Bifurcation Stenting: A primer Creighton Don, MD Assistant Professor of Cardiology University of Washington

Bifurcation lesions Why How The data…

Bifurcation lesions:why Large side branch supplying a reasonable territory Left main Cx-large OM LAD-large diag Ostial Cx/LAD RCA-PDA-PLV Disease in the main branch and ostium/proximal side branch Concern for losing the side branch Rescuing dissected/occluded/jailed side branch

Bifurcation lesions: HOW Step 1: Classify lesion Location of disease (Medina classification) Extent of disease (focal?) Size of prox/distal main branch and side branch Angulation of side branch “True Bifurcation” lesion http://www.sciencedirect.com/science/article/pii/S1936879812005572 Levy MS, Moussa ID. “Bifurcation Lesions and Interventions,” in SCAI Interventional Cardiology Board Review. 2nd ed. 2013. Sgueglia GA. Chevalier B. JACC Cardio Interv. 2012.

Bifurcation lesions: HOW Step 2: Decide on approach Not true bifurcation, side branch expendable or diffusely diseased, or not technically possible Provisional True bifurcation and suitable for stenting V-stenting Simultaneous Kissing Stents T-stenting Crush Mini-crush Reverse crush Tap Culotte

Provisional stenting Side branch free of disease, too small, too diseased 1. Wire main branch +/- side branch for “protection” 2. Stent main branch 3. Assess flow in side branch—IF compromised: 4. Rewire side branch and PTCA, culotte, T-stent, reverse crush, TAP Louvard V. Catheterization and Cardiovascular Interventions 71, (2) 175-183, 2007. http://onlinelibrary.wiley.com/doi/10.1002/ccd.21314/full#fig1

Recrossing Zhang JJ, Chen SL, Ye F, et al. Mechanisms and clinical significance of quality of final kissing balloon inflation in patients with true bifurcation lesions treated by crush stenting technique. Chin Med J (Engl) 2009;122:2086 –91. HR: 2.34, 95% confidence interval [CI]: 1.78 to 4.32, p < 0.001).

V-stenting No disease proximal to the branch Angle < 90 degrees Medina 0,1,1 Angle < 90 degrees No loss of side branch, no recrossing

True bifurcation stenting

Simultaneous kissing stents Double barrel Larger proximal vessel, smaller distal/side branch Simple to position/deploy, no loss of access, no recrossing Neocarina Challenging to recross, reintervene Increased thrombosis/restenosis? P. Mortier, M. De Beule, G. Dubini, Y. Hikichi, Y. Murasato, J.A. Ormiston Coronary bifurcation stenting: insights from in vitro and virtual bench testing EuroIntervention, 6 (Suppl J) (2010), pp. J53–J60

Crush, Mini-Crush Treats side/main branch without losing access Can treat size mismatched vessels Good for shallow angle bifurcation Complete coverage of carina Lots of metal over side branch/carina Difficult to recross More restenosis 1. Position both stents 2. Inflate side branch stent 3. Inflate main branch stent (Crush) 4. Recross and kiss

Reverse Crush Bail out for provisional stenting May be difficult to recross side branch stent Insures coverage of carina Doesn’t commit to bifurcation stent from beginning 1. Stent main branch 2. Wire and stent side branch 3. Crush side branch stent with a balloon in the main branch 4. Recross and kiss 2 4 1 3

T-Stenting Simple, can treat size mismatched vessels Can lose one branch while treating the other Need to recross stent Good for angles closer to 90 degrees Uncovered carina (<90 degrees) If the side stent is deployed into the main branch, then this may be called a “mini-crush or a modified-T stent

Culotte Complete coverage Good for shallow angle, harder for steep angle Loses access to alternate branch twice Recross stents twice Requires relatively equal sized vessels Difficulty advancing 2nd stent 1. Stent one branch 2. Wire and stent other branch 3. Recross original branch and kiss

T-stenting with protrusion (TAP) http://c2i2.digithalamus.com/vol_v_issue_2/Management_of_bifurcation_lesions.asp Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

Bifurcation stenting: why? Pro: Protects side branch Reduces ischemic burden Easier at the time of the PCI May not be able to salvage side branch after main branch is stented Con: More time, radiation, contrast More restenosis Jeopardizes the main branch Side branch lesion often not significant Side branch often stays open

BMS vs DES: One vs. two stents Yamashita T, et al. Bifurcation lesions: two stents versus one stent - immediate and follow-up results. J Am Coll Cardiol 2000;35:1145-51. Ge L, et al. In-hospital and 9-month outcome of treatment of coronary bifurcational lesions with sirolimus-eluting stent. Am J Cardiol 2005;95:757-60. Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

DES: One vs. two stents NS Steigen TK, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation 2006;114:1955-61. Colombo A, et al. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation 2004;109:1244-9. Pan M, et al. Rapamycin-eluting stents for the treatment of bifurcated coronary lesions: a randomized comparison of a simple versus complex strategy. Am Heart J 2004;148:857-64. Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

Nordic bifurcation studies Nordic I: Provisional versus 2 stent 70% with ‘true bifurcation’ lesions Similar procedural success, longer fluoro/procedure time Increased biomarker elevations MACE Stent thrombosis http://summitmd.com/pdf/pdf/1163_Erglis%20Korea.pdf Steigen TK et al. Circulation. 2006;114:1955-1961

Meta-analysis Brar SS, EuroIntervention. 2009 Sep;5(4):475-84

FFR of jailed side branches Nordic-Baltic Bifurcation Study III Provisional stentingFFR if TIMI 3 flow Randomized to kissing or no kissing Post-PCI 8-mo Koo BK, et al. Physiologic assessment of jailed side branch lesions using fractional flow reserve. J Am Coll Cardiol 2005;46:633-7. % stenosis FFR Kumsars I, Narbute I, Thuesen L, et al. Side branch fractional flow reserve measurements after main vessel stenting: a Nordic-Baltic Bifurcation Study III substudy. EuroIntervention 2012;7:1155– 61.

To Kiss or not to kiss Chen SL, Santoso T, JACC 2011 Sgueglia GA. Chevalier B. JACC Cardio Inter. 2012.

Balloon size for kissing Sgueglia GA. Chevalier B. JACC Cardio Inter. 2012.

AHA/ACC/SCAI Guidelines CLASS I: Provisional side-branch stenting should be the initial approach in patients with bifurcation lesions when the side branch is not large and has only mild or moderate focal disease at the ostium. (Level of Evidence: A) CLASS IIa: It is reasonable to use elective double stenting in patients with complex bifurcation morphology involving a large side branch where the risk of side-branch occlusion is high and the likelihood of successful side-branch reaccess is low. http://content.onlinejacc.org/article.aspx?articleid=1147816 Levine GN et al. JACC. Volume 58, Issue 24, December 06, 2011

Dedicated bifurcation stents Stentys Nitinol and cell design allow for side branch expansion Tryton Open cells in main branch allowing a “culotte” Sideguard Nitinol stent, ostium flares allowing “T-stenting” Antares II Double lumen stent, maintain side branch access Laborde J-C, EuroInterv.2007;3:162-165 http://www.trirememedical.com/products/procedure-animation.aspx

Take home points Keep it simple—use a provisional approach whenever possible If you’re unsure, wire the side branch ahead of time If the side branch needs to be ballooned, end with a kiss BUT, TIMI 3 flow and <50% stenosis can be left alone Consider FFR if you’re on the fence Large side branches with disease >5 mm likely require 2-stent strategy Difficult to access side branch may favor 2-stent strategy True complicated bifurcations will be easier to treat with a two stent strategy if you plan ahead E.g. recrossing into a diseased/jailed/occluded side branch can be challenging and upsizing your guide is painful Pull your trapped wires before post dilating (keep track of your wires) http://www.pcronline.com/eurointervention/27th_issue/06/ Hildick-Smith D et al. EuroIntervention. 6 (1). 2010.

Know your techniques http://www.medscape.org/viewarticle/727014_2