Floating stenting: yet another technique of bifurcational stenting?

If you surf the net to check tctmd.com or europcr. com, or the many other competing web sites, looking for talks on bifurcations, you will notice that they always start showing a tree branch or 2 rivers slowly merging and always finish saying that you have to use one stent only and cover the side-branch origin. Hopefully, next year they will start with bull horns instead, a Spanish national obsession, because the study by Medina et al in this issue of Revista Española de Cardiología challenges these traditional concepts and proposes new solutions. 1 The authors are among the first " amateurs " of intravascular ultrasound imaging, having applied it since the early 90s in their daily clinical routine 2 but still able to look with fresh eyes at the images and transform their practice based on the results. Alfonso Medina gained a worldwide reputation among the bifurcation enthusiasts for having saved them from the Babel Tower of the existing classifications. He introduced a logical sequence based on a simple concept which has become the new " esperanto " in the description of bifurcations. 3 Now he and his coauthors propose a single stent partially covering the ostium of the left circumflex artery (LCx) (" floating ") to treat the most difficult bifurcation, the bifurcation of the left main when the lesion is limited to the ostium of the left anterior descending (LAD) coronary artery. The first theorem of the provisional stent law 4 states that, if no plaque is present on the side branch on the wall opposite to the carina, ostium narrowings of the side-branch after stent implantation in the main vessel can promptly be reverted by kissing-balloon dilatation because the carina is always plaque free. The second theorem states that the plaque always extends into the bifurcation, which requires mandatory stent implantation across the side-branch. The technique applied in this study contradicts both theorems. Medina et al observed in a consecutive series that only a few lesions (19/71, 26.7%) have " vulnerable " carina anatomy at risk of malignant shift towards the side-branch. They identified with intravascular ultrasound (IVUS) a specific feature called " eyebrow sign " able to predict ostial compromise in 92.9% (13/14) of the cases. Is this a true novel finding adding useful information to guide our interventions? Previous papers showed that a shallow angle between LCx and LAD is predictive of LCx ostium …