interventional cardiology presentation

1. Bifurcation Lesions
By
Ahmed Kamel,MD,FEBC
National heart institute
Member of the European association of
percutaneous cardiovascular
intrvention

2. 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.

3. Classifications

4. 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.

5. • 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

6. • 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.

7. Commonly used PCI Strategies
Provisional stenting
The 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.

8. 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 stenting
4. T and protrusion (TAP)
5. V stenting
6. Simultaneous kissing stents SKS

9. 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.

10. • 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.

11. 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.

12. 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

13. Provisional Stent Technique:
The ‘simplest’ way to treat a bifurcation
lesion
Wire both vessels
Pre-dilate as
needed
Stent main branch
Rewire and
balloon side
branch (+/- kissing
balloon inflation
Side
Branch
Main
Branch

14. 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

15. The Crush Technique
•
Wire both vessels
Pre-dilate as needed
Position stents
Deploy side branch stent,
remove balloon/wire
Deploy main branch stent-
‘crushes’ side branch
stent
Rewire side branch and
perform kissing balloon
inflation
Main
Branch
Side
Branch

16. The Crush Technique

17. 2 layers of stent separate side branch
from the main branch…. can be
difficult to re-wire!

18. The Evolution of the ‘Crush’
Technique:
Post-Crush Kissing Balloon Inflation
After Kissing
Balloon Inflation
Before Kissing
Balloon Inflation

19. Kissing Balloons: Before and After

20. Classic Crush Technique Mini Crush Technique

21. 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

22. The Simultaneous Kissing Stent
(SKS) Technique
Wire both vessels
Pre-dilate as needed
Position stents
Deploy stents
simultaneously
Perform kissing balloon
post-dilatation
Main
Branch
Side
Branch

23. 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

24. The TAP Technique
(T stent And Protrusion)
Wire both vessels
Pre-dilate as needed
Position and deploy main
branch stent
Rewire side branch and
balloon dilate
Position side branch stent
so proximal edge
protrudes slightly into
main branch, ‘backstop’
balloon in main branch
Deploy side branch stent
first, then inflate main
branch balloon to kiss
Main
Branch
Side
Branch

25. 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

26. Culotte Technique
Wire both vessels
Pre-dilate as needed
Position and deploy stent
in most angulated branch
Remove first wire, wire
second branch and
balloon dilate
Position second branch
stent so proximal portion
equal with previous stent
edge and deploy
Rewire initially stented
branch and perform
kissing post-dilitation
Main
Branch
Side
Branch

27. Culotte Technique
Advantages:
• Complete coverage
• Good radial strength
Disadvantages :
• Complex
• Time consuming
• More restenosis than
single Stent

28. A final message to remember
• Finally an interventional cardiologist should keep
in mind the KISSSprincipal
Keep it safe
Keep it simple
Keep it swift

29. .. Let us go to the cases
Now