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Facts speak louder than words

Since its inception, evidence-based medicine has dramatically changed our way of thinking, shifting clinical practice away from case-based experiences to optimally improve patients’ healthcare. Clinical studies, particularly in randomized/multicenter clinical trials and observational studies with larger sample populations, have become a powerful resource to guide physician’s routine work [1]. Of note, interventional cardiology has benefited in many ways from modern clinical studies. Almost all interventionalists are extremely busy performing procedures and generating research results to determine the most appropriate stenting techniques for opening an occluded coronary artery for patients with obstructive coronary artery disease. If recanalization of a chronic total occlusion is one potential solution, stenting a coronary bifurcation lesion is somewhat of a logical intervention. With more devices and stenting techniques being used for bifurcated lesions, determining how to evaluate the potential risk of acute occlusion of a patented side branch (SB) is unavoidable. The complexity of coronary bifurcation lesions lies in the involvement of two daughter branches and/or one parent vessel, unpredictable shifts of both plaque and carina induced by devices, and wide discrepancies of vessel diameters from distal to proximal segments [2]. Acute intra-procedural occlusion of a SB is benign in most cases; however, it is not rare, and to some extent, is fatal if a SB diameter is larger (particularly left circumflex or larger diagonal branch). The Korean Coronary Bifurcation Stenting (COBIS) registry study [3] reported a higher rate of permanent occlusion of SBs among acutely occluded daughter vessels with a provisional stenting approach. As such, insight from the protective approaches, including jailed wires or jailed balloons, to build a stratification model predictive of the likelihood of acute SB occlusion is. From this perspective, the risk prediction of side branch occlusion in the coronary bifurcation intervention (RESOLVE) system [4] is dedicated to assessing SB occlusion and is an invaluable contribution to scoring the risk of SB occlusion and identifying the optimal stenting techniques for a given bifurcation lesion. In the current issue of Catheterization and Cardiovascular Interventions, Dr. Chen et al [5] reported an increased incidence of SB occlusion in Group II and Group III when compared with Group I, stratified by the ratio of diameter stenosis to the main vessel (MV) and/or SB median value(s). This study should be acknowledged, as it provided the interventional community with new information, offering at least a partial solution for the problems mentioned above, with true bifurcation lesions consisting of three patterns: Medina 1,1,1; Medina 0,1,1; and Medina 1,0,1. If there is no doubt about the complexity of the former two types of true bifurcations, Medina 1,0,1 should be questioned in some aspects: (1) Should the stenting procedure start from the MV or the SB?; (2) Is having a jailed wire in the MV needed if the procedure begins from a SB?; and (3) Is more frequent use of a jailed SB wire masking the real difference in the rate of SB occlusion in Group II and Group III (as it is used significantly in Group I)? On the other hand, exact assessment of the lesion location around a bifurcated area is one of the drawbacks of angiography. Herein, aggressive use of intra-coronary imagining tools should be valuable to guide stenting procedures. However, the simplicity of angiographic indexes is generally endorsed. Finally, another concern is the lack of universal acceptance of wider bifurcation angles as an independent factor of SB occlusion. Commendably, results from RESOLVE and our analysis, in matching the DEFINITION study [6], attempt to distinguish right from wrong: the more complex the bifurcation lesions are, the higher risk of SB occlusion. Given the high rate of clinical events after stenting bifurcation lesion, the analysis of clinical outcomes