This slides contains summeries of everything you need to know about PTCA of bifurcation lesion

1. Cath Presentation
Dr. Azim Anwar
Phase B Resident
UCC,BSMMU
Chairperson
Prof Professor Syed Ali Ahsan

2. • Afsar Ali, 45Y
• Chest Pain, SOB- 2 days
• Prev H/O- PCI to LAD, LCX >> 2012
• DM, HTN
• 110/80 mmhg, 97bpm, Soft HS1
• ECG: ST-T changes in V1-V6
• Trop I: 4ng/ml >> 12 ng/ml
•Diagnosis: NSTEMI with DM with HTN

3. Stent in situ- LAD, LCX

4. LAD stent in situ- Osteoprox-Distal part

5. dLM- 30-40%, opLCX-70%, opLAD-70%

6. opLCX- 70-80%, dLCX- 40-50%

7. opLCX- 70-80%

8. LAD- O/P 70% stenosis with ISR

9. dLAD- 60-70% stenosis with ISR

10. mRCA- 30-40%, dRCA- 40-50%

12. Consideration. . . .
1.Revascularisation / OMT ?
2. PCI / CABG ??
3. Technique ???
4. What about the guidelines ????

16. Syntax Scoring

26. Main Consideration: The Branch
• Will the side branch close?
1. Plaque at ostium and angulation (Aliabadi: Am J Cardiol,1997;80:994-997)
• Is the side branch large enough to Stent? (>2.5 mm) Dauerman HL, et al.
JACC.1998;32:1845-52)
• Is the side branch plaque lengthy (not focal)?
• Is the sidebranch angle (<70o ) ?
• Will it be difficult to rewire after main branch stent?

27. Stenting strategy in bifurcation
lesions—one or two stents?

28. Approach to Bifurcation lesion:

29. Important Notes
• Wiring starts with the most difficult branch.
• The second wire is inserted into the easier branch by limited
rotation manoeuvres to avoid wire wrap.
• Predilatation of the SB does reduce the risk of SB compromise after
MV stenting and also relieves ischemia in the SB territory.
• The diameter of the stent should be selected according to the distal
MB (not the proximal MB) in order to avoid excess carina shifting.

30. • The proximal part of the stent prior to the bifurcation may be
dilated with a short 0.5 mm bigger balloon. This is called “POT
technique”.
• The 7F or 8F guide catheters are preferred to reduce friction among
the hardware and allow easy manipulation
• IVUS should be used to choose the optimal stent size and to assess
the adequate stent deployment or requirement for post dilatation
of the stents.

31. Jailed guide wire
• A nonhydrophilic guide wire should be used.
• During deployment of the stent which jails the guide wire (jailing
stent), nominal pressure should be used so that retrieval of the jailed
wire is easier.
• The guide catheter should be pulled back into the aorta before
removing the jailed wire.
• In case the “jailed wire” cannot be pulled back easily, a balloon can be
advanced over the jailed wire.

32. Final kissing balloon inflation
• Using noncompliant balloon is an essential step to optimize
results.
• Balloon pressures during FKI should be nominal

33. IVUS guidance for bifurcation lesion PCI
• Selection of appropriate stent size and length
• Guiding the most appropriate technique
• Optimal expantion of stent avoiding stent under-
expansion, malapposition, incomplete lesion coverage
& overstretch of stent diameter

34. T
technique

35. V
technique

36. Culotte
technique

37. SKS
technique

38. Crush technique
• Classic Crush
• Mini Crush
• Double Kissing Crush (DK Crush)
• Reverse Crush

39. Crush
technique

40. Mini-Crush
• 1-2 mm of SB stent positioned in MV (proximal SB stent marker on MB wire or SB just covers
proximal edge of ostium)
• The SB stent is deployed & stent balloon withdrawn slightly with high RBP inflation (flares
proximal stent) – then angiogram to make sure no distal dissection
• The SB is crushed by a MV balloon or a stent
Ormiston J, JACC Intervention 2008

41. Mini-Crush
• Rewire SB with two step dilatation
• SB – high pressure dilatation NC balloon and then HP NC MB
• Final kissing balloon inflation 12 ATM
Ormiston J, JACC Intervention 2008

42. DK crush
 Position sidebranch stent in conjunction with a balloon in the mainbranch
 Deploy sidebranch stent
 Remove sidebranch balloon and wire
Crush sidebranch stent with mainbranch balloon
 Rewire sidebranch and perform a kissing balloon inflation

43. DK crush
 Remove sidebranch wire and balloon
 Position stent in the mainbranch and deploy it
 Rewire sidebranch and perform final kissing balloon inflation

44. Unsatisfactory result
• More than 75% residual stenosis
• Dissection in SB
• TIMI flow grade less than 3 in a SB more than 2.5 mm diameter
• Fractional flow reserve less than 0.75
• Persistent intraprocedural angina or electrocardiogram (ECG)
changes

45. Summary
• Bifurcations remain a challenge for PCI
• Provisional stenting preferred when possible
• Double wire when in doubt
• Final kiss provides better results
• Dedicated stents are a nice concept but have not improved
results when available