Creighton Don, MDAssistant Professor of CardiologyUniversity of Washington

BIFURCATION STENTING: A PRIMER

WhyHowThe data…

BIFURCATION LESIONS

Large side branch supplying a reasonable territory Left main Cx-large OM LAD-large diag Ostial Cx/LAD RCA-PDA-PLV

Disease in the main branch and ostium/proximal side branch

Concern for losing the side branch Rescuing dissected/occluded/jailed side branch

BIFURCATION LESIONS:WHY

Step 1: Classify lesion Location of disease (Medina classification) Extent of disease (focal?) Size of prox/distal main branch and side branch Angulation of side branch

BIFURCATION LESIONS: HOW

“True Bifurcation” lesion

Levy MS, Moussa ID. “Bifurcation Lesions and Interventions,”in SCAI Interventional Cardiology Board Review. 2nd ed. 2013. Sgueglia GA. Chevalier B. JACC Cardio Interv. 2012.

Step 2: Decide on approachNot true bifurcation, side branch expendable or

diff usely diseased, or not technically possible Provisional

True bifurcation and suitable for stenting V-stenting Simultaneous Kissing Stents T-stenting Crush

Mini-crush Reverse crush

Tap Culotte

BIFURCATION LESIONS: HOW

Side branch free of disease, too small, too diseased1. Wire main branch +/- side branch for “protection”2. Stent main branch3. Assess flow in side branch—IF compromised: 4. Rewire side branch and PTCA, culotte, T-stent, reverse crush, TAP

PROVISIONAL STENTING

Louvard V. Catheterization and Cardiovascular Interventions 71, (2) 175-183, 2007.http://onlinelibrary.wiley.com/doi/10.1002/ccd.21314/full#fig1

RECROSSING

HR: 2.34, 95% confidence interval [CI]: 1.78 to 4.32, p < 0.001).

No disease proximal to the branch Medina 0,1,1

Angle < 90 degreesNo loss of side branch, no recrossing

V-STENTING

TRUE BIFURCATION STENTING

Larger proximal vessel, smaller distal/side branchSimple to position/deploy, no loss of access, no

recrossingNeocarina

Challenging to recross, reintervene Increased thrombosis/restenosis?

SIMULTANEOUS KISSING STENTSDOUBLE BARREL

Treats side/main branch without losing accessCan treat size mismatched vesselsGood for shallow angle bifurcationComplete coverage of carinaLots of metal over side branch/carina

Diffi cult to recross More restenosis

1. Position both stents2. Inflate side branch stent3. Inflate main branch stent (Crush)4. Recross and kiss

CRUSH, MINI-CRUSH

Bail out for provisional stentingMay be diffi cult to recross side branch stent Insures coverage of carinaDoesn’t commit to bifurcation stent from beginning1. Stent main branch2. Wire and stent side branch3. Crush side branch stent with a balloon in the main branch4. Recross and kiss

REVERSE CRUSH

1

2

3

4

Simple, can treat size mismatched vessels

Can lose one branch while treating the other

Need to recross stentGood for angles closer to 90 degrees

Uncovered carina (<90 degrees) If the side stent is deployed into the

main branch, then this may be called a “mini-crush or a modified-T stent

T-STENTING

Complete coverageGood for shallow angle, harder for steep angleLoses access to alternate branch twiceRecross stents twiceRequires relatively equal sized vesselsDiffi culty advancing 2nd stent1. Stent one branch2. Wire and stent other branch3. Recross original branch and kiss

CULOTTE

T-STENTING WITH PROTRUSION (TAP)

Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

Pro: Protects side branch Reduces ischemic burden Easier at the time of the PCI May not be able to salvage side branch after main branch is

stentedCon:

More time, radiation, contrast More restenosis Jeopardizes the main branch Side branch lesion often not significant Side branch often stays open

BIFURCATION STENTING: WHY?

BMS VS DES: ONE VS. TWO STENTS

Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

DES: ONE VS. TWO STENTS

NS

Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

Nordic I: Provisional versus 2 stent70% with ‘true bifurcation’ lesionsSimilar procedural success, longer fluoro/procedure

time Increased biomarker elevations

NORDIC BIFURCATION STUDIES

Steigen TK et al. Circulation. 2006;114:1955-1961

MACE Stent thrombosis

META-ANALYSIS

Brar SS, EuroIntervention. 2009 Sep;5(4):475-84

Nordic-Baltic Bifurcation Study IIIProvisional stentingFFR if TIMI 3 flowRandomized to kissing or no kissing

FFR OF JAILED SIDE BRANCHES

Kumsars I, Narbute I, Thuesen L, et al. Side branch fractional flow reserve measurements after main vessel stenting: a Nordic-Baltic Bifurcation Study III substudy. EuroIntervention 2012;7:1155– 61.

Post-PCI 8-mo

% s

tenosi

sFF

R

TO KISS OR NOT TO KISS

Sgueglia GA. Chevalier B. JACC Cardio Inter. 2012.

BALLOON SIZE FOR KISSING

Sgueglia GA. Chevalier B. JACC Cardio Inter. 2012.

CLASS I: Provisional side-branch stenting should be the initial approach in patients with bifurcation lesions when the side branch is not large and has only mild or moderate focal disease at the ostium. (Level of Evidence: A)

CLASS IIa: It is reasonable to use elective double stenting in patients with complex bifurcation morphology involving a large side branch where the risk of side-branch occlusion is high and the likelihood of successful side-branch reaccess is low.

AHA/ACC/SCAI GUIDELINES

Levine GN et al. JACC. Volume 58, Issue 24, December 06, 2011

Stentys Nitinol and cell design allow for side branch expansion

Tryton Open cells in main branch allowing a “culotte”

Sideguard Nitinol stent, ostium flares allowing “T-stenting”

Antares II Double lumen stent, maintain side branch access

DEDICATED BIFURCATION STENTS

Keep it simple—use a provisional approach whenever possible

If you’re unsure, wire the side branch ahead of time If the side branch needs to be ballooned, end with a kiss

BUT, TIMI 3 flow and <50% stenosis can be left alone Consider FFR if you’re on the fence

Large side branches with disease >5 mm likely require 2-stent strategy

Diffi cult to access side branch may favor 2-stent strategy True complicated bifurcations will be easier to treat with a

two stent strategy if you plan ahead E.g. recrossing into a diseased/jailed/occluded side branch can be

challenging and upsizing your guide is painfulPull your trapped wires before post dilating (keep track of

your wires)

TAKE HOME POINTS

Hildick-Smith D et al. EuroIntervention. 6 (1). 2010.

KNOW YOUR TECHNIQUES