Subintimal bailout recanalization for acute stent-jailed side branch occlusion: a single-center retrospective case series with QFR assessment.

BACKGROUND

Acute side branch (SB) occlusion after main vessel (MV) stenting remains a challenging complication of bifurcation PCI, particularly when conventional true-lumen rewiring attempts fail. In such scenarios, operators face limited standardized bailout options, and guidance on decision-making is scarce.

METHODS

We retrospectively analyzed a highly selected single-center case series of patients with acute stent-jailed SB occlusion refractory to conventional rewiring who underwent chronic total occlusion (CTO)-derived subintimal bailout recanalization. A predefined technical framework was applied. Angiographic results were assessed using Thrombolysis in Myocardial Infarction(TIMI) flow, and angiography-derived quantitative flow ratio (QFR) was used as physiological confirmation of reperfusion.

RESULTS

Among 9,832 PCI procedures performed between 2019 and 2023, 15 consecutive patients met the inclusion criteria. Subintimal SB recanalization was achieved in all cases, resulting in restoration of TIMI 3 flow. Postprocedural SB QFR was successfully obtained in all patients, with a mean value of 0.91 ± 0.04; all exceeded the predefined ischemic threshold (QFR ≥ 0.80). No procedure-related perforation, tamponade, or device entrapment was observed. Limited follow-up angiography and QFR data, available in two patients, demonstrated stable or improved functional values.

CONCLUSIONS

In a highly selected case series managed at an experienced center, a structured subintimal bailout framework appears feasible for the treatment of acute stent-jailed SB occlusion when conventional rewiring fails. Integration of QFR provides objective physiological confirmation of SB reperfusion and may assist in procedural decision-making. These findings should be considered hypothesis-generating and warrant validation in larger, prospective studies.