Ostial & Bifurcation Lesions

Interventional Fellow Lecture

Series
 Bifurcation Lesions
• 20% of all PCI procedures
• Higher Acute Complication Rates
• Lower Success Rates
• Higher restenosis and TLR rates
– Restenosis Rate 21-57%
– TLR 8-43%
Bifurcation Lesions

Classification
Syntax Trial Classification
 Medina Classification of Bifurcation Lesions

Latib, A. et al. J Am Coll Cardiol Intv 2008;1:218-226

Bifurcation Lesions

Stenting Techniques
Provisional Approach
Main Vessel Sidebranch Double Wire Predilatation
Usually only
main branch
dilatation
1. The first step is to wire both the MV and the SB.
2. Next step is to decide the pre-dilation device for the MV and/or the
SB.
Stent Main Branch Remove Wire Rewire Sidebranch

3. Then, a stent is placed in the MV. The stent should be deployed at a pressure of
12–18 atm while leaving the SB wire to prevent plaque shift, closure or dissections
in the ostium. Rarely, post-dilation with a high-pressure balloon may be needed at
the area of maximal plaque burden for full stent expansion.
Kissing Postdilatation Ideal Final Result

4. If angiographic results in the MV and SB are satisfactory, the

procedure is completed and trapped guidewire in the SB behind the
stent struts can be removed gently.
The classic “T” technique consists of positioning Advantages
a stent first at the ostium of the SB, being careful This technique is simple and
to avoid stent protrusion into the MV technically less demanding.
Some operators leave a balloon in the MV to help It can be used for the
further locating the MV. coverage of lesions located
proximal tothe bifurcation.
After deployment of the stent and removal of the
balloon and the wire from the SB, a second stent Disadvantages
is advanced in the MV. In almost all cases, this
A wire is then re-advanced into the SB, and final technique leads to
kissing balloon inflation is performed. incomplete coverage of the
ostium of the SB.
The culottes technique uses
two stents and leads to full
coverage of the bifurcation
at the expense of an excess
of metal covering of the
proximal end
Both branches are pre-
dilated.
First a stent is deployed
across the most angulated
branch, usually the SB.
The non-stented branch is
then rewired through the
struts of the stent and
dilated.
A second stent is advanced
and expanded into the non-
stented branch, usually the
MV.
Finally, kissing balloon
inflation is performed.
 Culotte
Advantages
This technique is suitable for all angles of bifurcations
and provides near-perfect coverage of the SB ostium.

Disadvantages
This technique leads to a high concentration of metal
with a double-stent layer at the carina and in the
proximal part of the bifurcation.
The main disadvantage of the technique is that rewiring
both branches through the stent struts can be difficult
and time consuming.
V Technique consists of the delivery and implantation of two stents
together.
One stent is advanced in the SB, the other in the MV, and the two
stents touch each other, forming a small proximal carina
When the carina extends a considerable length (usually 3 mm) into
the main vessel, this technique is called simultaneous kissing
stents (SKS)
 SKS
• Advantages
The main advantage of these techniques is that the
access to either of the two branches is never lost.
• In addition, when a final kissing inflation is performed,
there is no need to recross any stent. Also, these
techniques provide a definite SB coverage, irrespective
of the angulation.

• Disadvantages
Potential of leaving a gap.
• Does not work for all angles
Crush:
Stent of the SB is deployed, and its
balloon and wire are removed.
The stent subsequently deployed in
the MV flattens the protruding cells
of the SB stent
Wire recrossing and dilation of the
SB with a balloon of a diameter at
least equal to that of the stent, and
then final kissing balloon inflation, is
recommended.

Advantages
The main advantage of the crush technique is that the immediate patency of both branches
is assured. In addition, this technique provides excellent coverage of the ostium of the SB.

Disadvantages
The main disadvantage is that the performance of the final kissing balloon inflation makes
the procedure more laborious because of the need to re-cross multiple struts
with a wire and a balloon.
The Reverse Crush
The main indication for performing the reverse crush is to allow an
opportunity for provisional SB stenting.
A stent is deployed in the MV, and balloon dilation with final kissing inflation
toward the SB is performed.
It is assumed that the result of the SB is suboptimal and hence stent
placement will be needed.
A second stent is advanced into the SB and left in position without being
deployed.
Then a balloon of the size matching the diameter of the MV is positioned at
the level of the bifurcation, making sure to retain inside the previously
deployed MV stent.
The stent in the SB is retracted about 2–3 mm into the MV and deployed,
the deploying balloon is removed, and an angiogram is obtained to
ascertain whether a good result is present at the SB (no further distal stent
in the SB is needed).
If this is the case, the wire from the SB is removed and the balloon in the
MV is inflated at high pressure, with final steps involving re-crossing into the
SB, performing SB dilation, and final kissing balloon inflation.
The Y Technique
This technique involves an initial pre-dilation,
followed by stent deployment in each branch
If the results are not adequate, a third stent
may also be deployed in the MV. This
technique is not commonly used at the
present.

Advantages
This technique is a last resort for treating
such demanding bifurcations in which there
is a need to maintain wire access to both
branches.

Disadvantages
The major limitation of this approach is
inadequate coverage of MV and SB
Bifurcation Lesions

Trial Data
 Concepts in Bifurcation Lesions
• Appropriate use of drug-eluting stents (DES)

• Randomized-controlled trials specifically in bifurcations

• Selective usage of 2 stents as intention-to-treat

• Acceptance of a suboptimal result in the side branch (SB), i.e., one

stent only on the main branch (MB), when treating bifurcations
involving a minor SB

• Better performance of any 2-stent technique

– (high pressure post-dilation, kissing inflation, and possibly intravascular
ultrasound)
 Registry Studies
• DES have become the preferred stent platform for the treatment of
coronary bifurcations.

• Marked reductions in MACE and target lesion revascularization

(TLR) rates compared with historical BMS controls.

• 1-stent strategy (MACE: 5.4% vs. 38%; TLR: 5.4% vs. 36%)
• 2-stent strategy (MACE: 13.3% vs. 51%; TLR: 8.9% vs. 38%)

• BMS indications:
– 1) contraindications to prolonged dual antiplatelet therapy;
– 2) Possibly in acute myocardial infarction due to concerns about a
higher risk of stent thrombosis
1 vs 2 Stents Strategy
 Nordic Trial
• Evaluate stenting of the main vessel and side branch
compared with a strategy of stenting of the main vessel
only and optional stenting of side branch

• Drugs/Procedures Used
– Stenting of the main vessel and side branch (MV+SB; n = 206)
– Stenting of the main vessel and optional stenting of side branch
(MV; n = 207)
– Following main vessel stenting, the side branch was dilated in
patients in the MV+SB group if TIMI flow grade was <3.
– If TIMI flow grade was 0 after dilation, the side branch was then
stented.
– Repeat angiography was performed at 8 months.
No significant statistical differences between provisional stenting and
comitted 2 stent strategy. Differences in crossover related to definition of
mandatory SB stenting.
 Importance of Sidebranch
• Koo et a. JACC 2005:
– FFR measurements on 94 jailed SB lesions
after stent implantation on the MB.
– No lesion with a 50% and <75% stenosis had
a FFR <0.75.
– Among 73 lesions with >75% stenosis, only
20 lesions were functionally significant.
 2 Stent Technique
• Niemela et al.: The Nordic Stent
Technique Study:
• A Randomized Study of Crush vs. Culotte
Stent Techniques with Sirolimus Eluting
Stents in Bifurcation Lesions
– Randomized study comparing 2 different 2-
DES techniques (Culotte vs. Crush).
– No difference in clinical outcomes at 6 months
– No long-term follow-up
Kissing Inflation
 2 Stent Technique
• Insufficient randomized data
• Multiple proposed algorithms to approach
bifurcation lesions
• Provisional stenting is preferred method
• 2 Stent Strategy for “true” bifurcation
lesions and large SB
Proposed Algorithm for Treating Coronary Bifurcations

Latib, A. et al. J Am Coll Cardiol Intv 2008;1:218-226

 Medina Classification of Bifurcation Lesions

Latib, A. et al. J Am Coll Cardiol Intv 2008;1:218-226

 General Current Approach
• Two wires should be placed in most bifurcations, and the SB wire should be
"jailed" in the majority after the deployment of the stent on the MB.

• This approach is important in protecting the SB from closure as the result of

plaque shift and/or stent struts during MB stenting.

• The jailed SB wire also facilitates rewiring of the SB

• TULIPE (Provisional T-stenting for Coronary Bifurcation Lesion Prospective

Evaluation) study: absence of jailed wire in sidebranch was associated with
a greater rate of reinterventions

• There is no need to remove the jailed wire during high-pressure stent

dilation in the MB.

• Avoid jailing hydrophilic guidewires because there is a risk of removing the

polymer coating.
Ostial Disease
 Main Branch Ostial Disease
• Important to accurately place stent to cover the lesion
entirely without protruding into the main branch.

• Intravascular ultrasound may be helpful to facilitate

appropriate stent placement.

• Two general approaches to treating these lesions:

– (a) placement of a stent at the ostium of the main vessel with a
balloon protecting the SB and with inflation of the SB balloon,
and kissing balloon only if plaque shift occurs
– (b) placement of a stent in the main vessel covering the origin of
the SB and then wiring the SB and performing kissing balloon
inflation in case the ostium of the SB deteriorates.
 Side Branch Ostial Disease
• Isolated ostial lesions of SB:
– The most common approach in treating these lesions is to place
a stent at the ostium of the SB, frequently with a low pressure
balloon inflated in the MV (stent pull-back technique)

• If there is deterioration of the main vessel at the site of

the bifurcation after stent placement, the balloon in the
main vessel is inflated, protecting the stent by a
simultaneous inflation of the stent delivery balloon.

• In cases of suboptimal angiographic results in the main

vessel, a stent can be deployed with final kissing balloon
dilation.
 Aorto-Ostial Disease
• Prior to any PCI intracoronary Nitroglycerin should be
administered to rule out catheter induced spasm.

• Judkins Catheter is generally employed, side-hole

catheter in case of damping. Coaxial alingment and
avoidance of deep intubation.
Aorto-Ostial Disease
Aorto-Ostial Disease
 Aorto-Ostial Disease
• A series of small studies, no major randomized trials

• One study (Iakouvou et al.) reported benefit in TLR for

Cypher (6.3% vs 28%) and angiographic restenosis
(11% vs 51%)

• Some small studies comparing stents to lasers,

atherectomy, cutting balloon, but none showed
superiority to stenting
Thank You