Bifurcation LesionsBy

Ahmed Kamel,MD,FEBCNational heart institute

Member of the European association of percutaneous cardiovascular intrvention

Definition

• A bifurcation lesion is a coronary artery narrowing occurring adjacent to, and/or involving, the origin of a significant side branch.

• A significant side branch is a branch which you don’t want to lose.

Classifications

Medina Classification

• In the year 2006 Alfonso Medina et al published their more practical and easily used classification,They divided bifurcation lesions into three segments:

Proximal segment of the main branch, side branch ostia, and distal segment of the main branch.

• Any involvement of each segment will receive the suffix 1 if diseased , otherwise suffix 0 was assigned starting from left to right.

• For example, lesion 1,0,1 means that proximal segment, and side branch ostia are diseased but the distal part of the main branch is free of disease

• This classification is easier to remember in comparison to older classifications. For this reason, the European Bifurcation Club has

endorsed this classification in their publications.

Commonly used PCI Strategies

Provisional stentingThe operator wires both vessels and predilate as

needed then stenting of the main vessel only with stenting of the side branch if there was plaque shifting with side branch lesion of 75% or more or TIMI flow less than III.

Two stent technique.

The operator’s plan is to stent both the main vessel and the side branch by one of these techniques

1. Cullotte 2. Crush &Mini crush.3. T stenting4. T and protrusion (TAP)5. V stenting6. Simultaneous kissing stents SKS

Single stent or two stents? that is the question

• There were many trials that compared between the use of a single stent technique or a two stent technique .

• The most important are BBC and NORDIC bifurcation I That randomized 413 to either a single stent technique with optional second stent if needed with a two stent strategy from the start using serolimus eluting stents in both groups with a 6 months follow up.

• After 6 months there was no difference between the two groups in cardiac death, MI ,TVR and stent thrombosis but the two stent strategy required more procedural time ,contrast.

• After 5 years follow up there was insignificant difference between both groups.

If a two stent technique Crush or Cullotte

• The NORDIC II bifurcation study compared between the crush and culotte techniques in bifurcation lesions that required the use of two stent technique from the start.

• A total of 424 patients were randomized ,209 patients received crush stenting while 215 received cullotte stenting with a 6 month follow up .

• Both techniques were similar clinical and angiographic results.

Should we do final kissing?

• The Nordic III bifurcation study randomized 477 patients with a bifurcation lesion where 238 patients had final kissing balloon dilatation and 239 patients had no final kissing .The primary end points were major adverse cardiac events (cardiac death,MI,TVR,stent thrombosis)

• Final kissing balloon dilatation reduced side branch restenosis

Provisional Stent Technique:The ‘simplest’ way to treat a bifurcation

lesion

Wire both vesselsPre-dilate asneededStent main branchRewire andballoon sidebranch (+/- kissingballoon inflation

SideBranch

MainBranch

Provisional Stent Technique

Advantages • Simple • Less Metal • Easier to treat restenosis • Less thrombosis? • Less restenosis

Disadvantages • Residual stenosis at side branch• If side branch stent needed may be harder to insert through stent

The Crush Technique

•Wire both vesselsPre-dilate as neededPosition stentsDeploy side branch stent,remove balloon/wireDeploy main branch stent-‘crushes’ side branchstentRewire side branch andperform kissing ballooninflation

MainBranch

SideBranch

The Crush Technique

2 layers of stent separate side branchfrom the main branch…. can be difficult to re-wire!

The Evolution of the ‘Crush’Technique:

Post-Crush Kissing Balloon Inflation

After KissingBalloon Inflation

Before KissingBalloon Inflation

Kissing Balloons: Before and After

Classic Crush Technique Mini Crush Technique

Advantages• Assures ostium coverage• Prevents loss of side branch• Can be used if side branch and main branch are different sizes

Disadvantages• Complex• Time consuming• Difficult to rewire• Sometimes cant perform final kiss•Difficult to treat restenosis• More restenosis than single stent

The Simultaneous Kissing Stent(SKS) Technique

Wire both vesselsPre-dilate as neededPosition stentsDeploy stentssimultaneouslyPerform kissing balloonpost-dilatation

MainBranch

SideBranch

Simultaneous Kissing Stent Technique

Advantages • Simple• Maintain Wire Access to both branches at all times• Minimal Ischemic Time

Disadvantage • Can be difficult to rewire• Longer carinas can cause trouble later• Requires larger vessels of similar size• More restenosis than single stent

The TAP Technique (T stent And Protrusion)

Wire both vesselsPre-dilate as neededPosition and deploy mainbranch stentRewire side branch andballoon dilatePosition side branch stentso proximal edgeprotrudes slightly intomain branch, ‘backstop’balloon in main branchDeploy side branch stentfirst, then inflate mainbranch balloon to kiss

MainBranch

SideBranch

TAP Technique

Advantages • Relatively simple• Assures ostium coverage• Less metal at side branch ostium compared to crush

Disadvantages

• Excessive stent protrusion can cause main branch access problems later• More restenosis than single Stent

Culotte TechniqueWire both vesselsPre-dilate as neededPosition and deploy stentin most angulated branchRemove first wire, wiresecond branch andballoon dilatePosition second branchstent so proximal portionequal with previous stentedge and deployRewire initially stentedbranch and performkissing post-dilitation

MainBranch

SideBranch

Culotte Technique

Advantages:

• Complete coverage• Good radial strength

Disadvantages :

• Complex• Time consuming• More restenosis than single Stent

A final message to remember

• Finally an interventional cardiologist should keep in

mind the KISSS principal

Keep it safeKeep it simple Keep it swift

.. Let us go to the casesNow