CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/side-branch-occlusionIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • ImageA side branch with TIMI flow under 3, a stenosis over 70 percent, or a dissection of NHLBI type B or more after main vessel stenting 1.
  • MonitorNew ST changes in the branch territory 2.
  • PatientChest pain after the main vessel stent.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Leave the jailed wire in place: it marks the branch and helps rewiring 1.
  2. Proximal optimization (POT) of the main vessel stent if not done, with the balloon's distal marker at the carina 1.
  3. Rewire the branch through a distal strut, ideally with a new wire 1.
  4. Balloon the branch, then kissing balloon inflation and a final POT 1.
  5. Cannot rewire: pass a low profile balloon over the jailed wire and inflate to reopen the branch, then rewire 1.
  6. Stent the branch if the result is poor (T and protrusion, culotte or another two stent technique) 1.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

Who to call

The escalation ladder, first call first.

  1. Second operator: to hold the main vessel wire and the guide while you rewire.

The bailout step by step

Rescue of an occluded side branch 1

  1. Keep both wires.
  2. POT the main vessel stent proximal to the carina.
  3. Rewire the branch through a distal strut, using a microcatheter if needed.
  4. If you cannot: a low profile balloon over the jailed wire, inflate, then rewire through the main vessel stent.
  5. Balloon the branch, kissing inflation, final POT.
  6. If the branch is large and the result poor, stent it.

Prevent

  • Wire important side branches before main vessel stenting 1.
  • Size the main vessel stent to the distal main vessel and POT 1.
  • Assess the branch ostium with imaging or physiology when its disease is unclear 1.

After care and documentation

  • ECG and troponin.
  • Document the branch, its size, the flow before and after and the technique used.

Practice

No emergency simulator case for side branch occlusion yet; the PCI simulator in the app teaches bifurcation steps. Browse the case library.

References

  1. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 16, Bifurcations.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 25, Acute vessel closure.
  3. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/side-branch-occlusion. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.