Bifurcation pci

1. Bifurcation lesion
Dr. Md. Ahasanul Kabir
Resident, Phase-B
UCC, BSMMU

2. Bifurcation lesion
Definition:
-Lesions occurring at , or adjacent to, a significant division of a major epicardial
coronary artery.
True Bifurcation:
-Main branch(MB) and side branch(SB) are both significantly narrowed(>50%
stenosis)
Non-true Bifurcation:
-All other lesions that are involved in bifurcation.

4. Epidemiology
15-20 % of all PCIs involve bifurcations of importance
Lower initial success rate
Higher restenosis rate
Higher thrombosis rate

8. Why challenging?
• 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

9. Anatomical Considerations
Y-angulation precise stent placement with complete ostial coverage is
often difficult or geometrically impossible.

11. Stenting of bifurcation lesions
Provisional:
Main vessel stenting ± side branch angioplasty
(Provisional) T-stenting, TAP,
REVERSE INTERNAL CRUSH, REVERSE CULOTTE.
Elective:
Culotte-stenting
Crush technique (reverse crush)
T TECHNIQUE AND TAP
V STENTING
Y STENTING(SKS technique)

13. When a wire is needed in the SB?
The SB has a narrowing at its ostium.
The MB has severe stenosis with a large plaque burden and the SB
originates with an angle of <45°.
The ostium of the SB deteriorates after predilatation of the MB

14. 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.

15. 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.

16. 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.

17. Approach to Bifurcation lesion:

20. ESC says:

22. THANK YOU