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Coronary bifurcation lesions correspond to nearly 20–25% of all percutaneous coronary interventions (PCI) [1, 2]. Interventions in this subset of lesions pose a technical challenge with high early and late complication rates [3]. PCI of bifurcation lesions can be performed using a variety of techniques, depending on the plaque distribution across the main and daughter branches, and the bifurcation geometry [4]. The fractal geometry of coronary bifurcations defines a discrepancy in diameters between the proximal main vessel (MV) and the daughter branches — the distal MV (main branch, MB) and side branch (SB) [5]. Kissing balloon inflation (KBI) has been one of the first proposed stent-optimization techniques specific for bifurcation lesions and continues to play an essential role in bifurcation PCI by optimizing stent apposition and improving SB access. However, the application of KBI requires SB recrossing after main vessel stenting, which adds additional procedure and fluoroscopy time, as well as contrast. It also requires certain operator experience, especially in cases with SB occlusion after stenting. Additional disadvantages of KBI are the elliptical deformation of the proximal MV, which can further compromise long-term results [6]. Proximal optimization technique (POT) has been proposed as a stent-optimization technique able to adjust the tubular design of the coronary stent to the natural bifurcation anatomy [7]. It was expected that POT could correct stent apposition, respecting fractal vessel anatomy, without compromising and even improving SB patency. However, studies demonstrated that for the preservation of SB patency, without any functional vessel flow compromise, an additional SB balloon dilation is required [8]. The optimal result of POT is highly dependent on the precise balloon positioning, and inaccurate placing of the balloon may lead to uncomplete strut apposition to the SB lateral wall [9, 10]. Moreover, it is currently demonstrated that even an appropriately positioned POT balloon (according to the current criteria [4]) could cause further elliptical deformation at SB ostium thus additionally stenosing it [11]. Therefore, proposed herein is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and kissing-balloon inflation.
Proximal optimization with kissing balloon inflation (POKI) technique
The POKI procedure was performed adhering to the following steps:
Therefore, the current findings have important clinical implications. This novel stent optimization technique combines the benefits from POT and KBI and may provide improved post-PCI results in bifurcation lesions. POKI technique shortens the procedure time by combining POT and KBI in a one-step approach. The operator should not be concerned about further carina shifting as SB ostium is dilated simultaneously. Furthermore, the visualization of the SB balloon at the stent border provides a firm marker of the carina position and facilitates the positioning of the MV POT balloon. If during inflation the POT balloon slips proximally, it should be positioned one marker distally after deflation, without doubting excessive carina shifting.
Conclusions
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It was released for Microsoft Windows, PlayStation 3, Xbox 360.and the Wii U. Black Ops 2 is the ninth game in the Call of Duty series and a sequel to Call of Duty: Black Ops, which was released in 2010.
In conclusion, Black Ops 1 and 2 are not available on the PS4 because they were developed for previous-generation consoles, game developers prioritize creating new titles for current-generation consoles, and backward compatibility is not guaranteed across console generations.
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