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

2. Bifurcation lesions
Why
How
The data…

3. 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

4. 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
Levy MS, Moussa ID. “Bifurcation Lesions and Interventions,”
in SCAI Interventional Cardiology Board Review. 2nd ed
Sgueglia GA. Chevalier B. JACC Cardio Interv

5. 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

6. 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) ,

7. 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).

8. 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

9. True bifurcation stenting

10. 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

11. 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

12. 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

13. 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

14. 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

15. T-stenting with protrusion (TAP)
Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

16. 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

17. 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:
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:
Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

18. 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:
Colombo A, et al. Randomized study to evaluate sirolimus-eluting stents implanted at coronary bifurcation lesions. Circulation 2004;109:
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:
Latib A, Columbo A. Controversies and Consensus in Imaging and Intervention. Vol 5, 2, 2007.

19. 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
Steigen TK et al. Circulation. 2006;114:

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

21. 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.

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

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

24. 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.
Levine GN et al. JACC. Volume 58, Issue 24, December 06, 2011

25. 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:

26. 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)
Hildick-Smith D et al. EuroIntervention. 6 (1)

27. Know your techniques