In the past three decades, significant progress has been made in the treatment of coronary artery disease. From the introduction of balloon angioplasty by Andreas Grüntzig in 19771 to metallic drugeluting stents with thin stent struts coated with cytotoxic or cytostatic drugs,2,3 with biocompatible/biodegradable polymers,4 with or without endothelial progenitor cell-capturing technology.5 However, current standard treatment with metallic stents has its shortcomings, such as late in-stent restenosis, late and very late stent thrombosis, impaired vasomotion in the stented segment6–8 and hindrance of repeat revascularisations. To potentially overcome the shortcomings of metallic stents, fully bioabsorbable stents (i.e. scaffolds) were developed.9 After preclinical testing and clinical evaluation in relatively simple coronary artery lesions,10–12 the ABSORB everolimus-eluting bioresorbable vascular scaffold (BVS) received CE-mark approval on 14 December 2010 and is since then increasingly being used in clinical practice across Europe and the rest of the world. This adoption in clinical practice led to a broad extension of, officially offlabel, indications in which the ABSORB BVS is being used, such as ST-segment elevation myocardial infarction (STEMI),13 chronic totally occluded (CTO) arteries and bifurcation lesions.
The use of bioresorbable technology in coronary bifurcation lesions may have potential benefits compared with metallic stents. For example, bioresorbable scaffolds could prevent permanent obstruction of a side branch (SB) after full absorption of the struts in front of this SB, leading to increased blood flow in the SB. Another potential benefit of the ABSORB BVS in bifurcation lesions might be a lower risk of late stent thrombosis, due to the absorption of non-apposed SB (NASB) struts at long term. These NASB struts are known to be often uncovered and thus a potential nidus for stent thrombosis.14 However, in all preclinical and clinical trials on the BVS, patients with SB ≥2 mm were excluded from enrolment, so limited data are available about the use of the BVS in bifurcation lesions. Therefore, the ‘Instructions for use’ of the ABSORB BVS does not indicate the use of the device in lesions involving a SB >2.5 mm. This led to some practical concerns about the use of the ABSORB BVS in coronary bifurcation lesions. For example, does the ABSORB BVS, with a strut thickness of 150 μm, allow for the same bifurcation techniques being used in metallic stent? Is the BVS, due to the lactic acid material, easier to fracture? This article will focus on data provided from in vitro and in vivo assessment of the ABSORB BVS in coronary bifurcation lesions and will provide practical recommendations based on these data and our own experience.