Introduction

Managing bifurcation lesions remains one of the most complex challenges in interventional cardiology. The European Bifurcation Club (EBC) White Paper has provided a structured, evidence-based approach to bifurcation stenting, outlining the optimal step-by-step techniques for both provisional and two-stent strategies. However, translating these recommendations into real-world practice requires visual guidance and hands-on understanding. 

To bridge this gap, we have developed a comprehensive instructional video series that follows the precise techniques outlined in the EBC White Paper.  

By watching these videos, you may gain a structured, step-by-step guide to mastering bifurcation techniques, ensuring more predictable, reproducible, and successful interventions in your daily practice. 

Provisional Bifurcation

Step by Step Technique

A One-Stent Provisional Technique may be applied to many bifurcation anatomies and represents the gold standard for the majority of noncomplex bifurcated lesions.  

  • A 1-stent technique may be practiced according to “provisional” (more commonly adopted) and “inverted provisional” (selected cases) approach. 

The steps recommended by EBC for “provisional” are outlined in this video.  

DK-Culotte Bifurcation

Step by Step Technique

The Culotte Technique is a technique to complement the provisional approach when a second stent is required. 

  • This is also called “classic” culotte. In clinical practice, culotte is often performed by implanting the first stent in the SB and this sequence is usually called “inverted” culotte. 

  • The technique shown in the video is a DK Culotte, due to the addition of one additional Kissing Balloon Inflation, after MB stenting, prior to SB stenting. This additional KBI may provide better SB scaffolding, easier rewiring, improved stent expansion, and potentially lower restenosis2,3.

The recommended steps for “DK Culotte” are outlined in this video.  

DK-Crush Bifurcation

Step by Step Technique

The DK-Crush Technique is an upfront 2-stent technique and has reached a IIb recommendation for the treatment of true Left Main bifurcation lesions in the ESC guidelines (2018).

However, while EBC recognizes the importance of DK-crush, it highlights the potential complexity of the technique, recommending careful lesion selection and advocates appropriate training for interventional cardiologists willing to adopt this technique.

The steps recommended by EBS for “DK-Crush” are outlined in this video.

T - Bifurcation

Step by Step Technique

The T-Bifurcation stent technique is used when a 2nd stent is required during a provisional (or inverted provisional) approach to a bifurcation lesion.

T and TAP stenting represent the easiest way to implant the second stent. Following the provisional stent implant, if the bifurcation angle is close to 90°, the placement of the 2nd stent in a T configuration may be performed. For more acute angles, a TAP technique may be more appropriate.

The steps recommended by EBS for “T-Stenting” are outlined in this video.

The TAP Bifurcation stent technique is used when a 2nd stent is required during a provisional (or inverted provisional) approach to a bifurcation lesion.

T and TAP stenting represent the easiest way to implant the second stent. Following the provisional stent implant, if the bifurcation angle is acute, which may increase the limitations of the T technique, the placement of the 2nd stent in a TAP (T and Protrusion) configuration may be considered.

The steps recommended by EBS for “TAP-Stenting” are outlined in this video.

Click below to access the EBC White Paper
European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions1

We extend our deepest gratitude to the European Bifurcation Club for developing this white paper on “Stenting techniques for patients with bifurcation coronary artery lesions”. This invaluable resource has provided the detailed, step-by-step guidance upon which each of the techniques demonstrated has been performed. 

A special thanks to Dr. Olivier Darremont (Clinique Saint Augustin, Bordeaux) for his collaboration with the Boston Scientific R&D Team since early 2020. His expertise has been instrumental in performing and guiding each of the techniques shown. As a Board Member and co-founder of the European Bifurcation Club, as well as a co-author of this white paper, his contributions have been truly invaluable. 

We also sincerely appreciate Prof. James Spratt (St. George’s University Hospital, London) for giving his invaluable time, guidance, and feedback to the engineering team throughout the development process. 

Finally, a heartfelt thank you, to Boston Scientific R&D, BSC EDUCARE & Gosling Creative Teams in Galway, Paris and London. Your technical expertise and unwavering support for clinical education, continue to inspire us every day. 

 

  1. Burzotta F, Lassen JF, Louvard Y, Lefèvre T, Banning AP, Daremont O, Pan M, Hildick-Smith D, Chieffo A, Chatzizisis YS, Džavík V, Gwon HC, Hikichi Y, Murasato Y, Koo BK, Chen SL, Serruys P, Stankovic G. European Bifurcation Club white paper on stenting techniques for patients with bifurcated coronary artery lesions. Catheter Cardiovasc Interv. 2020 Nov;96(5):1067-1079. doi: 10.1002/ccd.29071. Epub 2020 Jun 24. PMID: 32579300; PMCID: PMC8915133. 
  2. Sheng Tu, et. al. Five-Year Outcomes of Double Kissing Mini-Culotte Stenting vs. Mini-Culotte Stenting Using Drug-Eluting Stents for the Treatment of True Coronary Bifurcation Lesions. Frontiers in Cardiovascular Medicine, 2024​. doi: 10.3389/fcvm.2024.1336750 
  3. Sheng-Lin Chen, et. al. Comparison of Double Kissing Crush Versus Culotte Stenting for Unprotected Distal Left Main Bifurcation Lesions: Results From a Multicenter, Randomized, Prospective DKCRUSH-III Study. Journal of the American College of Cardiology, 2013​. doi: 10.1016/j.jacc.2013.01.023​ 

 

Discover the Left Main Academy

Programme overview

A Modern PCI approach to Left Main Bifurcation PCI.

This step-by-step educational journey, created and delivered by top KOLs, connect multiple proficiencies with the aim to achieve better clinical & patient outcomes in the treatment of the Left Main & Bifurcations.

Live or on-demand, learn at your own pace.

What it is about

  • On demand education: e-learning modules, clinical cases, expert talks
  • EDUCARE training courses
  • IVUS imaging, lesion preparation and stent strategy optimization for Left Main & Bifurcations

Modules

Module 1

Introduction to the Left Main

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Description: In this introductory module, Dr. Simon Walsh explains how and why Left Main disease manifests as it does. At the end of this module, you will be able to put current evidence into context for each individual patient to optimize treatment.

Learning objective: Understand the Left Main PCI, exploring the associated diseases and clinical data.

Module 2

Role of IVUS in the Left Main

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Description: In this module, we will focus on the the pivotal role Intravascular Imaging (IVUS) plays in successful Left Main PCI. Prof. James Spratt will go over the key areas where IVUS can support your PCI procedure, such as planning, lesion preparation and optimizing the stent area to prevent complications.

Learning objective: Evaluate how IVUS can support Left Main PCI with a systematic IVUS 123 approach.

Module 3

Treatment Strategies of the Left Main

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Description: In this module hosted by Dr.Gregor Leibundgut, you will find out more about the importance of stent strategy when treating the Left Main and/or its Bifurcations: the key factors to consider, how to set up for success, optimal stent design characteristics, and the different techniques. After completing this module, you will be able to select the most appropriate stent strategy for each individual patient.

Learning objective: Choose an optimal stent strategy in treating Left Main Bifurcations.

Module 4

Calcium treatment in the Left Main

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Description: In the final module, Prof. James Spratt will guide you through the basics of lesion preparation in Left Main PCI, its importanceand the impact of calcium on mechanical outcomes. You will learn about the different technologies available and how to select the optimal lesion preparation tool in your Left Main PCI.

Learning objective: Prepare the Left Main vessels with the appropriate tools and technologies available.

Let's find out what Dr. Rigger says about the Left Main Academy

Left Main Bifurcation Live Case Series

In this live case series, Prof James Spratt and Dr Thierry Lefèvre will guide us through a progressive and comprehensive educational journey, with live cases from top centers and opeartors across the globe. We are also joined by over, 30 leading clinical experts, giving their perspectives on how Modern Left Main PCI is performed.

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Perfect Your Practice

Series of roundtables around key topics concerning the treatment of Left Main and Bifurcations.

A panel of international experts and key opinion leaders are discussing and bringing concrete example about the role IVUS in LM PCI, the importance of the lesion preparation, and the different stent strategies when treating bifurcations.

Live Sessions

Live Session 1

IVUS in LM: from practice to data

Learning objectives

  • The importance of IVUS in the treatment strategy during a LM procedure
  • Understand the recent evidence on Intravascular Imaging
  • How to optimise, through a stepwise systematic approach, a Left Main procedure with the use of Intravascular Imaging

Faculty


Prof James Spratt
St George’s University Hospital NHS Trust, London, UK

José de la Torre Hernández
University Hospital Marques de Valdecilla, IDIVAL, Santander, Spain

Gabriele Luigi Gasparini
Humanitas Research Hospital, Milan, IT

Stephane Carlier
Université de Mons, Mons, BE
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Live Session 2

Systematic approach in the treatment of Left Main bifurcation stenoses

Learning objectives

  • To comprehend the key factors to consider with lesion complexity
  • To learn how to select the most appropriate stent strategy
  • To understand the importance of IVUS in the treatment of Left Main bifurcation lesions

Faculty


Prof James Spratt
St George’s University Hospital NHS Trust, London, UK

Dr Kalaivani Mahadevan
Portsmouth Hospitals University NHS Trust, Portsmouth, UK

Dr Paolo Canova
Hospital Papa Giovanni XXIII, Bergamo, IT

Dr Gregor Leibundgut
University Hospital of Basel, Basel, CH
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