Side branch stenosis

1. Side branch stenosis /closure
Dr Sandeep Bansal,
MD ( Internal Medicine )-PGIMER,Chandigarh
DM(Cardiology),DNB(Cardiology),MNAMS,
FESC,FSCAI,FCAPSC,FAPSIC,FIMSA,FISC
Consultant in Cardiology
Professor and Head
Department of Cardiology
Vardhman Mahavir Medical College and Safdarjung Hospital,
New Delhi-110029, India

2. Seven classification systems for bifurcation lesion

3. Anatomical, physiological and clinical relevance of
a side branch : Which branch really needs a stent?

4. -,,LAST DIGIT - 0
LAST DIGIT -1

5. THE ANGLE
ANGLE – A- IF <110 MAY COMPLICATE
WIRE INSERTION AND CHANGES AFTER
WIRE INSERTION
ANGLE – B- PREDICTIVE OF SIDE
BRANCH CLOSURE SO WIRE IT
WIRING SIDE BRANCH AND JAILING IT IS THE MOST
IMPORTANT STEP TO KEEP SIDE BRANCH OPEN IN
BIFURCATION PCI .

6. Incidence and Angiographic Predictors of Side Branch
Occlusion Following High-Pressure lntracoronary Stenting
Proposed mechanisms of SBO include
• “snow plow effect,”
• Carinal shift
• thrombus formation,
• dissection,
• spasm,
• plaque embolization, and
• side branch ostial compromise by stent
material.
Threatened side branch morphologies characterized by side branches
• with >50% ostial narrowing
• when origin is spanned by the diseased segment of the index lesion (la),
• arises adjacent to, but is partially contiguous with, 3 e diseased index lesion (1 b).
• In the TULIPE study , only the angle between the side branch and the main branch was
predictive of side branch occlusion

7. Natural history of small and medium-sized side
branches after coronary stent implantation

8. Incidence and independent predictors for acute and chronic
side branch occlusion after coronary stent implantation

11. WHEN DO I NEED TO INTERVENE IN SB
• >2MM SIZE
• DOCUMENTED LARGE AREA OF ISCHEMIA
• SB ORIGINATING IN DISEASED SEGMENT
• OSTIUM OF SB IS DISEASED.

12. ONE STENT OR TWO STENTS

13. THE ANGLE
Type A - stenting the side
branch ostium and then the
main branch over the side
branch.
Type B is also a T-stenting
technique starting with the
main branch.
(T-stenting, Crush stenting, Culotte stenting and Kissing stent).

14. THE ANGLE
Type C or “culotte” stenting
consisted of implanting a stent in
the proximal segment of the main
branch covering each of the two
branches (double proximal
stenting).
Type D involved the stenting of the
distal main branch and side branch
ostia with or without proximal
stenting.

15. IS SIDE-BRANCH PREDILATATION PRIOR TO PROVISIONAL
STENTING HELPFUL OR HARMFUL?
91%
89%
SB predilation (n=187)
No SB predilation (n=185)
p: ns
Event-free survival (cardiac death, AMI , TLR)
Only three studies are available: one is a
randomised clinical trial and the other
two are observational registries (COBIS /
SPANISH )

16. IS SIDE-BRANCH PREDILATATION PRIOR TO PROVISIONAL
STENTING HELPFUL OR HARMFUL?
• SB PREDILATATION is neutral in terms of late MACE,
but…
• It resulted in improved TIMI flow after MB stenting and
less indication to subsequently treat the SB:
- 32% less, if SB % stenosis>50% (visual estimation) criterion is
considered .
- 18% less, if SB TIMI flow<III criterion is considered.
• If rewiring of the SB is required, predilatation did not
hinder this maneuver.

17. WHAT DO I DO ?
CLINICAL FEATURE USEFUL TECHNIQUES
OSTIAL SIDE BRANCH
OCCLUSION
SB BALLOON ANGIOPLASTY BEFORE
MAIN VESSEL STENTING / RESCUE FOR
LARGER BRANCHES.
LARGE PLAQUE IN MAIN
VESSEL
ROTATIONAL ATHERECTOMY
INSTENT RESTENOSIS OF
MAIN BRANCH
ROTATIONAL ATHERECTOMY
MAIN BRANCH DISSECTION
AFTER INITIAL BALLOON
DILATION
HYDROPHILLIC WIRE TO SB FOLLOWED
BY BALLOON ANGIOPLASTY AND
STENTING OF MAIN BRANCH
LARGE SIDE BRANCH
OCCLUSION AFTER PCI
CONSIDER WIRE TRAPPING AND RESCUE
REVERSE CRUSH

18. PREVENTING SB NARROWING BY MB STENT

19. The Szabo Technique for Precise
Ostial Stent Placement

22. Thank you for your kind attention