The Acute Changes of Fractional Flow Reserve in DK (Double Kissing), Crush, and 1-Stent Technique for True Bifurcation Lesions

Clinical outcomes following different stenting techniques for coronary bifurcation lesions: a systematic review and network meta-analysis of randomised controlled trials

BACKGROUND

Controversy still exists regarding the optimal treatment of coronary bifurcation lesions.

AIMS

We aimed to analyse the evidence from randomised controlled trials (RCTs) to compare outcomes following different bifurcation stenting techniques.

METHODS

We systematically searched for RCTs comparing different techniques published up to July 2022. We then conducted a pairwise meta-analysis to compare outcomes between provisional stenting (PS) versus upfront 2-stent techniques. Moreover, we performed a network meta-analysis (NMA) to compare all strategies with each other. The primary endpoint was major adverse cardiac events (MACE).

RESULTS

Twenty-four RCTs (6,890 patients) analysed PS, T-stenting, double-kissing (DK)-crush, crush, or culotte stenting. The pairwise meta-analysis did not reveal a significant difference between the PS and 2-stent techniques. However, the prespecified sensitivity analysis, which included RCTs exclusively enrolling patients with true bifurcation lesions, showed a lower rate of MACE following 2-stent techniques, and meta-regression indicated that a longer side branch lesion was associated with a greater benefit from the 2-stent strategy, which was the most apparent in RCTs with a mean lesion length >11 mm. NMA revealed that DK-crush was associated with the lowest MACE rate (odds ratio 0.47, 95% confidence interval: 0.36-0.62; p<0.01; PS as a reference).

CONCLUSIONS

Overall, 2-stent techniques were not significantly better than PS in terms of clinical outcomes. However, the results of the sensitivity analysis suggested that there might be a benefit of a 2-stent approach in selected patients with true bifurcation lesions, especially in the case of long side branch lesions. An NMA revealed that DK-crush was associated with the lowest event rates when compared with other techniques.

Long-term prognostic value of Murray law-based quantitative flow ratio in jailed left circumflex coronary artery after left main crossover stenting

We aimed to evaluate the impact of new Murray law-based QFR of jailed left circumflex coronary artery (LCx) on long-term clinical outcomes after left main coronary artery (LM) simple crossover stenting. 164 patients who underwent LM-to-left anterior descending coronary artery simple crossover stenting and had appropriate angiographic view of LCx for QFR computation were enrolled. The primary clinical outcome was the 5-year target lesion failure (TLF), defined as a composite of cardiac death, a target vessel myocardial infarction or target lesion repeat revascularization. The mean QFR of the LCx after LM stent implantation was 0.88 ± 0.09, and 29 patients (17.7%) had a low QFR (< 0.80), which was significantly associated with a higher 5-year rate of TLF when compared with the high QFR group (27.6% vs. 6.7%; HR: 4.235; 95% CI 1.21-14.95; p = 0.0015). The 5-year LCx ostium-related TLR rate in the low QFR group was also higher (17.2% vs. 3.0% in the high QFR group; HR: 6.07, 95% CI 1.63-22.59, p = 0.002). In a multivariate Cox regression analysis, a low QFR in the LCx after LM stenting was an independent predictor of the 5-year TLF rate (HR: 3.21, 95% CI 1.21-8.53; p = 0.019). ROC analysis showed that QFR a negative predictive value (NPV) of 89.6% ([AUC] 0.73, 95% CI 0.58-0.88, p < 0.05), the cutoff point is 0.85. The patients with a low QFR (< 0.80) in jailed LCX after LM simple crossover stenting had worse 5-year outcomes than those with a high QFR. Conversely, a QFR ≥ 0.85 of jailed LCx could serve as a good predictor of low risk of adverse outcome in LCx ostium. The QFR computation of the jailed LCx may be helpful to determine whether an additional procedure is required for the jailed side branch.

Provisional or 2-Stent Technique for Bifurcation Lesions in the Second-Generation Drug-Eluting Stent Era

Background

For bifurcating coronary lesions, a provisional stent technique is recommended compared with a routine 2-stent strategy. However, much of these data are from trials involving first-generation drug-eluting stents (DES) or bare-metal stents where the risk of restenosis with the 2-stent technique is higher. We investigated the efficacy of various 2-stent techniques versus a provisional stent technique for bifurcation lesions with newer-generation DES.

Methods

PubMed and Embase were searched through May 2022 for randomized control trials investigating bifurcation percutaneous coronary intervention techniques using newer-generation DES, and a meta-analysis was conducted. The primary end point was major adverse cardiovascular events (MACE) at the longest reported follow-up time.

Results

Our study identified 13 randomized control trials including 4041 patients. Compared with the provisional technique, 2-stent techniques significantly decreased MACE (hazard ratio [HR], 0.76; 95% CI, 0.59-0.97; P = .03), target vessel myocardial infarction (HR, 0.38; 95% CI, 0.20-0.71; P = .002), and target vessel revascularization (HR, 0.66; 95% CI, 0.47-0.93; P = .02). There were no significant differences in all-cause mortality (HR, 0.94; 95% CI, 0.62-1.45; P = .79), cardiovascular mortality (HR, 0.82; 95% CI, 0.49-1.38; P = .45), myocardial infarction (HR, 1.00; 95% CI, 0.73-1.37; P = .99), and stent thrombosis (HR, 0.86; 95% CI, 0.52-1.44; P = .58). Of the 2-stent techniques, the double kissing crush technique significantly decreased MACE and target lesion revascularization than other 2-stent techniques.

Conclusions

In this era of newer-generation DES, a 2-stent approach, especially the double kissing crush technique, is superior to a provisional stenting technique for a bifurcation lesion, with a significant reduction in MACE, target vessel myocardial infarction, and revascularization.

Physiological Approach for Coronary Artery Bifurcation Disease: Position Statement by Korean, Japanese, and European Bifurcation Clubs

Coronary artery bifurcation lesions are frequently encountered in cardiac catheterization laboratories and are associated with more complex procedures and worse clinical outcomes than nonbifurcation lesions. Therefore, anatomical and physiological assessment of bifurcation lesions before, during, and after percutaneous coronary intervention is of paramount clinical importance. Physiological assessment can help interventionalists appreciate the hemodynamic significance of coronary artery disease and guide ischemia-directed revascularization. However, it is important to understand that the physiological approach for bifurcation disease is more important than simply using physiological indexes for its assessment. This joint consensus document by the Korean, Japanese, and European bifurcation clubs presents the concept of a physiological approach for coronary bifurcation lesions, as well as current knowledge, practical tips, pitfalls, and future directions of applying physiological indexes in bifurcation percutaneous coronary intervention. This document aims to guide interventionalists in performing appropriate physiology-based assessments and treatment decisions for coronary bifurcation lesions.

Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention

Background Bifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive. Methods and Results Extensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta-analysis produced pooled relative risk (RR) and 95% CI of 2-stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta-analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta-analysis showed no significant differences in all-cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2-stent techniques and provisional stenting. Frequentist network meta-analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38-0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39-0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39-0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28-0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2-stent techniques, including T-stent or T and protrusion, dedicated bifurcation stent, and culotte. Conclusions Double kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2-stent techniques. Superiority of 2-stent strategy over provisional stenting was observed in subgroup meta-analysis stratified to side branch lesion length ≥10 mm.

Meta-Analysis Comparing Outcomes With Bifurcation Percutaneous Coronary Intervention Techniques

There have been mixed results regarding the efficacy and safety of various percutaneous coronary intervention bifurcation techniques. An electronic search of Medline, Scopus, and Cochrane databases was performed for randomized controlled trials that compared the outcomes of any bifurcation techniques. We conducted a pairwise meta-analysis comparing the 1-stent versus 2-stent bifurcation approach, and a network meta-analysis comparing the different bifurcation techniques. The primary outcome was major adverse cardiac events (MACEs). The analysis included 22 randomized trials with 6,359 patients. At a weighted follow-up of 25.9 months, there was no difference in MACE between 1-stent versus 2-stent approaches (risk ratio [RR] 1.20, 95% confidence interval [CI] 0.92 to 1.56). Exploratory analysis suggested a higher risk of MACE with a 1-stent approach in studies using second-generation drug-eluting stents, if side branch lesion length ≥10 mm, and when final kissing balloon was used. There was no difference between 1-stent versus 2-stent approaches in all-cause mortality (RR 0.95, 95% CI 0.69 to 1.30), cardiovascular mortality (RR 1.07, 95% CI 0.68 to 1.68), target vessel revascularization (TVR) (RR 1.22, 95% CI 0.90 to 1.65), myocardial infarction (MI) (RR 1.04, 95% CI 0.69 to 1.56) or stent thrombosis (RR 1.10, 95% CI 0.68 to 1.78). Network meta-analysis demonstrated that double kissing crush technique was associated with lower MACE, MI, TVR, and target lesion revascularization, whereas culotte technique was associated with higher rates of stent thrombosis. In this meta-analysis of randomized trials, we found no difference between 1-stent versus 2-stent bifurcation percutaneous coronary intervention approaches in the risk of MACE during long-term follow-up. Among the various bifurcation techniques, double kissing crush technique was associated with lower rates of MACE, target lesion revascularization, TVR, and MI.

Evolution of the Crush Technique for Bifurcation Stenting

Bifurcation lesions are frequently encountered, associated with greater procedural complexity and consequently are at higher risk for restenosis and stent thrombosis. Early trials in bifurcation percutaneous coronary intervention favored a provisional stenting approach, but contemporary randomized trials have highlighted potentially superior outcomes using a double-kiss crush technique in unprotected distal left main stem bifurcation lesions. Although the evidence is greatest for double-kiss crush, many operators favor a mini-crush or nano-crush single-kiss approach. In this review, the authors describe the iterations of the crush technique and the evidence for each and review general principles for bifurcation percutaneous coronary intervention.

Predictors and 3-year outcomes of compromised left circumflex coronary artery after left main crossover stenting

BACKGROUND

There are few predictors of decreased fractional flow reserve (FFR) in the left circumflex coronary artery (LCx) after left main (LM) crossover stenting.

OBJECTIVES

We aimed to determine the predictors for low FFR at LCx and possible treatment strategies for compromised LCx, together with their long-term outcomes.

METHODS

Altogether, 563 patients who met the inclusion criteria were admitted to our hospital from February 2015 to November 2020 with significant distal LM bifurcation lesions. They underwent single-stent crossover percutaneous coronary intervention (PCI) under intravascular ultrasound (IVUS) guidance with further LCx intervention based on the measured FFR.

RESULTS

The patients showed significant angiographic LCx ostial affection post-LM stenting, but only 116 (20.6%) patients had FFR < 0.8. The three-year composite major adverse cardiac events (MACE) rates were comparable between the high and low FFR groups (16.8% vs. 15.5; p = 0.744). In a multivariate analysis, low FFR at the LCx was associated with post-stenting minimal luminal area (MLA) of LCx (odds ratio [OR]: 0.032, p < .001), post-stenting LCx plaque burden (OR: 1.166, p < .001), poststenting LM MLA (OR: 0.821, p = .038), and prestenting LCx MLA (OR: 0.371, p = .044). In the low FFR group, those with compromised LCx managed with drug-eluting balloon had the lowest three-year MACE rate (8.1%), as compared to either those undergoing kissing balloon inflation (KBI) (17.5%) or stenting (20.5%) (p = 0.299).

CONCLUSION

Unnecessary LCx interventions can be avoided with FFR-guided LCx intervention. Poststenting MLA and plaque burden of the LCx, and main vessel stent length are poststenting predictors of low FFR.

Percutaneous Coronary Intervention Techniques for Bifurcation Disease: Network Meta-analysis Reveals Superiority of Double-Kissing Crush

BACKGROUND

Provisional T-stenting (PS) is generally recommended to treat patients with coronary bifurcation disease (CBD) percutaneously, but PS may not fit all complex bifurcation anatomies. Therefore, several types of up-front 2-stent techniques have been described. We aimed to identify the best percutaneous coronary intervention (PCI) technique to manage patients with CBD.

METHODS

We systematically reviewed randomized controlled trials (RCTs) including patients undergoing CBD PCI which included several types of PCI techniques-PS, double-kissing (DK) crush, T-stenting and protrusion, culotte, dedicated bifurcation stents, crushing, and T-stenting-and we compared device-oriented clinical events (DOCEs), a composite of cardiac death, target-vessel myocardial infarction, stent thrombosis, and target-lesion or target-vessel revascularization, in a network meta-analysis. We included 26 RCTs, leading to a pooled population of 10,339 patient-years and a total of 1229 DOCEs.

RESULTS

The DK-crush technique was associated with the lowest DOCE rate, with a relative risk of 0.62 (95% CI 0.42-0.92) compared with the PS technique. DK-crush had the highest probability (model likelihood 90.2%, area under the cumulative ranking curve 98.0%) of being the best technique among those explored to reduce DOCEs in patients receiving CBD PCI.

CONCLUSIONS

When a 2-stent strategy is considered in a patient with CBD, the DK-crush technique reduces DOCEs compared with other bifurcation techniques based on all available RCTs.

Modified double-stent strategy may be an optimal choice for coronary bifurcation lesions: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

The modified double-stent and provisional stenting strategies have been widely used in patients with coronary bifurcation lesions, but what is the optimization has not been clearly defined. This meta-analysis is to elucidate the benefits from modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions.

METHODS

Electronic databases were searched to identify studies comparing the modified double-stent and provisional stenting strategies in patients with coronary bifurcation lesions. The clinical outcomes were divided into early (≤6 months) and late (>6 months) events according to the follow-up duration. The early endpoints included cardiac death, myocardial infarction, target lesion revascularization or target vessel revascularization, and major adverse cardiac events (MACE), and the late endpoints also include stent thrombosis in addition to the early endpoints index. The angiographic endpoint was in-stent restenosis. Data were analyzed by the statistical software RevMan (version 5.3).

RESULTS

A total of 6 studies involving 1683 patients with coronary bifurcation lesions were included in this meta-analysis, which found that the modified double-stent strategy was associated with a lower risk of cardiac death (odds ratio [OR] = 0.29, 95% confidence intervals [CI] 0.11-0.78, P = .01), myocardial infarction (OR = 0.41, 95% CI 0.21-0.82, P = .01), target lesion revascularization or target vessel revascularization (OR = 0.31, 95% CI 0.15-0.63, P = .001), and MACE (OR = 0.41, 95% CI 0.22-0.74, P = .003) compared with provisional stenting in the early follow-up endpoint events, while the risk of cardiac death and stent thrombosis were similar between both strategies (OR = 0.59, 95% CI 0.31-1.10, P = .09; and OR = 0.62, 95% CI 0.34-1.15, P = .13; respectively) in the late follow-up endpoint events. There were significant differences between both strategies in myocardial infarction (OR = 0.42, 95% CI 0.24-0.75, P = .003), MACE (OR = 0.44, 95% CI 0.31-0.62, P < .00001), and target lesion revascularization or target vessel revascularization (OR 0.35, 95% CI 0.25-0.49, P < .00001) between both strategies in the late follow-up endpoint events. The risk of in-stent restenosis favored the modified double-stent strategy (OR 0.29, 95% CI 0.20-0.43, P < .00001).

CONCLUSION

The modified double-stent strategy is associated with excellent clinical and angiographic outcomes except for the occurrence of cardiac death and stent thrombosis late-term outcome compared with provisional stenting strategy in patients with coronary bifurcation lesions. These findings suggest that the modified double-stent strategy can be recommended as an optimization in patients with coronary bifurcation lesions.

Physiological evaluation of the provisional side-branch intervention strategy for bifurcation lesions using instantaneous wave-free ratio

Background

The provisional side-branch intervention strategy remains the gold standard approach for repair of coronary bifurcation lesions. We performed this study to evaluate the clinical and functional outcomes of using the instantaneous wave-free ratio (iFR) for physiological assessment in provisional side-branch repair of bifurcation lesions.

Methods

Fifty patients with coronary bifurcation lesions were equally divided into two groups: (I) an iFR-guided side-branch intervention group and (II) a conventional group, in which the operator selected a different interventional method. After the procedure, we performed a six-month follow-up for postoperative ejection fraction (EF) and clinical cardiac outcomes.

Results

Our results showed that the iFR measurement procedure was technically feasible in bifurcation lesions, with no procedural-related complications. Moreover, measuring iFR significantly predicted the side-branch percent stenosis after stenting of the main branch (r = −0.81, p < 0.0001). Compared to the conventional group, the iFR-guided group showed a significantly shorter procedural time (MD = −14.6 min, 95% CI [−27.7, −1.4]) and hospital stay duration (MD = −0.92 days, 95% CI [−1.6, −0.28]). However, no significant differences were recorded between the iFR-guided and conventional groups in terms of postoperative EF (p = 0.9), six-month heart failure class (p = 0.89), or post-interventional angina (p = 0.066).

Conclusion

Using iFR for physiological assessment during the provisional side-branch intervention strategy can reduce the procedural time and length of hospital stay in patients with bifurcation lesions. Larger trials should compare the clinical outcomes of iFR to other physiological assessment methods such as the fractional flow reserve (FFR) in patients with coronary bifurcation lesions.

ClinicalTrials.gov number: NCT02785510

Randomized Comparison of FFR-Guided and Angiography-Guided Provisional Stenting of True Coronary Bifurcation Lesions: The DKCRUSH-VI Trial (Double Kissing Crush Versus Provisional Stenting Technique for Treatment of Coronary Bifurcation Lesions VI)

OBJECTIVES

This study sought to compare the outcomes of fractional flow reserve (FFR)-guided and angiography (Angio)-guided provisional side-branch (SB) stenting for true coronary bifurcation lesions.

BACKGROUND

Angio-guided provisional SB stenting after stenting of the main vessel provides favorable outcomes for the majority of coronary bifurcation lesions. Whether an FFR-guided provisional stenting approach is superior has not been studied.

METHODS

A total of 320 patients with single Medina 1,1,1 and 0,1,1 coronary bifurcation lesions undergoing stenting with a provisional SB approach were randomly assigned 1:1 to Angio-guided and FFR-guided groups. SB stenting was performed for Thrombolysis In Myocardial Infarction flow grade<3, ostial SB stenosis>70%, or greater than type A dissection after main vessel stenting in the Angio-guided group and for SB-FFR<0.80 in the FFR-guided group. The primary endpoint was the 1-year composite rate of major adverse cardiac events (cardiac death, myocardial infarction, and clinically driven target vessel revascularization).

RESULTS

Comparing the Angio-guided and FFR-guided groups, treatment of the SB (balloon or stenting) was performed in 63.1% and 56.3% of lesions respectively (p=0.07); stenting of the SB was attempted in 38.1% and 25.9%, respectively (p=0.01); and, when attempted, stenting was successful in 83.6% and 73.3% of SBs, respectively (p=0.01). The 1-year composite major adverse cardiac event rate was 18.1% in both groups (hazard ratio: 0.91, 95% confidence interval: 0.48 to 1.88; p=1.00). The 1-year target vessel revascularization and stent thrombosis rates were 6.9% and 5.6% (p=0.82) and 1.3% and 0.6% (p=0.56) in the Angio-guided and FFR-guided groups, respectively.

CONCLUSIONS

In this multicenter, randomized trial, angiographic and FFR guidance of provisional SB stenting of true coronary bifurcation lesions provided similar 1-year clinical outcomes. (Randomized Study on DK Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions; ChiCTR-TRC-07000015).

Coronary bifurcation lesions: Present status and future perspectives

Coronary bifurcation lesions (CBLs) are challenging and associated with a higher rate of adverse events than non-bifurcation lesions. In the era of drug-eluting stents, 2 primary interventional strategies for treating CBL include the complex strategy the main vessel (MV) and side-branch (SB) stenting, and the simple strategy MV stenting combined with provisional SB stenting. The meta-analysis of the simple vs. complex strategies demonstrated an increased incidence of myocardial infarction in the complex strategy. Likewise, the Tryton dedicated bifurcation stents, as compared with the simple strategy, increased the rate of myocardial infarction. In contrast, the Nordic-Baltic Bifurcation Study IV demonstrated that event rates were not significantly different comparing the simple vs. complex strategies in true bifurcation lesions involving a large SB. Fractional flow reserve (FFR) has emerged as a powerful catheter based tool for the functional assessment of a stenosis, but the role of FFR on the long-term outcomes of patients with CBL has not been studied. Given the recent evidence that Tryton stents (a dedicated bifurcation stent) increased event rates, and the lack of benefit from using 2-stent techniques (the Nordic Baltic Bifurcation Study IV) in true CBL, assessing the FFR of the SB seems now of outmost importance, but randomized data are lacking. An intravascular study showed that kissing balloon inflation (KBI) significantly reduced SB stenosis, restored stent lumen at the carina, and expanded stent in the proximal segment. However, a recent randomized study showed no significant benefit of routine KBI. This review highlights current concepts and future perspectives in patients with CBL.

Stenting strategy for coronary artery bifurcation with drug-eluting stents: a meta-analysis of nine randomised trials and systematic review

AIMS

The present study sought to compare angiographic and clinical outcomes of a simple strategy versus a complex strategy in patients with coronary bifurcation lesions undergoing drug-eluting stent implantation.

METHODS AND RESULTS

Medline, the Cochrane Library, and other internet sources were searched for randomised trials comparing simple strategy versus complex strategy for treating patients with bifurcation lesions. Nine eligible randomised trials including 2,569 patients were identified. The meta-analysis showed that cardiac death (odds ratio [OR]: 0.99, 95% confidence interval [CI]: 0.40- 2.41, p=0.98) and stent thrombosis (OR: 0.64, 95% CI: 0.31-1.34, p=0.24) were similar in the simple and the complex strategy. Compared with the complex strategy, the simple strategy was associated with a reduced risk of either early or follow-up myocardial infarction (OR: 0.53, 95% CI: 0.36-0.79, p=0.002; OR: 0.60, 95% CI: 0.43-0.86, p=0.01, respectively). The overall risks of side branch restenosis (OR: 1.44, 95% CI: 0.73-2.87, p=0.30), target lesion (OR: 1.72, 95% CI: 0.95-3.12, p=0.07) and target vessel revascularisation (OR: 1.59, 95% CI: 0.94-2.69, p=0.09) were comparable between the two groups. In the true bifurcation, with large side branches, and DK-crush subgroups, there were higher rates of reintervention seen in the simple strategy than in the complex strategy.

CONCLUSIONS

A complex strategy remains an optional treatment for patients with coronary bifurcation lesions without severe safety concerns. A complex strategy may be an optimal treatment for true bifurcation lesions with large side branches.

Clinical applications of fractional flow reserve in bifurcation lesions

Percutaneous coronary intervention (PCI) for coronary bifurcation lesions has been associated with lower procedural success rates and worse clinical outcomes compared with PCI for simple coronary lesions. Angiographic evaluation alone is sometimes inaccurate and does not reflect the functional significance of bifurcation lesions. The fractional flow reserve (FFR) is an easily obtainable, reliable, and reproducible physiologic parameter. This parameter is epicardial lesion specific and reflects both degree of stenosis and the myocardial territory supplied by the specific artery. Recent studies have shown that FFR-guided provisional side branch intervention strategy for bifurcation lesions is feasible and effective and can reduce unnecessary complex interventions and related complications. However, an adequate understanding of coronary physiology and the pitfalls of FFR is essential to properly use FFR for PCI of complex bifurcation lesions.

Editorial: at the bifurcation of the last frontiers

The concept of coronary angioplasty percutaneous coronary intervention (PCI) was pioneered by Andreas Gruntzig. Since then, several modifications, innovative devices, techniques, and advances have revolutionized the practice of interventional cardiology. Coronary bifurcation and chronic total occlusion are the last two frontiers that continue to challenge the skills of the interventional cardiologists. Proceedings of the second Bifurcation Summit held from November 26 to 28, 2009 in Nanjing, China are published in this symposium. In a general review, the state of the art in management of bifurcation lesion is summarized in the statement of the "Bifurcation Club in KOKURA." A new-presented concept was the "extension distance" between the main vessel and the sidebranch ostia and its association with restenosis. The results of two studies on shear stress (SS) after PCI showed that contradictory lower SS after stenting was associated with lower in-stent restenosis. There was better fractional flow reserve after double kissing crush technique than provisional one-stent technique. There was also lower rate of stent thrombosis after bifurcation stenting with excellent final angiographic results. In a negative note, the SYNTAX score had no predictive values on trifurcated left main stenting. In summary, different aspects of percutaneous management for bifurcated lesion are described seen from different perspectives and evidenced by novel techniques and strategies.