Bifurcation Lesions - Kissing Stents

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Kissing Stent Technique


Benefits:

Ensures complete coverage of the side branch ostium
Immediate patency of parent and side branch
Access to both branches maintained through procedure
No need for final kissing balloon

Detriments:

Un-endothelialized layer of stents forming neo-carina may predispose to stent thrombosis.
8Fr Guide system required
May be difficult to re-access side branch or parent vessel


Technical Considerations:

Requires minimum of a 8Fr Guiding system
Optimal angle of bifurcation less than 90 degrees. 

Technique:

1) Using a minimum 8Fr guide system, both the parent and side branch are wired. Predilation is recommended to ensure optimal balloon expansion and ease stent delivery. It is important to identify which wire is placed in which branch. We recommend either using 2 separate colored guide wires, keeping a marker on 1 wire, or covering a wire with a sterile towel while not in use.

Kissing Stents
Kissing Stents


2) Any disease distal to the side branch or parent vessel should optimally be repaired before the kissing stents are deployed.

3) Both stents are advanced into the side branch and parent vessel. This may require further predilitation. Generally, the stents are advanced beyond the delivery point. Operator preference differs with respect to amount of overlap. Some operators form a long segment of overlap (>5mm), while others try to minimize overlap. It is absolutely essential that both vessels are covered during the balloon inflation. Optimal placement is ensured by advancing both stents distal to the intended deployment site then pulling them back into position. The proximal marker segements should be aligned, with positional confirmation in at least 2 separate views.

Kissing Stents
Kissing Stents
Kissing Stents
Kissing Stents


4) Using 2 Insufflators, both stents are inflated to low pressure. Then alternating with side branch and parent branch inflated to optimal deployment size. There is some risk of over sizing the main branch with the overlapping stent segments. In the case where proximal disease may interfere with the 2 overlapping stents, a proximal stent may be deployed prior to inflating the 2 distal stents. (Pants-and-trousers technique)

Kissing Stents
Kissing Stents


5) Angiography should now be performed to ensure adequate side branch coverage and stent deployment. Distal edge dissections or disease should be addressed before wire removal \ from the vessels.


Kissing Stents
Kissing Stents
Variations of this method may be used to stent trifurcation disease. While an 8Fr catheter can be used depending on the stent system, optimally a 9 Fr system should be used in this  
situation.
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