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DR SRIDHAR BABU
WHAT IS BIFURCATION LESION?
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
A ( approach) – between proximal MB & SB.
It defines difficulty in accessing side branch. ...
Possible locations
 LAD – diagonal
 LCX – obtuse marginal
 RCA – PDA
 LMCA bifurcation
APPROACH TO BIFURCATION LEISONS
INCIDENCE
 Account for 16% PCI
 Procedural complications – 9%
 Restenosis as high as 36%
 Lower initial success rate
A...
Technical problems
 Difficulty in access to the side branch
 Plaque shift
 Lesion recoil
 Ineffective lumen expansion
...
Anatomical Considerations
Y-angulation precise stent placement with complete ostial coverage is
often difficult or geometr...
The outer walls of bifurcation points are subjected to
diastolic flow reversal, which leads to oscillatory shear
stress.
...
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
Classification of bifurcation lesions
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
Limitations of Medina classification
 Does not take into account
1. Length of disease in the ostium of the SB
2. Length o...
 Mohaved classification
 Mohaved classification
Movahed
classification
APPROACH TO BIFURCATION LEISONS
Provisional stenting versus elective double vessel stenting
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
Major adverse cardiac event (MACE) and TLR incidence in
randomized trials comparing 1-stent (1S) with 2-stent (2S)
strateg...
MAIN BRANCH RESTENOSIS RATE AFTER DES
APPROACH TO BIFURCATION LEISONS
SIDE BRANCH RESTENOSIS RATE
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
BASIC PRINCIPLES
 Ramifications of coronary tree follow minimal energy cost in providing
myocardial blood flow.
 Relatio...
APPROACH TO BIFURCATION LEISONS
OPTIMAL VIEW
 SB ostium is rarely visualized from 2 orthogonal views, and may be
explored from single angle called workin...
Guide selection
 A 6-F guiding catheter can be used if the operator performs a
provisional stenting technique .
 Techniq...
ONE OR TWO GUIDEWIRES ?
 GUIDEWIRE IN EACH BRANCH - improve patency of SB after MB
stenting.
 It also good marker of SB ...
BIFURCATION LESION – a)STENT SIZE ACCORDING TO DISTAL MB REFERNCE
b) STENT SIZE ACCORDING TO PROXIMAL MB REFERENCE RESULT ...
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
when a wire is needed in the SB?
 1) the SB has a narrowing at its ostium.
 2) the MB has severe stenosis with a large p...
SHOULD WE PREDILATE SB LESION OR NOT?
 Kissing balloon predilatation is not recommended because of risk of
extensive diss...
APPROACH TO BIFURCATION LEISONS
PROXIMAL OPTIMISATION TECHNIQUE ( POT )
 Provides solution to under deployment of proximal MB stent.
 Carried out by sho...
IS KBI NEEDED AFTER SINGLE STENT DEPLOYMENT ?
 KBI allows SB ostium treatment & apposition of MB stent struts on SB
ostiu...
HOW TO CARRY KBI APPROPRIATELY ?
 Step 1: Insert a free wire in SB through struts of the MB stent, if
possible closest to...
Characteristics of bifurcations with difficult SB access
 CAG predictors - severe calcifications,
 severe stenosis with ...
Primary side branch wiring – non complex SB access
 J tip angle(L1) is usually modulated
according to the side branch tak...
It is usually advisable to wire the branch which appear more difficult to do.
APPROACH TO BIFURCATION LEISONS
Complex side branch access
 When the problem is a distal wide angle ( LCx take-off from LMCA), a
useful solution is to sh...
Anterograde in MEDINA 1,1,1
(Wide angle & sub occlusive
SB)
Pullback wiring in MEDINA
1,1,1
APPROACH TO BIFURCATION LEISONS
Reverse wiring in 0,0,1 with
extreme angle > 150
SB wiring with VENTURE
APPROACH TO BIFURCATION LEISONS
Side branch re-wiring after MB stent implantation
 The success in SB rewiring is the key point of bifurcation interventio...
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
When are two stents needed? Intention to treat
 SB when they are relatively large in diameter (>2.5 mm) & territory of
di...
1)Provisional
Mainvessel stenting ± sidebranch angioplasty
(Provisional) T-stenting, TAP,
REVERSE INTERNAL CRUSH, REVERSE ...
DEFINITION OF PROVISIONAL SIDE BRANCH STENTING
 Main objective is focusing on MB, while maintaining the SB patency.
 Str...
 RELETIVE SIMPLICITY .
 REQUIRING SINGLE STENT IN 80-90% OF CASES &
 RESULTING IN SIMILAR OUTCOME COMPARED WITH MORE CO...
Provisional stenting of Bifurcations:
place a stent in the MB
postdilate the MB stent
at high pressure
place a wire into t...
 Double stenting techniques which are certainly more complex, time
consuming & expensive than provisional stenting.
 Non...
APPROACH TO BIFURCATION LEISONS
The culotte technique
The culotte technique
 It provides near-perfect coverage of the carina & SB ostium at the
expense of an excess of metal c...
Culotte technique
 Not advisable when there is large discrepancy in
vessel size between the proximal MB and the SB
becaus...
APPROACH TO BIFURCATION LEISONS
The crush technique
The crush technique (SB stent crushed by the MB stent)
 immediate patency of both branches is assured & therefore it shou...
APPROACH TO BIFURCATION LEISONS
1. Inability to wire the SB.
 Make Sure That The Wire Is Directed Towards The Distal
Part But Not The Proximal Part.
 If...
REVERSE CRUSH
TECHNIQUE main reason for performing the
“reverse crush” is
to allow an opportunity for
provisional SB sten...
Step crush
The final result is basically similar to the one obtainedwith the “standard crush”
technique, with the only dif...
Dk crush
 In the DK crush, kissing balloon (KB) inflation is
performed after crushing the SB stent with a balloon.
 This...
APPROACH TO BIFURCATION LEISONS
T- and modified T-techniques
 The T-technique is the most frequently utilised to crossover from
provisional stenting to s...
APPROACH TO BIFURCATION LEISONS
modified T-technique
APPROACH TO BIFURCATION LEISONS
V technique
SKS TECHNIQUE
APPROACH TO BIFURCATION LEISONS
V & simultaneous kissing stent (SKS) techniques
• Advantages –
 Access to both branches is always preserved during the pr...
 LIMITATIONS –
 balloon barotrauma to the proximal MB.
 If a proximal stent is needed almost always the risk of leaving...
2011 ACCF/AHA/SCAI Guideline for PCI
APPROACH TO BIFURCATION LEISONS
Favourable features for provisional stenting
in unprotected LMCA
 inSignificant stenosis at the ostial LCX with
MEDINA 1,...
UNFavourable features for provisional stenting in
unprotected LMCA
 significant stenosis at the ostial LCX with
MEDINA 1,...
L.M.C.A. BIFURCATION STENTING
APPROACH TO BIFURCATION LEISONS
IVUS in bifurcation stenting
 Determining anatomic configuration, selecting treatment strategy &
assessing final result a...
IVUS guidance for bifurcation lesion PCI
 IVUS can select the appropriate stent size and length as well as guiding
the mo...
Impact of IVUS guidance on outcome
 Park et al in 758 pts - non-LMCA bifurcation lesions : IVUS-guided
stenting significa...
FFR in bifurcation stenting
 Bifurcation lesion is very unique as it is the only lesion in which
stenting is not better t...
 CAG evaluation is more difficult for bifurcation lesions due to vessel
overlap, angulations, stent struts across SB & im...
Limitations of conventional bifurcation stenting
 MV stent distortion by side access
 Side branch and wire jailing
 Sid...
APPROACH TO BIFURCATION LEISONS
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Conclusion
 Bifurcation stenosis pose a technical problem.
 The complexity of the lesion treatment lies in SB.
 Potenti...
APPROACH TO BIFURCATION LEISONS
APPROACH TO BIFURCATION LEISONS
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APPROACH TO BIFURCATION LEISONS
Approch to bifurcation lesion
Approch to bifurcation lesion
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Approch to bifurcation lesion

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Approch to bifurcation lesion

  1. 1. DR SRIDHAR BABU
  2. 2. WHAT IS BIFURCATION LESION? APPROACH TO BIFURCATION LEISONS
  3. 3. APPROACH TO BIFURCATION LEISONS A ( approach) – between proximal MB & SB. It defines difficulty in accessing side branch. If this angle more can be ↓ by guide wire insertion, which facilitates SB access after MB stenting. B ( between) – between the two distal branches. If it small independently predicts SB occlusion after MB stenting
  4. 4. Possible locations  LAD – diagonal  LCX – obtuse marginal  RCA – PDA  LMCA bifurcation APPROACH TO BIFURCATION LEISONS
  5. 5. INCIDENCE  Account for 16% PCI  Procedural complications – 9%  Restenosis as high as 36%  Lower initial success rate APPROACH TO BIFURCATION LEISONS
  6. 6. Technical problems  Difficulty in access to the side branch  Plaque shift  Lesion recoil  Ineffective lumen expansion  High periprocedural complication rate  Sub optimal immediate and long term results  Risk of side branch occlusion APPROACH TO BIFURCATION LEISONS
  7. 7. Anatomical Considerations Y-angulation precise stent placement with complete ostial coverage is often difficult or geometrically impossible. APPROACH TO BIFURCATION LEISONS
  8. 8. The outer walls of bifurcation points are subjected to diastolic flow reversal, which leads to oscillatory shear stress. Oscillatory (as versus laminar) shear stress is less efficient in stimulating eNOS. Monocytes bind more avidly to areas of oscillatory shear than to areas subjected to linear shear.  oscillatory shear stress is proatherogenic The shear stress hypothesis Hsiai, T.K et al ATVB 2001; 21: 1770 APPROACH TO BIFURCATION LEISONS
  9. 9. APPROACH TO BIFURCATION LEISONS
  10. 10. APPROACH TO BIFURCATION LEISONS Classification of bifurcation lesions
  11. 11. APPROACH TO BIFURCATION LEISONS
  12. 12. APPROACH TO BIFURCATION LEISONS
  13. 13. Limitations of Medina classification  Does not take into account 1. Length of disease in the ostium of the SB 2. Length of the LMCA before the bifurcation 3. Trifurcation 4. Vessel angulation 5. no differentiation is made between a normal segment (lesion free segment) and a <50% lesion 6. presence of calcifications is not identified APPROACH TO BIFURCATION LEISONS
  14. 14.  Mohaved classification  Mohaved classification Movahed classification APPROACH TO BIFURCATION LEISONS
  15. 15. Provisional stenting versus elective double vessel stenting APPROACH TO BIFURCATION LEISONS
  16. 16. APPROACH TO BIFURCATION LEISONS
  17. 17. APPROACH TO BIFURCATION LEISONS
  18. 18. Major adverse cardiac event (MACE) and TLR incidence in randomized trials comparing 1-stent (1S) with 2-stent (2S) strategies. APPROACH TO BIFURCATION LEISONS
  19. 19. MAIN BRANCH RESTENOSIS RATE AFTER DES APPROACH TO BIFURCATION LEISONS
  20. 20. SIDE BRANCH RESTENOSIS RATE APPROACH TO BIFURCATION LEISONS
  21. 21. APPROACH TO BIFURCATION LEISONS
  22. 22. BASIC PRINCIPLES  Ramifications of coronary tree follow minimal energy cost in providing myocardial blood flow.  Relation between 3 diameters is simplified by Finet.  Dprox = (Ddistal + Dside) x 0.678. APPROACH TO BIFURCATION LEISONS
  23. 23. APPROACH TO BIFURCATION LEISONS
  24. 24. OPTIMAL VIEW  SB ostium is rarely visualized from 2 orthogonal views, and may be explored from single angle called working view.  For LMCA – RAO or LAO view with caudal inclination.  For LAD – D : AP with marked cranial angulations.  For LCx – OM : slight LAO or RAO with caudal angulations.  For distal RCA : AP with cranial angulations. APPROACH TO BIFURCATION LEISONS
  25. 25. Guide selection  A 6-F guiding catheter can be used if the operator performs a provisional stenting technique .  Techniques such as the T, the reverse crush, and the step crush can all be used with a 6-F guiding catheter.  The modified T technique requires at least a 7-F guiding catheter.  Culottes, Y, V techniques require at least 8-F guiding catheters APPROACH TO BIFURCATION LEISONS
  26. 26. ONE OR TWO GUIDEWIRES ?  GUIDEWIRE IN EACH BRANCH - improve patency of SB after MB stenting.  It also good marker of SB origin in case of SB occlusion after MB stenting.  It can also be used to reopen SB by pushing balloon over jailed guide wire.  Best way to avoid SB occlusion – select MB stent diameter according to distal MB diameter in order to avoid carina shifting.  Wire modifies angle A – thus facilitates guide wire exchange, balloon & stent advancement.  TULIP – study use of one wire while starting the procedure is a predictor of SB treatment failure. APPROACH TO BIFURCATION LEISONS
  27. 27. BIFURCATION LESION – a)STENT SIZE ACCORDING TO DISTAL MB REFERNCE b) STENT SIZE ACCORDING TO PROXIMAL MB REFERENCE RESULT IN CARINA SHIFT APPROACH TO BIFURCATION LEISONS CARINA IS USUALLY FREE OF ATHEROMA – risk of side branch occlusion is mainly because of carina shifting ( rather plaque shifting), when MB stent size distal to bifurcation is too large.
  28. 28. APPROACH TO BIFURCATION LEISONS
  29. 29. APPROACH TO BIFURCATION LEISONS
  30. 30. when a wire is needed in the SB?  1) the SB has a narrowing at its ostium.  2) the MB has severe stenosis with a large plaque burden and the SB originates with an angle of <45°.  3) the ostium of the SB deteriorates after pre- dilatation of the MB. APPROACH TO BIFURCATION LEISONS
  31. 31. SHOULD WE PREDILATE SB LESION OR NOT?  Kissing balloon predilatation is not recommended because of risk of extensive dissections in unstented segments.  Predilatation of MB left to discretion of operator based on type of lesion.  Predilatation of SB is subject of controversy – better avoid.  DRAWBACKS - Because while dilating ostium dissection may develop prevents access to SB across stent struts of MB stent. APPROACH TO BIFURCATION LEISONS
  32. 32. APPROACH TO BIFURCATION LEISONS
  33. 33. PROXIMAL OPTIMISATION TECHNIQUE ( POT )  Provides solution to under deployment of proximal MB stent.  Carried out by short bigger NC balloon just proximal to Carina.  Changes the orientation of SB Ostium facilitating the insertion of guide wire, Balloon & if necessary stent in the SB, as well as projection of stents in the SB Ostium.  POT is useful in especially in bifurcation lesion with large SB. APPROACH TO BIFURCATION LEISONS
  34. 34. IS KBI NEEDED AFTER SINGLE STENT DEPLOYMENT ?  KBI allows SB ostium treatment & apposition of MB stent struts on SB ostium.  It also enables correction of stent distortion & inadequate apposition.  Drawbacks : Procedural complexity , stent ovalisation, proximal dissection.  Final KBI is strongly recommended after complex technique with two stents, remains controversial in case of single stent. APPROACH TO BIFURCATION LEISONS
  35. 35. HOW TO CARRY KBI APPROPRIATELY ?  Step 1: Insert a free wire in SB through struts of the MB stent, if possible closest to the carina.  Pre shaping of MB wire, utilisation of POT , use of hydrophilic or more rigid wire & orientable micro catheter may help.  Hydrophillic wires should not be jailed.  In persistent difficulties advancement & subsequent inflation of very small balloon over jailed wire may restore flow & help in crossing.  Step 2 : After insertion of free wire in SB, jailed wire must be withdrawn.  Step 3: Selection of Balloons – Diameter must match 2 distal branches. Balloons must be sufficiently short & use of NC balloons to ↓ dissection. APPROACH TO BIFURCATION LEISONS
  36. 36. Characteristics of bifurcations with difficult SB access  CAG predictors - severe calcifications,  severe stenosis with a large plaque burden in the proximal MV, tortuosity in the proximal MV limiting guide wire manipulations,  severe stenosis of the SB ostium(TIMI flow <3) .  Distal bifurcation angle - is an important issue in terms of access to SBs.  SB wiring is usually easy when angle is < 70°, while access more difficult if angle > 70°, and can be particularly difficult when it exceeds 90°.  Natural distribution 80±27° for LAD/LCX, 46±19° for LAD /D1, 48±24° for LCX/OM1 & 53±27° for PDA/PLA, respectively. APPROACH TO BIFURCATION LEISONS
  37. 37. Primary side branch wiring – non complex SB access  J tip angle(L1) is usually modulated according to the side branch take off angle.  Length of tip(L2) is usually adjusted according to diameter of the main vessel lumen. APPROACH TO BIFURCATION LEISONS
  38. 38. It is usually advisable to wire the branch which appear more difficult to do. APPROACH TO BIFURCATION LEISONS
  39. 39. Complex side branch access  When the problem is a distal wide angle ( LCx take-off from LMCA), a useful solution is to shape the tip with a wide smooth bend or with a double bend (later is being more practical when the SB lesion is tighter).  when the SB take-off is ≥ 90 ° & the stenosis is sub-occlusive -  Ante grade wiring, by pushing the wire directly into the SB.  Pullback wiring.  Other methods for complex SB are - “reverse wire” & Venture catheter. APPROACH TO BIFURCATION LEISONS
  40. 40. Anterograde in MEDINA 1,1,1 (Wide angle & sub occlusive SB) Pullback wiring in MEDINA 1,1,1 APPROACH TO BIFURCATION LEISONS
  41. 41. Reverse wiring in 0,0,1 with extreme angle > 150 SB wiring with VENTURE APPROACH TO BIFURCATION LEISONS
  42. 42. Side branch re-wiring after MB stent implantation  The success in SB rewiring is the key point of bifurcation interventions.  Now commonly accepted best way is to wire the side branch by using a pullback rewiring technique.  Important is to obtain a curve sufficiently wide to let the wire scratch the MV stent struts.  When difficulty in rewiring changing either the shape of the guide wire's tip or the guide wire in favor of stiffer or more hydrophilic ones.  Rewiring site may influence the type of MBstent distortion after SB dilation, as crossing of the distal side cells of the MB stent is associated to better ostium scaffolding & ↓ need of SB stenting. APPROACH TO BIFURCATION LEISONS
  43. 43. APPROACH TO BIFURCATION LEISONS
  44. 44. APPROACH TO BIFURCATION LEISONS
  45. 45. When are two stents needed? Intention to treat  SB when they are relatively large in diameter (>2.5 mm) & territory of distribution.  Have severe disease that extends well beyond the ostium (≥ 10-20 mm).  Have an unfavorable angle for re-crossing after MB stent implantation. APPROACH TO BIFURCATION LEISONS
  46. 46. 1)Provisional Mainvessel stenting ± sidebranch angioplasty (Provisional) T-stenting, TAP, REVERSE INTERNAL CRUSH, REVERSE CULOTTE. 2) elective Culotte-stenting Crush technique (reverse crush) T TECHNIQUE AND TAP V STENTING Y STENTING(SKS technique) Stenting of Bifurcation Lesions APPROACH TO BIFURCATION LEISONS
  47. 47. DEFINITION OF PROVISIONAL SIDE BRANCH STENTING  Main objective is focusing on MB, while maintaining the SB patency.  Strategy is to deploy stent from proximal to distal segment of MB.  In some cases, stent is deployed from proximal segment of MB to SB also called as inverted provisional technique.  Advantages –  because of open nature optimally MB & Bifurcation are dealt with single stent.  When necessary 2nd stent can be used for SB with culotte or T stenting technique.  Procedure can be carried with 6F guiding catheter. APPROACH TO BIFURCATION LEISONS
  48. 48.  RELETIVE SIMPLICITY .  REQUIRING SINGLE STENT IN 80-90% OF CASES &  RESULTING IN SIMILAR OUTCOME COMPARED WITH MORE COMPLX STRATEGIES MADE THIS METHOD GOLD STANDARD.  EVEN FOR THE LM STENTING AS BY SYNTAX DATA.  Drawbacks –  Difficulty in ensuring permanent access to SB.  Potential problems in recrossig stent struts towards the SB in implanting 2nd stent in the SB after stenting the MB. APPROACH TO BIFURCATION LEISONS
  49. 49. Provisional stenting of Bifurcations: place a stent in the MB postdilate the MB stent at high pressure place a wire into the SB results are evaluated dilatation of the SB and kissing balloon inflation APPROACH TO BIFURCATION LEISONS
  50. 50.  Double stenting techniques which are certainly more complex, time consuming & expensive than provisional stenting.  None of the RCT’s studies showed a clear advantage for routine double stenting over a provisional strategy.  Other side of coin is patients with complex bifurcation anatomy such as large SBs with severe disease extending more than a few mm from the ostium were not well represented in these trials.  There is still a need for an individualized approach to bifurcation PCI & that 2 stents are still needed in 20-30% of true bifurcations . APPROACH TO BIFURCATION LEISONS elective double vessel stenting
  51. 51. APPROACH TO BIFURCATION LEISONS The culotte technique
  52. 52. The culotte technique  It provides near-perfect coverage of the carina & SB ostium at the expense of an excess of metal covering in proximal MB.  Best immediate angiographic result & theoretically it may guarantee a more homogeneous distribution of struts & drug .  Can be used in all bifurcation lesions irrespective of bifurcation angle.  Open-cell stents are preferred when the SB diameter is >3 mm.  Disadvantages –  Complexity in the rewiring of both branches through the stent struts,  Not advisable if both branches are dissected after predilatation. APPROACH TO BIFURCATION LEISONS
  53. 53. Culotte technique  Not advisable when there is large discrepancy in vessel size between the proximal MB and the SB because the proximal segment of the SB stent will not attain good apposition to the vessel wall of the proximal MB .  Conventional practice - challenged in the Nordic Stent Technique Study, where the authors recommended stenting of the MB first to avoid acute closure of the MB.  This approach guarantees patency of the MB APPROACH TO BIFURCATION LEISONS
  54. 54. APPROACH TO BIFURCATION LEISONS The crush technique
  55. 55. The crush technique (SB stent crushed by the MB stent)  immediate patency of both branches is assured & therefore it should be applied in conditions of instability or when the anatomy appears complex.  should be avoided in wide angle bifurcations.  Only SB has to be re-wired & not both branches as in culotte technique.  The crush technique has evolved and is nowadays performed with less stent protrusion into the MB (i.e., mini-crush) & mandatory 2-step FKI.  crush” technique can therefore be considered as a sort of simplified “culottes” technique  The mini-crush may be associated with more complete endothelialisation and easier re-crossing of the crushed stent. APPROACH TO BIFURCATION LEISONS
  56. 56. APPROACH TO BIFURCATION LEISONS
  57. 57. 1. Inability to wire the SB.  Make Sure That The Wire Is Directed Towards The Distal Part But Not The Proximal Part.  If The Primery Guide Wire Failes Try Hydrophilic Wires. If They Also Fail Consider Tapered Tip Wires(MIRACLE). 2. INABILITY TO PASS BALOON IN TO SB.  USE COMPLIANT MONORAIL 1.5 MM BALOON.  IF FAILS REWIRE SB THROUGH A DIFFERENT SITE AND RE ATTEMT BALOON CROSSING.  IF FAILS THEN USE FIXED WIRE BALOON SYSTEMS. Potential failure modes of crush and suggested solutions APPROACH TO BIFURCATION LEISONS
  58. 58. REVERSE CRUSH TECHNIQUE main reason for performing the “reverse crush” is to allow an opportunity for provisional SB stenting APPROACH TO BIFURCATION LEISONS
  59. 59. Step crush The final result is basically similar to the one obtainedwith the “standard crush” technique, with the only differencebeing that each stent is advanced and deployed separately so that a 6 F guide may be used. APPROACH TO BIFURCATION LEISONS
  60. 60. Dk crush  In the DK crush, kissing balloon (KB) inflation is performed after crushing the SB stent with a balloon.  This technique facilitates access to the SB in addition to optimising stent apposition at the SB ostium. APPROACH TO BIFURCATION LEISONS
  61. 61. APPROACH TO BIFURCATION LEISONS
  62. 62. T- and modified T-techniques  The T-technique is the most frequently utilised to crossover from provisional stenting to stenting the SB and is most suited to bifurcations where the angle between the branches is close to 90°.  associated with the risk of leaving a small gap between the stent implanted in the MB and the one implanted in the SB.  In majority T-stenting technique is performed after MB & provisional SB stenting for a suboptimal result or flow-limiting dissection in the SB. APPROACH TO BIFURCATION LEISONS
  63. 63. APPROACH TO BIFURCATION LEISONS modified T-technique
  64. 64. APPROACH TO BIFURCATION LEISONS V technique
  65. 65. SKS TECHNIQUE APPROACH TO BIFURCATION LEISONS
  66. 66. V & simultaneous kissing stent (SKS) techniques • Advantages –  Access to both branches is always preserved during the procedure with no need for rewiring any of the branches.  V-stenting is relatively easy and fast.(ideal in emergencies). • V-stenting is ideal for Medina 0,1,1 bifurcations with a large proximal MB that is relatively free from disease & with a <90° distal angle. • Reserve this technique for patients with a short LMCA free from disease & critical disease of both the LAD and LCX ostia. APPROACH TO BIFURCATION LEISONS
  67. 67.  LIMITATIONS –  balloon barotrauma to the proximal MB.  If a proximal stent is needed almost always the risk of leaving a small gap.  final kissing inflation is performed there is no need to re-cross any stent.  Generally try to limit the length of the new carina to < 5 mm. APPROACH TO BIFURCATION LEISONS
  68. 68. 2011 ACCF/AHA/SCAI Guideline for PCI APPROACH TO BIFURCATION LEISONS
  69. 69. Favourable features for provisional stenting in unprotected LMCA  inSignificant stenosis at the ostial LCX with MEDINA 1,1,0 or 1,0,0  Large size of LCX with >2.5mm in diameter  Right dominant coronary system  Narrow angle with LAD  No concomitant disease in LCX  Focal disease in LCX APPROACH TO BIFURCATION LEISONS
  70. 70. UNFavourable features for provisional stenting in unprotected LMCA  significant stenosis at the ostial LCX with MEDINA 1,1,1; 1,0,1 or 0,1,1.  Diminutive LCX with <2.5mm in diameter  Left dominant coronary system  Wide angle with LAD  Concomitant disease in LCX  Diffuse disease in LCX APPROACH TO BIFURCATION LEISONS
  71. 71. L.M.C.A. BIFURCATION STENTING APPROACH TO BIFURCATION LEISONS
  72. 72. IVUS in bifurcation stenting  Determining anatomic configuration, selecting treatment strategy & assessing final result are key factors in bifurcation lesion treatment that may have a significant impact on acute and long-term outcomes.  Furukawa et al demonstrated that side branches showing at IVUS diffuse plaque around the ostium with >50% stenosis were at higher risk for occlusion.  SB occlusion was uncommon (<10%) after PCI if no plaque was present at the side branch ostium.  Important role in the decision-making process when treating a distal LMCA bifurcation stenosis. APPROACH TO BIFURCATION LEISONS
  73. 73. IVUS guidance for bifurcation lesion PCI  IVUS can select the appropriate stent size and length as well as guiding the most appropriate technique.  Helpful in optimally expand the stent avoiding stent under-expansion, malapposition, incomplete lesion coverage & overstretch of stent diameter.  “Incomplete crushing”, defined as incomplete apposition of side branch or main vessel stent struts against the main vessel wall proximal to the carina, was found in > 60% of lesions – mechanism for high restenosis rate.  Therefore, optimisation of the result in the side branch is still the goal even in the DES era APPROACH TO BIFURCATION LEISONS
  74. 74. Impact of IVUS guidance on outcome  Park et al in 758 pts - non-LMCA bifurcation lesions : IVUS-guided stenting significantly ↓ very late stent thrombosis in the DES group, while it did not have any effect on TLR.  Stent under-expansion, incomplete lesion coverage, edge dissections & longitudinal plaque shifting, which likely contribute to DES thrombosis are often missed by CAG & are detected by IVUS.  MAIN-COMPARE registry in LMCA lesions - undergoing PCI of the LMCA, 77.5% were treated with IVUS guidance.  3-year outcome showed a strong trend towards a lower mortality risk with IVUS guidance group. APPROACH TO BIFURCATION LEISONS
  75. 75. FFR in bifurcation stenting  Bifurcation lesion is very unique as it is the only lesion in which stenting is not better than angioplasty & even angioplasty is not better than a “leave it alone” strategy.  CAG evaluation overestimates the functional severity of jailed SB lesions in every step of the provisional strategy for bifurcation lesions.  FFR-guided provisional side branch intervention strategy is feasible & effective.  Functional status of jailed SB lesions after DES implantation does not change significantly during follow-up. APPROACH TO BIFURCATION LEISONS
  76. 76.  CAG evaluation is more difficult for bifurcation lesions due to vessel overlap, angulations, stent struts across SB & image foreshortening.  It is technically difficult to perform IVUS or OCT in jailed SB lesions.  FFR can be easily measured in bifurcation lesions both before & during intervention.  CAUTION - When FFR is measured for SB ostial lesions, the influence of proximal & distal lesions should be considered.  If there is a significant proximal stenosis, FFR overestimates the severity of SB ostial lesion.  In contrast, FFR underestimates the lesion severity when there is a significant distal SB lesion. APPROACH TO BIFURCATION LEISONS
  77. 77. Limitations of conventional bifurcation stenting  MV stent distortion by side access  Side branch and wire jailing  Side branch accessibility  Limitations in re-wiring, re-ballooning and stenting of SB  FKI with danger of dissection  Wire crossings  Incomplete coverage of bifurcational area  Complexity, duration and contrast and X ray exposure APPROACH TO BIFURCATION LEISONS
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  101. 101. Conclusion  Bifurcation stenosis pose a technical problem.  The complexity of the lesion treatment lies in SB.  Potential reasons for 1 ̊ or 2ry failure in stenting the SB are : Presence of gap between the 2 stents Carina/ Plaque shifting from MB Injury to SB ostium- excessive balloon artery ratio APPROACH TO BIFURCATION LEISONS
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