Technology limitations of BRS in bifurcations

Recommended techniques for bifurcation stenting continue to be revised with specific attention to bioresorbable scaffolds (BRS). Optimal procedural success and long-term outcomes with BRS can perhaps be improved with careful attention to implantation techniques. Good vessel preparation is imperative for optimal expansion of the scaffold, and proper vessel sizing is necessary to ensure compliance with scaffold expansion limits and preservation of proper scaffold function. The European Bifurcation Club (EBC) recommends provisional stenting for the majority of bifurcation lesions: permanent metallic stents are sized according to the distal vessel diameter, with subsequent post-dilatation of the proximal vessel to ensure stent apposition in the proximal main vessel. Recent BRS-specific modifications to the EBC recommendation suggest that selecting the scaffold size based on the diameter of the proximal main vessel can mitigate the risk of overexpansion and potential strut fracture. Expansion of the BRS requires a thoughtful balance between the risk of malapposition associated with underdeployment and the risk of strut fracture due to overdeployment. Post-dilatation of scaffolds should be performed, always respecting the maximum expansion limit, to correct any potential scaffold malapposition and minimise flow disturbances. Finally, dual antiplatelet therapy plays an important role in BRS bifurcation treatment to avoid thromboembolic events.