure was 142.2 +/- 16.2 and 78.9 +/- 9.5 respectively versus 164.9 +/- 25.2 and 89.1 +/- 14.8 before treatment (p<0.0001). A non-significant improvement in creatinine clearance at six months was also observed in patients with renal failure prior to treatment: 48.7 +/- 17.1 ml/min vs. 69.2 +/- 160.3. Renal artery stenting in cardiac patients with renal artery stenosis is associated with a very high success rate, with few complications and an improvement in hypertension and renal function.

[The best of interventional cardiology in 2006]. / L'essentiel de l'année 2006 en cardiologie interventionnelle.

The year 2006 was a landmark in interventional cardiology. Confirmations of results of large-scale trials and meta analyses, the commercialisation of new drug-elution stents, discussions about well established methods, questions about long-term outcomes of dilated patients, have made 2006 a particularly rich year in controversy, especially during its last three months.

[The best of interventional cardiology in 2005]. / L'essentiel de l'année 2005 en cardiologie interventionnelle.

During 2005, the evolution of interventional cardiology has largely been dominated by the trial of active endoprostheses, whose advantage has been consistently shown by various studies, mete-analyses and surveys. Extending their use to new indications and evaluating new drugs have also been studied. In parallel, clinical trials have been performed in the promising field of percutaneous treatment of valvular heart disease, particularly mitral insufficiency and calcified aortic stenosis in the adult.

Coronary angiography using 4 or 6 French diagnostic catheters: a prospective, randomized study.

Diagnostic catheter size has been progressively decreased in order to reduce complications (particularly access-site complications) and permit early ambulation after coronary angiography. However, excessive down-sizing can result in poor catheter conformation and poor imaging quality of coronary angiograms (CA). This study randomly compared the accuracy and angiographic quality (QUAL) of CA performed with 4 French (Fr) vs. 6 Fr diagnostic catheters. Injections were done manually using a low-viscosity, non-heated, low-osmolality contrast media (Iomeprol). CAs were performed via the femoral approach using Judkins catheters. Handling, torque, selectively and stability were graded from 1 (excellent) to 4 (unacceptable) by the operator. QUAL was also graded from 1 (unacceptable) to 10 (excellent) by the operator in all patients and by an independent Core laboratory in 50 patients matched for gender and weight. Between January and April 1997, a total of 405 consecutive patients were randomized. Mean age was 63.4 +/- 11.1 years and 79% were male. Clinical characteristics of patients, quality of left coronary catheter and cross-over rates (1.5% with 6 Fr vs. 3.9% with 4 Fr catheters) were similar in both groups. Using the right coronary catheters, the only difference was handling, which was found to be easier with 6 Fr catheters (1.16 +/- 0.55 vs. 1.34 +/- 0.77, respectively; p = 0.007). Similarly, handling difficulty using the pigtail catheter was the only significant difference between the two groups (1.16 +/- 0.50 vs. 1.33 +/- 0.77, respectively; p = 0.009), but no cross-over was necessary in either group. The QUAL of CA was slightly but significantly better with 6 Fr than with 4 Fr catheters but considered non-diagnostic (< 7/10) in 1.4% vs. 6.8% of left CAs (p = NS). Procedural time (21.0 +/- 7.2 minutes vs. 19.0 +/- 8.1 minutes; p = 0.007) was shorter with 4 Fr catheters, but x-ray exposure, compression times and amount of contrast media used were similar. Ambulation was obtained at 2 hours in 15.1% vs. 34.0% of patients (p < 0.001) and at 4 hours in 43.8% vs. 52.4% (p < 0.05), respectively. The incidence of the worst access-site complication (moderate hematoma) was similar (1%) in both groups. CA can be performed using 4 Fr catheters and manual injections of low-viscosity contrast media with acceptable angiographic results in the majority of cases. This is associated with a shorter procedural time and earlier ambulation, and a decreased but acceptable angiographic quality.

The problem of arteria lusoria in right transradial coronary angiography and angioplasty.

The retroesophageal right subclavian artery (arteria lusoria) is one of the anatomical abnormalities encountered by interventional cardiologists who perform right transradial procedures. We report on 11 patients with arteria lusoria in whom 14 right transradial coronary angiography or angioplasty procedures were attempted among a series of 3,730 consecutive right transradial attempts. This abnormality can be easily detected by angiographic visualization, in the anteroposterior projection, of the angle of the catheter when it engages the ascending aorta, and by manual angiography at the ostium of the right subclavian artery. In such a case, catheterization of the ascending aorta may be difficult or even impossible (7.1%). Selective catheterization of both coronary arteries is more difficult, takes longer, and requires more catheters. The Judkins catheters are recommended, although they are seldom used for the left coronary artery via the right radial approach, for both arteries. All catheter exchanges should be performed on long guidewires.

Amplatzing a 6 Fr Judkins right guiding catheter for increased success in complex right coronary artery anatomy.

Stent supported angioplasty is being performed in an increasing number of patients and, with advances in device technology, more morphologically complex lesions are being treated. In such a setting, it is extremely important to deliver the device to the target lesion. We describe a new technique that allows successful stent delivery in complex right coronary anatomy using the Judkins right guiding catheter. Cathet Cardiovasc Intervent 2001;53:405-409.

Outcome after combined reperfusion therapy for acute myocardial infarction, combining pre-hospital thrombolysis with immediate percutaneous coronary intervention and stent.

BACKGROUND: Primary therapies in acute myocardial infarction (thrombolysis and angioplasty) have inherent limitations which may be overcome by combining them. So far, no trial has demonstrated a clinical benefit in combining mechanical and pharmacological treatment strategies. METHODS: From January 1995 to December 1999, out of 1010 patients admitted to our institution for acute myocardial infarction, 148 had received pre-hospital full dose thrombolysis within 12 h of onset. One hundred and thirty-one patients were included and underwent immediate angioplasty and stenting when suitable, independent of the infarct-artery patency (TIMI grade flow 0-3). In-hospital outcome was assessed and clinical information was collected for a mean (+/-SD) of 2+/-1 years. RESULTS: Ninety-minute angiography revealed a patent (TIMI grade 3) infarct artery in 65 patients (49%). Immediate angioplasty was performed in 119 patients (91%) with stent implantation in 114 (96%). Angioplasty achieved TIMI 2, 3 flow in 98%, and complete patency (TIMI 3 flow) in 92%. Six other patients underwent deferred revascularization (surgery in one patient, angioplasty in five) and six received medical treatment. Stent thrombosis and reinfarction occurred in three patients (2.3%). In-hospital death occurred in six patients (4.6%), including four patients presenting with cardiogenic shock. Major bleeding was observed in 2.3% of cases. No patient had emergency surgery. Freedom from death and reinfarction at 2 years was 90% and freedom from death, reinfarction and target vessel revascularization was 83%. CONCLUSION: A strategy of combined reperfusion using full dose pre-hospital thrombolysis and immediate angioplasty with stent implantation in a non-selected acute myocardial infarction population is safe and achieves high and early patency rates. This preliminary experience suggests that a combined strategy in acute myocardial infarction may have a significant impact on both early and long-term outcomes.

Coronary angiography through the radial or the femoral approach: The CARAFE study.

In a previous study, the radial approach for coronary angiography was shown to be associated with a lower success rate and longer procedural and X-ray times compared to the femoral approach. However, this approach is associated with a steep learning curve. A series of 210 consecutive nonselected patients were randomized to femoral versus right radial approach or femoral versus left radial approach by two experienced operators. Clinical characteristics were similar in the three groups. Technical failure occurred in one patient in the right radial group with subsequent crossover to left radial artery. The number of coronary catheters used was lower in the right radial group (1.4 +/- 0.7 vs. 2.1 +/- 0.4 for the two other groups). The procedural duration was longer with left radial (14.2 +/- 3.3 min; P < 0.05) approach than with right radial (12.4 +/- 5.8 min) and femoral (11.2 +/- 3.3 min) without significant differences between femoral and right radial. X-ray exposure was shorter in the femoral group (3.1 +/- 1.7 min) than in both radial groups (right: 3.8 +/- 2.2 min; left: 4.2 +/- 1.7 min). The angiographic quality was not different between the three groups for RCA, but was less good for LCA through right radial approach. Bed rest and hospital stay were shorter in the two radial groups. The comfort was judged better with the transradial approach. An ad hoc PTCA was performed in 45.7% of femoral patients, 41.4% of right radial, and 44.3% of left radial with immediate sheath withdrawal (closure device for femoral group). There were no severe complications in the three groups, but two patients from the femoral group were discharged later because of vascular complications. The total cost of coronary angiography was higher in the femoral group. In conclusion, after the learning period, transradial coronary angiography can be performed with a high success rate, low rate of complication, and good angiographic quality. It is associated with a slight increase in procedural (LR) and fluoroscopy times, but permits earlier ambulation and discharge, improves patient comfort, and reduces the cost.

[Treatment of unstable angina: early invasive strategy]. / Traitement de l'angor instable: la stratégie invasive précoce.

Unstable angina is one of the main reasons for admission to a cardiology department and the risk of myocardial infarction is high. Non-Q wave myocardial infarction used to be assimilated to unstable angina. Myocardial infarction without prolonged ST segment elevation and with troponin increase is now the category used to describe this condition. CPK elevation, EKG and clinical parameters are involved in the acute prognosis of patients with unstable coronary syndrome. The FRISC II trial was the first study to demonstrate the superiority of systematic early angiography followed by a revascularization procedure selected according to the type of lesions to be treated, compared with conventional management. The use of stents combined with GPIIb/IIIa inhibitors has increased the safety of PTCA and seems to have a synergetic effect. The superiority of early invasive management using stents and GPIIb/IIIa inhibitors was confirmed by the TACTICS. The risks of bleeding complications associated with this therapeutic strategy are minimized by the TIMI classification. This classification no longer corresponds to the current norms of patient safety and comfort. Several methods can be used in order to decrease the risk of bleeding complications; the radial approach is undoubtedly the most efficient one.

Stenting of bifurcation lesions: a rational approach.

The occurrence of stenosis in or next to coronary bifurcations is relatively frequent and generally underestimated. In our experience, such lesions account for 15%-18% of all percutaneous coronary intervention > (PCI). The main reasons for this are (1) the coronary arteries are like the branches of a tree with many ramifications and (2) because of axial plaque redistribution, especially after stent implantation, PCI of lesions located next to a coronary bifurcation almost inevitably cause plaque shifting in the side branches. PCI treatment of coronary bifurcation lesions remains challenging. Balloon dilatation treatment used to be associated with less than satisfactory immediate results, a high complication rate, and an unacceptable restenosis rate. The kissing balloon technique resulted in improved, though suboptimal, outcomes. Several approaches were then suggested, like rotative or directional atherectomy, but these techniques did not translate into significantly enhanced results. With the advent of second generation stents, in 1996, the authors decided to set up an observational study on coronary bifurcation stenting combined with a bench test of the various stents available. Over the last 5 years, techniques, strategies, and stent design have improved. As a result, the authors have been able to define a rational approach to coronary bifurcation stenting. This bench study analyzed the behavior of stents and allowed stents to be discarded that are not compatible with the treatment of coronary bifurcations. Most importantly, this study revealed that stent deformation due to the opening of a strut is a constant phenomenon that must be corrected by kissing balloon inflation. Moreover, it was observed that the opening of a stent strut into a side branch could permit the stenting, at least partly, of the side branch ostium. This resulted in the provocative concept of "stenting both branches with a single stent." Therefore, a simple approach is currently implemented in the majority of cases: stenting of the main branch with provisional stenting of the side branch. The technique consists of inserting a guidewire in each coronary branch. A stent is then positioned in the main branch with a wire being "jailed" in the side branch. The wires are then exchanged, starting with the main branch wire that is passed through the stent struts into the side branch. After opening the stent struts in the side branch, kissing balloon inflation is performed. A second stent is deployed in the side branch in the presence of suboptimal results only. Over the last 2 years, this technique has been associated with a 98% angiographic success rate in both branches. Two stents are used in 30%-35% of cases and final kissing balloon inflation is performed in > 95% of cases. The in-hospital major adverse cardiac events (MACE) rate is around 5% and 7-month target vessel revascularization (TVR) is 13%. Several stents specifically designed for coronary bifurcation lesions are currently being investigated. The objective is to simplify the approach for all users. In the near future, the use of drug-eluting stents should reduce the risk of restenosis.