Bifurcation stenting

Dr Virbhan Balai
FNB (Interventional Cardiology) Fellow
DNB (Cardio), MD (Med),DLO, MBBS
MSSH, New Delhi

BIFURCATION LESIONS
• Bifurcation lesion -: is occurring at, or adjacent
to, a significant division of a major epicardial
coronary artery.
• “True” bifurcations -; MB and the SB are
both significantly narrowed (>50% diameter
stenosis).
• “Nontrue” bifurcations-; include all the other
lesions involving a bifurcation.

BIFURCATION CLASSIFICATION
• Six diff. classifications of bifurcation lesions
• “Medina” classification is the most simplified
and widely used to classify bifurcation lesion.
• “1” means >50% diameter stenosis
• “0” = absence of stenosis,, Starting from prox.
MB, distal MB, & prox.SB:
– 1,1,1 = critical stenosis in all three seg.
– 1,1,0 = only the prox. & distal MB are affected.

 Limitation of the Medina classification:
 Length of the stenosis involving the SB is not
specified (key element to properly plan the Tt).

85 pt`s were randomly assigned to either
stenting both br. (Group A) or stenting the MB
only with PS of the SB (Group B).
Crossover rate was very high, 51.2% in the
provisional group and 4.7% in the two-stent
group.

• Restenosis at 6 months did not differ
significantly b/w the double stenting (28.0%)
and the provisional SB stenting (18.7%) groups
(P = .53).
• During the 6-month follow-up, there was no
significant difference b/w groups in death, MI,
TVR, or TVF (19.0% vs. 13.6%).

 Second study; Pan and coworkers
 Compared two strategies for the SES Tt of bif.
lesions in 91 pt`s with “true” coronary bif.
lesions.
 6-month MACEs and restenosis rate of the MB
and of the SB were similar in the two study
groups.

Nordic Bifurcation Study
 413 pt`s were randomized to two stents (n = 206) or PS
(n = 207) with SES implantation.
 The crossover from prov to 2 stent was allowed if TIMI
flow following SB dilation was 0 and was only 4.3%.
 At 6 months, there was no diff b/w the two groups reg
C death, MI, index lesion MI, TVR, TLR and ST.
 At 5-year follow-up, the combined safety and efficacy
end point of cardiac death, non procedure related MI,
TVR remained similar and were seen in 15.8% of pt`s
in the PS group, 21.8% in the two stent group (P = .15)

Bifurcations Bad Krozingen (BBK) study

BBK II trial
 300 pt`s with bif lesions requiring SB stenting
were randomized to undergo T stenting and
TAP or culotte stenting.
 9-month angio follow-up, which was available
for 91% of the pt`s, revealed higher binary
restenosis rate after TAP as compared with
culotte (17.0% vs. 6.5%, P = .006),
 1-year incidence of TLR was 12% in the TAP
group and 6% in the culotte group (P = .069).

CACTUS trial
 350 pt`s were randomly allocated to either provisional
T (173) or crush (177) SES implantation, with
mandatory FKBI in both groups.
 92% pt`s had true bifurcations, crossover rate in the
prov. T group was 31%.
 @ 6 months; angio restenosis rates were not diff. b/w
the crush group (4.6% and 13.2% in the MB and SB,
respectively) and the PS group (6.7% and 14.7% in the
MB and SB, respectively; P = not sig.).
 Pri clinical outcome (death, MI, revas.) was also similar
in both groups (15.0% prov. vs. 15.8% crush, P = NS).

 500 pt`s were randomly allocated to either a
simple strategy (prov. T) or a complex strategy
(either crush or culotte) using PESs.
 In the simple strategy; the MB was stented, f/b
by optional kissing balloon dilatation/T stent.
 In the complex strategy; both br were
systematically stented (culotte or crush tech)
with mandatory kissing balloon dilatation.

 @ 9-month clinical follow-up, there was a sig
diff b/w the two groups in terms of death, MI,
or revas. (simple 8.0% vs. complex 15.5%).
 This difference was largely driven by the
higher incidence of MI in the complex group
(11.2% vs. 3.6%, P = .001).

The DKCRUSH-II trial
• 370 pt`s with coronary bif lesions; DK-crush (185) or PS tech
(185).
• @ 12 months-: MACE (cardiac death, MI, or TVR) & def ST rates
were similar b/w DK (10.3% and 2.2%) and PS groups (17.3% and
0.5%, P =.070 and P = .372, resp.).
• Angio restenosis rates in the MV, and the SB were lower in the DK
group (3.8% and 4.9%) than the PS group (9.7% and 22.2%, P =
.036 and P < .001, resp), as well as TVR (6.5% vs. 14.6%, P =
.017).
• @ 5 years ; MACE occured more frequently in prov strategy, as
compare to DK-crush (23.8% vs. 15.7%, P = .051). TLR rate was
higher in pt`s with PS vs DK-crush (16.2% vs. 8.6%, P = .027),
particularly in pt`s with anatomically more complex lesions.

DKCRUSH-III study
 419 pt`s with UP LM distal bif lesions.
 At 1-year higher MACE rate in culotte group compared
with the DK group (16.3% vs. 6.2%, P = .001),, mainly
driven by increased TVR rate (11.0% vs. 4.3%, P =
.016).
 At 3 years, MACE remained more freq in the culotte vs
DK-crush group (23.7% vs. 8.2%, P < .001), mainly
driven by a higher rate of TVR (18.8% vs. 5.8%, P <
.001) and MI (8.2% vs. 3.4%, P = .037).
 Definite ST, 3.4% in pt`s treated with culotte,, no def
ST in DK-crush group (0.007).

DKCRUSH-V (Double Kissing Crush Versus Provisional
Stenting for LM Distal Bifurcation Lesions) randomized trial
 Multicentre, randomised, 482 pt`s with
UPLMb lesion,, DK group or PS group
 @ 12-month TLF rate with DK-crush (5.0%)
vs. PS group (10.7%), P = .02.
 DK-crush- less TLR (3.8 vs. 7.9%, P = .06),
and lower rates of MI (0.4% vs. 2.9%, P = .03)
and ST (0.4% vs. 3.3%, P = .02).

 @ 3 years TLF rate with DK-crush (8.3%) vs.
PS group (16.9%), P = .005.
 Def / or prob ST @ 3 years 0.4% in DK group
and 4.1% in PS group (P=0.006).

CLINICAL OUTCOMES IN RCT`S COMPARING ONE- VERSUS
TWO-STENT STRATEGY, UTILIZING DES

 424 pt`s were randomized to either crush or
culotte stenting utilizing SES.
 At 6-month; there was no diff. b/w the two groups
in terms of death, postproc. MI, or revas. (pri end
point: crush 4.3% vs. culotte 3.7%, P = .87).
 Higher incidence of periproc. MI and ISR in the
crush group (crush 10.5% vs. culotte 4.5%, P =
.046).
 At 3-year ; Clinical outcomes remained similar in
the crush and the culotte groups, with MACE
rates of 20.6% versus 16.7% (P = .32).

SEA-SIDE study.
 Randomized 150 consecutive pt`s with bifurcated lesions
undergoing systematic provisional-stenting to SES or EES.
 The primary procedural end point - occurrence of any trouble in the
SB management was similar between SES and EES (16% vs. 11%,
P = .34).
 The primary angiographic end point- Post PCI 3D QCA estimated
MLA showed similar post-PCI results in the MV and better results
in the SB with EES than with SES.
 Clinical outcome at 18 months showed no diff in rates of target bif
failure (9.0% in SES vs. 10.7% in EES patients, P = .57).

CORPAL study
 SES and EES compared
 293 pt`s with bif lesions were treated utilizing
the prov SB stenting tech.
 In-hosp. outcome and 12-month follow-up
MACE was similar between SES and EES
(6.2% vs. 6.1%, P = .84).

 A pooled analysis of these two randomized
trials (SEA-SIDE and CORPAL) showed
similar MACE free survival at 3 years,
 Exploratory landmark analysis for late events
(occurring after 1 year) showed significantly
fewer MACE in the EES group (1.4% vs.
5.4%, P = .02).

Z-SEA-SIDE Study
Prospective extension of the SEA-SIDE study,
Performance of a ZES was compared with that
using SES and EES.
ZES demonstrated improved performance
compared with SES (SB “trouble” rate 4% vs.
16%, P = .014) and SB angio results, while
ZES were similar to EES.

 5-year follow-up study of the LEADERS all
comers randomized trial showed a sup. long-
term efficacy of BES compared with an SES.
 BES also lower rate of very late ST b/w years
1 and 5.

Guiding Catheter Selection
 6-Fr guiding catheter – for most bif lesions, bcz a
prov strategy is utilized most of the times.
 The two stents can only be inserted and deployed
sequentially.
 7- or 8-Fr guiding catheter- elective 2 stent tech,
 When operator in doubt regarding Tt strategy
 Std crush tech and the V or kissing stents tech –
requires 7 or 8 Fr guiding catheter .

Algorithm for stenting bifurcation lesions

General Outline When Treating a Bifurcation
Lesion
 SB stenting - when SB diseases extends beyond the ostium and the
SB has a sig. area of distribution.
 Provisional SB stenting- most frequently used approach
1. Placement of two wires (MB and SB)
2. Predilatation of MB or both branches, when needed
3. Stenting of the MB
4. Stent optimization with POT
5. Recrossing with a wire into the SB
6. Crossing with a balloon into the SB
7. FKBI, with mod. pressure (8 atm) in the SB, until the balloon is fully
expanded.
8. Final POT, if result in the SB is adeq. after FKBI
9. Placement of a sec. stent in the SB when the result is unsatisfactory
(>75% residual stenosis, dissection, TIMI flow grade <3 in a SB ≥2.5
mm or FFR <0.80)

SB wire should be kept until the stenting
procedure on the MB has been completed,
including postdilatation.
During jailed wire retrieval; avoid any trauma
to coronary ostium with the guiding catheter,,
 Guiding catheter tends to be pulled in as jailed
wire is removed.

In the prov tech, wire cross through the distal strut
is recommended bcz it creates better SB
scaffolding.
To optimize SB access through the distal strut
(carina strut), the POT is suggested.
If unsatisfactory result after MB stenting,, SB
stenting should be performed with
T stenting or TAP-stenting,
Reverse/internal crush or culotte, followed by kissing
balloon inflation.

Difficult Side Branch Access
1. Abort the procedure bcz the risk of closing the SB is too high, given the
size and distribution of the br (typically an angulated LCX).
2. Use a microcatheter in order to navigate reshaped wire in unfavorable
MV anatomies or the SuperCross catheter with different preshaped tip
curves.
3. Perform rotational atherectomy on the MV with the intent to remove
the plaque, which prevents entry toward the SB.
4. Dilate the MV with a balloon, hoping plaque modification will result in
favorable plaque shift and facilitate access toward the SB.
5. Use the “reverse wire” technique, creating a unique guidewire tip with
two sharp curves (a longer proximal curve to create a loop in the distal
MV and an opposite short distal curve to engage the SB ostium during
the wire pullback)
6. Use the Venture wire control catheter , low-profile catheter with a tip
that can be deflected up to 90 degrees to facilitate wire orientation and
provide excellent backup support.

• Use of a relatively stiff wire can be a solution,
due to the better steerability and penetration
force.
• Use of hydrophilic wires can also be
considered; however, the risk of subintimal
passage is increased when using stiff and/or
hydrophilic wires.

 FKBI is done if the SB is dilated through the MB stent
struts, to correct MB stent distortion and proximal
expansion and provide better scaffolding of the SB ostium
to facilitate future access to the SB.
 Nordic III and CORPALKISS studies demonstrated no
systematic clinical advantage of routine kissing strategy
when a single-stent treatment is used.
 However, angio follow-up at 8 months in the NORDIC III
study showed lower SB restenosis rate in pt`s with true bif
lesions when FKBI was performed (7.6% vs. 20.0%, P =
.024).
 Study by Koo et al. found FKBI restores normal FFR in the
SB in the majority of pt`s.

DKCRUSH-VI Trial
Randomized study investigated the impact of
angio-guided vs FFR-guided SB Tt,
In 320 pt`s undergoing bif PCI with prov SB
stenting strategy.
SB Tt (balloon or stent) tended to be less freq
in the FFR-guided group (56.3% vs. 63.1%, P =
.07), and there was no diff in the 1-yr rate of
MACE or TVR.
– JACC Cardiovasc Interv. 2015;8:536–546

Lesions in which FKBI is required, (>75% residual
stenosis at the SB, TIMI flow grade <3, or FFR <0.80).
Two appropriate strategies are-
 Either to use a pressure wire to interrogate the
significance of the SB lesion and treat or not accordingly,
 Simply to do FKBI on all angiographically significant
ostial SB lesions
Sequential MB-SB-MB balloon inflation is proposed as
a simpler alternative to FKBI.
» JACC Cardiovasc Interv. 2012;5:47–56.

A Second Stent in the Side Branch Following
Provisional Approach
When not satisfied with the result obtained with
balloon dilatation of the SB, implant a sec stent
using one of the following strategies:
T technique
 TAP technique
 Culotte, or reverse/internal crush
FFR or imaging techniques, such as OCT, can be
used in the evaluation of SB result after balloon
dilation.

T technique
 Most freq utilized tech to transition from prov stenting
to stenting the SB.
 T technique = advancing a sec stent into the SB
(following adeq dilation of the MB stent struts).
 Stent is positioned at the ostium of the SB trying to
minimize any possible gap.
 Sec kissing balloon inflation is performed.
 Disadv - risk of leaving a small gap b/w the stent
implanted in the MB and the stent implanted in the
SB. This gap may be factor contributing to an uneven
distribution of the drug, hence leading to ostial
restenosis at the SB.

2. TAP technique
 Modification of the T stenting tech
 Minimal protrusion of the SB stent within the MB
 This technique can be described as follows:
a. Sec. stent is advanced in the SB in a way to
minimally protrude (1 or 2 mm) into the MB.
b. Balloon is advanced in the MB.
c. SB stent is deployed as usual (12 atm or more), and
the MB balloon is simultaneously inflated at 12 atm
or more.
d. Both balloons are deflated and removed.

3.Reverse/internal crush: crush
performed after main branch stenting
a. After stenting the MB, a second stent is advanced into the SB and left in
position without being deployed.
b. A balloon sized according to the diameter of the MB, and shorter than
the stent already deployed, is advanced in the MB and positioned at the
level of the bif, taking care to stay inside the stent previously deployed in
the MB.
c. SB stent is retracted about 3 mm or less into the MB and deployed. The
deploying balloon is removed, and an angiogram is obtained to verify the
absence of any distal dissection and the need of an additional stent. If
such is the case, the wire from the SB is removed and the balloon in the
MB is inflated at high pressure (12 atm or more).
d. The SB struts are recrossed with a wire and a balloon (a 1.5 mm balloon
is sometimes needed). The balloon is sized to the SB reference diameter
and inflated at high pressure (12 to 20 atm).
e. The final kissing balloon is performed. This technique has been
completely superseded by the TAP.

Reverse/internal crush technique

4. The provisional culotte technique.
• Proposed as a prov SB stenting strategy in Y
shape angulated bif lesions.
• This technique can be described as follows:
a. After MB stenting, a Sec stent is advanced in the
SB protruding into the MB to overlap with the
proximal part of the MB stent and expanded
following removal of MB wire.
b. MB is rewired through the stent struts and
dilated.
c. Finally, kissing balloon inflation is performed.

The European Bifurcation Club Approach to
Bifurcation Stenting
1. MEDINA classification should be used for bif lesions (1,0) and
MADS classification for bif stenting techniques (MADS: Main,
Across, Distal, Side, based on the manner in which the first stent
has been implanted).
2. Prov T stenting remains the gold standard tech for most bif.
3. Large SBs with ostial disease extending >5 mm from the carina are
likely to require a two-stent strategy.
4. In prov tech, after wiring both br, the MB should be predilated
when required, while SBs without sev calcification or long sig
lesion (>5mm) do not require routine predilatation.
5. SB wire should be jailed behind the MB stent in true bif lesions.
6. MB stent is selected according to distal MB diameter and
postdilatation, or KBI, are required to optimize the prox MB stent
diam.

8. SB treatment is indicated if the ostium is pinched or the
flow is limited after POT.
9. SB wire crosses through the distal strut following MB
stenting.
10. Kissing balloon inflation for carina reconstruction is
optional in the provisional stenting but mandatory in two-
stent techniques.
11. The procedure should be finalized by POT after kissing to
correct the proximal MB stent distortion.
12. Intravascular imaging is a valuable supplement in
bifurcation treatment and is especially useful in complex
lesions due to the limitations of angiography alone.

TWO STENTS AS INTENTION-
TO-TREAT
• Only for selected “true” bifurcations following
the evaluation of additional parameters:
A. Size and the territory of distribution of the SB
B. Length of the lesion at the ostium of the SB
C. Angle b/w MB and SB and the narrowing at
the ostium of the SB
– The narrower the angle b/w the two branches, the
higher the risk of plaque prolapse and
compromise of the ostium of the SB.

TWO-STENT TECHNIQUES
 Culotte Technique
 Technique Description
 Step 1: Both branches are predilated.
 Step 2: A stent is deployed across the most angulated
branch, usually the SB and optimized with POT.
 Step 3: The nonstented branch (MB) is rewired through the
stent struts and dilated.
 Step 4: A sec stent is advanced and expanded into the
nonstented branch, usually the MB and optimized with
POT.
 Step 5: Finally, kissing balloon inflation and final POT is
performed.

Culotte - is suitable for all angles of bif.
Provides near-perfect coverage of the SB ostium.
Disadv - high conc of metal with a double-stent
layer at the carina and in the prox. part of the bif.
Rewiring both br through the stent struts can be
difficult and time consuming.
Performing the POT after each stent implantation
may help rewiring.

Mini-Crush Tech (SB Stent Crushed by the MB Stent)
• “Mini” highlights the need to decrease as much as
possible the amount of stent overlap b/w SB and
MB.
• Req. 7- or 8-Fr guiding catheter
• Adv of the crush tech- imm patency of both br`s
is ensured.
• Disadv - performance of the FKBI makes the
procedure more laborious, due to the need to
recross multiple struts with a wire and a balloon.

• Technique Description
• Step 1: Both branches are wired and fully dilated.
Particular attention is paid to dilate the SB.
• Step 2: The stent for the SB is positioned in the SB, and
then the MB stent is advanced.
• Step 3: The SB stent is pulled back into the MB for
about 2 to 3 mm. This step is verified in at least two
projections.
• Step 4: The stent in the SB is deployed at least at 12
atm. balloon is deflated,removed from guiding
catheter. check angio, wire is removed from SB,, stent
MB at high pressure, >12 atm and optimized with POT.

• Step 5: A wire is advanced in the SB aiming to
cross through the central or proximal strut.
• Step 6: A second balloon is advanced over the
wire which was left in place in the MB, and
kissing balloon inflation is performed at 8 atm
or more.

Step Crush and Double-Kissing Crush
 6-Fr guiding catheter
 The only difference with std crush is that each
stent is advanced and deployed separately.
 DK-crush - other variants of the crush
technique.

Technique Description
 Step 1: The same as the standard crush tech.
 Step 2: A stent is advanced in the SB protruding a few millimeters
into the MB. A balloon is advanced in the MB across the bifurcation.
 Step 3: The stent in the SB is deployed, the balloon is removed, an
angiogram is performed, and if the result is adequate, the wire is
also removed. The MB balloon is then inflated (to crush the
protruding SB stent) and removed. Optionally, kissing balloon
inflation can be performed at that time (double-kissing crush
technique).
 Step 4: A second stent is advanced in the MB and deployed (usually
at 12 atm or more).
 Next steps are similar to crush techn -> recrossing into the SB, SB
stent dilatation, and FKBI.

V and SKS Techniques
V and SKS are performed by delivering and
implanting two stents together.
One stent is advanced in SB; the other one in MB.
Both stents are pulled back to create a new carina
as close as possible to the original one.
Main adv of V tech is that the operator will never
lose access to any of the two br`s.
When an FKBI is performed, there is no need to
recross any stent.

When the two stents protrude into the MB with
the creation of a double barrel and a very
proximal carina, the tech is called SKS.
V tech preferred for selected bif lesions where
the lesions are distal to the bif (Medina 0,1,1).

• Technique Description
• Step 1: Both branches are wired and fully
predilated.
• Step 2: The two stents are positioned into the
br`s with a minimal protrusion of both stents
in the main proximal branch.
• Long (5 mm or more) double barrel in the proximal MB
(SKS).
• Step 3: Inflate both balloons simultaneously.

V tech, a metallic neocarina is created within
the vessel proximal to the bif.
Lesions considered most suitable for this
techare very prox lesions, such as bifurcation
of a short LMCA free of disease.
Ideally angle b/w the two br`s should be < 90
degrees.

“Y” and the “Skirt” Techniques
 It was the first bifurcation stenting technique
demonstrated in a live case course.
 Predilatation, f/b stent deployment in each
branch. If the results are not adequate, a third
stent may also be deployed in the MB.
 To approximate the prox stent to the already-
deployed stents, it is necessary to modify the
stent delivery system by placing one stent over
two balloons (“skirt” stenting).

Flower Petal Stenting
 The tech of “flower petal” stenting involves implanting a
stent in the SB with a single strut protruding into the MB;
the protruding strut closest to the carina is wired and dilated
to create a larger strut or “flower petal”; this protruding
petal is then flattened and plastered down over the carina
with a series of MB inflations, including a MB stent and
kissing balloon inflations, thus ensuring complete ostial
coverage and scaffolding.
 Most challenging part of this tech is wiring a single strut
close to the carina, and in the original description, this req
IVUS guidance.
 Tech is suitable for a 6-Fr guide catheter and is mainly
applied in bif lesions located in the distal LM.

Main Characteristics of Two-Stent
Techniques

Left Main Bifurcation Stenting
• Distinct anatomical features and clinical significance
epitomize the approach to p/c LM Tt.
1. LM anatomy
Mean LM IVUS-derived ref diam is est to be 5 mm,
ranging from 3.5 to 6 mm.
Angio appearing isolated stenosis at the ostium of LAD
or CX is often a cont atherosclerotic plaque involving
the LM.
Larger mean diameter and characteristic plaque
distribution of LM arteries, SB (i.e., CX) is frequently
clinically relevant, as it supplies >10% of the
myocardium in >95% of cases.

Indications for LM treatment
 Angiographic stenosis >50% and the proof of
myocardial ischemia.
 If there is angiographic ambiguity,, IVUS
derived MLA < 6 mm2 and FFR < 0.80.
 Evaluation of a LM stenosis with FFR may be
inaccurate if LAD or CX disease is present.

Evidence for p/c LM treatment
 Two most recent randomized studies, utilizing contemporary 2nd
Gen DES, are
 EXCEL and NOBLE trials, which included 1905 and 1201 pt`s
with LM disease, resp.
 in both of these trials, >80% of pt`s had a distal LM bif stenosis.
 EXCEL trial demonstrated noninferiority of PCI with EES to CABG
in terms of death, stroke, or MI at 3 years (15.4% vs. 14.7%, P for
noninferiority = .02).
 NOBLE trial, which utilized a thicker strut stainless steel BES,
showed a reduction in the 5-year rate of death, nonprocedural MI,
stroke, or any repeat coronary revas. with CABG compared with
PCI (19% vs. 29%, respectively, P = .0066).

LM stenting technique
1. The use of one guidewire may be considered in cases of
an isolated ostial and/or midshaft LM disease, whereas
two guidewires are recommended for all
nonostial/midshaft LM PCI.
2. MB preparation (e.g., predilatation, rota) is recommended
in the majority of cases prior to LM stenting, whereas SB
preparation may be contemplated in case of severe ostial
disease, calcified stenosis, and/or difficult SB access.
3. Stent sizing should consider maximum expansion
capacities of current DES platforms to accommodate the
mean LM diameter of ≈5 mm. If PCI involves distal LM
bifurcation, the stent should be sized according to the
distal reference diam (i.e., prox LAD or CX for most of the
cases).

4. Prov SB stenting is recommended for distal LM
disease that does not involve both br`s, with
implantation of one stent in most cases and the
essential role of POT to ensure adequate stent
expansion in the LM stem.
5. If both branches of LM bifurcation are stenotic,
stepwise provisional strategy is recommended, with
the possible extension to a two-stent technique if SB
stenting is deemed necessary, most commonly
utilizing the T/TAP tech in the presence of a wide bif
angle or the Culotte tech if the angle is narrower.

6. For centers more comfortable with the DK-crush tech,
it may be considered a viable alternative, based on
the results of a recent randomized DKCRUSH-V trial.
7. Regardless of the tech used, high-pressure KBI is
considered mandatory if two-stent approach is
applied.
8. Based on observational evidence indicating clinical
benefit of IVUS guidance for LM PCI, the use of I/C
imaging is encouraged in general, and whenever
angio ambiguity or unexpected intraprocedural
difficulties are encountered.

Isolated Ostial LAD or LCX Lesion
1. Approach to ostial LAD lesion
 LM 0,1,0 lesion (ostial LAD) is traditionally
considered to be unfavorable for PCI.

 IVUS guidance is encouraged to assess plaque
distribution before deciding which technique
should be applied in a specific lesion.
 Precise LAD ostial stenting consists of
scaffolding the countercarina, with a mild
protrusion of the stent covering the ostium of
the circumflex.
 Proximal stent marker should be positioned
just proximal to the angiographic carina.

• Disadvantages of precise ostial LAD stenting
are as follows:
a. If the device is positioned too proximally, it
protrudes into the LMCA, which may
compromise an LCx and make repeated
intervention difficult;
b. If the ostial LAD lesion is not totally covered
by the stent, acute recoil and late restenosis
is expected.

• Optimal positioning of the stents is critical for
the treatment of this lesion.
• With ostial disease, there is frequent
involvement of the distal LMCA, and thus the
impending danger of incomplete lesion
coverage if stenting is not extended to the
involved LM.

2. Approach to isolated SB ostial (0,0,1)
bifurcation lesions:
• Lesions at the ostium of a diagonal/OM/PLV
branch Osital SB lesions

• “sad story of the ostial diagonal lesion” and too aggressive Tt of these
lesions may not always be the best approach. Occasionally a simple
cutting balloon dilatation at the ostium of a diagonal branch is a
minimalistic approach that should be considered.
• Brunel et al. have developed an “inverted” technique for the treatment of
Medina 0,0,1 lesions, derived from the usual provisional T stenting.
• Stent is implanted from the proximal MB into the SB, with reopening of
the strut through the distal MB and systematic final kissing balloon.
• Alternative approaches – Use single short stent (precise ostial positioning
is very difficult and complete ostial coverage is difficult/impossible except
for 90-degree bifurcation), shunt technique, or dedicated stents.
• Evaluate the functional significance, with FFR, of the lesion located at the
SB.
• Finally we should not dismiss the fact that optimal medical therapy is
areasonable approach.

Dedicated Bifurcation Stents
• Dedicated bifurcation stents can be broadly
divided into:

1. Stents for provisional SB stenting that
facilitate or maintain access to the SB after MB
stenting and do not require recrossing of MB
stent struts (e.g., Petal, former AST stent, Multi-
link Frontier/Pathfinder/SBA Invatec Twin-Rail
Nile Croco/Pax Antares -Med SideKick
2. Stents that usually require another stent
implanted in the bifurcation (e.g., Axxess Plus,
Sideguard , Tryton. )

• Tryton stent, which is compared with the
provisional approach in the randomized
Tryton IDE trial.
• The TRYTON IDE trial (Randomized Controlled
Study to Evaluate the Safety & Effectiveness of
the Tryton Side Branch Stent Used with DES in
Treatment of de Novo Bifurcation

BioResorbable Scaffolds
• BRSs (Absorb BVS, Abbot Vascular) showed
increased rates of major cardiovascular
events.

ROLE OF ADJUNCTIVE
PROCEDURES
• Intracoronary Imaging
• EBC recommends the use of IVUS for most
interventions involving the LM, esp. distal
bifurcation with a two-stent strategy.

• Atherosclerotic plaque is usually of diffuse nature in the LM and
often difficult to be adequately assessed by angiography only.
• Isolated plaque at the ostium of LAD is seen angiographically in only
9% of cases, whereas using advanced imaging, in >90% there is a
continuous plaque stretching from proximal LAD into the LM.
• In case of a discrepancy in the measured MLA on IVUS pullback from
both LAD and CX, the smallest MLA is the most accurate.
• IVUS-derived data can be used for the following stages of procedure
planning:-
• Determining the adequate stent diameter and length

• Anticipating proximal optimization—
• After stent implantation in the MV, IVUS can be used to
optimize the final result:
• Detection of edge stenosis/dissection (geographic miss)
• Evaluation of stent apposition and expansion in the MV
including the LM stem
• Control of SB rewiring (e.g., abluminal wire position)
• Evaluation of stent expansion and apposition in the SB,
particularly at the level of SB ostium, if the second stent is
needed
• Ruling out longitudinal stent distortion

Rotational Atherectomy
In a setting of a very calcific lesion
The operator’s judgment remains the most
frequent tool dictating the choice of rotational
atherectomy.
Burr size is typically small, with the intent to
modify the plaque, minimizing the risk of
embolization.
SB stent under-deployment due to inadequate
preparation - restenosis at the ostium of the SB.

Cutting and Scoring Balloons
• Bifurcation lesions with a fibrotic plaque at
the SB ostium are an ideal setting for this
device.
• The REDUCE III randomized trial evaluated the
role of cutting balloon dilatation before
stenting versus standard balloon dilatation in
a variety of lesions.

AngioSculpt catheter, which includes nitinol
spiral wires that wrap around the balloon
catheter, can be used for lesion preparation.
As the balloon inflates, the spiral wires score
fibrotic or fibro-calcific plaque, stabilizing
balloon position (which avoids slippage) and
may lower the risk of dissection.
AGILITY trial (Angiosculpt Coronary Bifurcation
Study)

Associated Pharmacological
Treatment
• Protocol of periprocedural heparin- same
• Heaprin 100 U/kg without elective GP IIb/IIIa
inhibitors.
• 70 U/kg with elective GP IIb/IIIa inhibitors.

• GP IIb/IIIa inhibitors is reserved to thrombus-
containing lesions and in selected pt`s with
ACS.
• 600-mg loading dose of clopidogrel in the
catheterization laboratory or loading dose of
ticagrelor or Prasugrel.
• Duration of DAPT following bifurcation two-
stent strategy is usually for a minimum of 6
months and usually extended to 1 year.

KEY POINTS
• Always consider an ostial lesion as a possible bif lesion,
except in cases of aorto ostial location.
• 6-Fr guiding catheter is appropriate most of the time;
when in doubt, use 7- or 8-Fr.
• Do not risk losing the SB; when in doubt, always protect
it with a wire.
• If there are difficulties wiring the SB, consider dilating
the MB first.
• Prov stenting does not mean accepting a poor final
result for an important SB.
• Prov SB stenting remains the gold std tech for most bif.

• Tt of a bif lesion with two stents (main and SBs) is
an acceptable approach.
• Do not forget the FKBI preceded by high pressure
inflation on the SB when implanting two stents.
• When dedicated DES for bif lesions become
available, many concepts may change, including
the emergence of a more liberal usage of a two
stent strategy.
• Optimal antiplatelet therapy is always a key factor
for short- and long-time success.
• Keep yourself updated for new developments

Bifurcation stenting

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