1) Bifurcation stenting approaches are based on the angiographic configuration of lesions in the main and side branches. Significant disease (>50% stenosis) in the side branch ostium increases the risk of side branch closure and restenosis. 2) The default approach is one-stent with provisional side branch treatment. Two-stent techniques are used if the side branch has significant disease and high closure risk features. 3) Techniques like crush, culotte, and T-stenting aim to provide full coverage of both branches, but have limitations and risks. Physiologic assessment with IVUS and FFR can help decide if jailed side branches require intervention.

1. BIFURCATION STENTING
Coronary artery disease
Subha RathaYatra 2014

2. GUESS SOMETHING PEEINGTHROUGH STENTWINDOW?

3. BASIS
 The approach to bifurcation lesions is based on the angiographic configuration of
the lesion(s) in the main branch and the side branch
 Significant disease (>50% stenosis) in the ostium of the side branch increases the
likelihood of side-branch closure as well as the restenosis rate after PCI

4. ONE STENTVSTWO STENT STRATEGY
 Default approach is one-stent technique ± provisional angioplasty/stent to side
branch
 Use two-stent technique if side branch is significant and has high-risk features for
closure

5. RISK
 The risk of side-branch closure with an ostial narrowing approaches 15%
 PCI across an uninvolved side branch carries a less than 1% risk of occlusion

6. CLASSIFICATION

7. MEDINA CLASSIFICATION

8. GUIDE CATHETER
 7 F or 8 F guiding catheter should be selected if the operator anticipates using
two stents
 A 6 F guiding catheter can accommodate only two monorail balloon
 8 F guiding catheter can accommodate two stent systems as well as other large-
diameter PCI devices such as the Rotablator or the Flextome Cutting Balloon
 The maximum Rotablator burr that can be used with a 6 F guiding catheter is 1.5
mm
 It may be prudent to “upsize” guiding catheters when approaching any
bifurcation lesion so that all options remain available if trouble occurs during the
procedure

9. GUIDEWIRE
 To protect the side branch, two guidewires are placed, one in the side branch and
one in the main vessel
 The order of inflation is relatively unimportant
 Wire markers or using two different wire types is helpful to reduce confusion
during balloon inflations and wire repositioning
 When using a two-guidewire system, the guidewires may become entangled after
multiple wire manipulations
 . Efforts should be made to avoid guidewire entanglement, which will prevent
advancement of the balloon and may result in failure to recross the stenosis.

10. BALLOON
 Standard balloon use
 Different balloon sizes may be required for each branch
 Sequential balloon inflations or simultaneous “kissing” balloon inflations can be
performed with elimination of plaque shifting being the advantage of the latter
 It is important to make sure that the main vessel can accommodate both balloon
diameters when performing kissing balloon inflations (proximal vessel should be
at least two thirds of the combined balloon diameters)
 After stent placement in the main branch and the side branch, simultaneous
kissing balloon inflations are critical to restore the circular and fully expanded
stent to each lumen
 Failure to perform final kissing balloon inflation will likely lead to restenosis

11. SEQUENTIAL BRANCH INFLATIONS
 Dilate the main vessel first, the side branch second, and finish dilation in the main
branch
 A sequential main-side-main branch inflation strategy provides a safe and
straightforward approach
 Sequential inflations may result in suboptimal main vessel dilation and plaque
shifting , requiring repeated dilatations
 An unprotected major vessel dissection will require reinstrumentation and
jeopardize further attempts to open the side branch
 Serial inflations, first in one branch then in the other, as opposed to simultaneous
balloon inflations in both branches, may limit the need for extra manoeuvres.

12. T STENTING-2 STENTS
 The side branch off ostium ,therefore
no crush

13. IAKOVOU I., GE L.,AND COLOMBOA.: CONTEMPORARY STENTTREATMENTOF
CORONARY BIFURCATIONS. J AM COLLCARDIOL 2005; 46: PP. 1446-1455
 AlthoughT stenting is less laborious than both culotte and crush, theT-technique
invariably leads to inadequate coverage of the SB ostium and has consequently
been discontinued in a number of institutions except for either isolated SB ostial
lesions or when the result of a provisional single-stent strategy is suboptimal

14. V STENT-2 STENTS

15. Y STENTS-3 STENTS

16. DOUBLE BARREL(V STENTVARIANT)

17. CULLOTTE TECHNIQUE
 Angle <70 degree
 Bend branch stenting first

18. CHEVALIER B., GLATT B., ROYERT., AND GUYON P.: PLACEMENT OF
CORONARY STENTS IN BIFURCATION LESIONS BYTHE “CULOTTE”
TECHNIQUE. AM J CARDIOL 1998; 82: PP. 943-949
 First described by Chevalier et al. using BMS, the culotte technique results in two
layers of stent proximal to the bifurcation, full coverage of the SB ostium and of
both branches distal to the bifurcation.The technique is suitable for all angles of
bifurcation, but it does leave a double stent layer at both the carina and the
proximal part of the bifurcation. Furthermore, rewiring both branches through
stent struts may prove both difficult and time consuming.

19. CRUSHTECH
 Side branch stenting protrudes into
and get crushed after main stent
expansion

20. COLOMBOA., STANKOVIC G., ORLIC D.,CORVAJA N., LIISTRO F., AIROLDI F., CHIEFFO A.,
SPANOSV., MONTORFANO M.,AND DI MARIO C.: MODIFIEDT-STENTINGTECHNIQUE
WITH CRUSHING FOR BIFURCATION LESIONS: IMMEDIATE RESULTSAND 30-DAY
OUTCOME.CATHETER CARDIOVASC INTERV 2003; 60: PP. 145-151
 CRUSH was first introduced by Colombo et al. as a modifiedT-stenting technique
using DES, ensures uninterrupted patency of both the MB and the SB as well as
excellent coverage of the ostium of the SB. Final kissing balloon (FKB) dilatation is
now considered mandatory to allow optimal strut contact and drug delivery to the
ostium of the SB 15 16 .

21. MINICRUSH
 The minicrush technique differs from classical crush in the amount of the SB stent
protruding into the MB, with protrusion into the proximal end of the SB ostium in
the latter, limiting multiple layering of stent struts and allowing for more
complete stent endothelialization

22. REVERSE CRUSH
 The reverse crush technique is employed when a provisional single-stent strategy
becomes suboptimal. Following the placement of a stent in the SB, an
appropriately sized balloon is positioned in the MB at the level of the bifurcation,
before retracting the SB stent 2–3 mm into the MB and deploying it. If the result in
the SB is satisfactory, the deploying balloon and SB wire are removed and the MB
balloon is inflated, thus crushing the SB stent. Subsequent steps are similar to
those of conventional crush technique.

23. 1VS 2 STENT STRATEGY IN DES ERA

24. ONLY FOR EXPERTS
 Crush
 Culottes
 Angle is < 70 degree
 Excellent coverage in excellent hand

25. CRUSH
 Wire both vessels
 Predilate both
 Two stents are then advanced and positioned into each vessel of the bifurcation
with the proximal end of the side-branch stent in the main vessel
 The side-branch stent is deployed first
 The main-branch stent is then deployed
 The side branch then needs to be rewired and balloon dilated
 Final kissing balloon inflation is then performed to complete the procedure

26. IAKOVOU I., GE L.,AND COLOMBOA.: CONTEMPORARY STENTTREATMENTOF
CORONARY BIFURCATIONS. J AM COLLCARDIOL 2005; 46: PP. 1446-1455
 The simultaneous kissing stent (SKS) technique is considered most suitable for
proximal bifurcation lesions, such as a distal left–main bifurcation lesion with an
angle of <90° between the two branches .The technique has the advantage that
control of the MB and the SB are not lost at any stage during the procedure and
FKB dilatation can be undertaken without the need to recross either stent.

28. JAIL FOR ONLY UNPARDONABLE MISTAKE
 Physiologic Guidance for Bifurcation or Jailed Side-Branch Stenting is decided
by IVUS and FFR

29. IVUS
 To overcome visual elusion of best result

30. FFR
 By using FFR, the “jailed” side branches with an FFR >0.75 have a very low clinical
event rate without further balloon or stent therapy to the side branch
 Performing FFR of ostial side-branch lesions that appear to be <70% from
angiography can prove that most of these lesions are not physiologically
significant

31. KEEP IT SIMPLE STUPID: KISS
 Wire both main branch and side branch if side-branch loss is important.
 Consider treating side branch first (i.e., balloon dilatation, rotational atherectomy, or cutting balloon).
 Dilate and stent main branch; reassess side branch (can use FFR to determine hemodynamic significance).
 Provisional PTCA + stent side branch. If stenting side branch, stent with pullback technique.
 Choice of two-stent technique depends on size of proximal vessel, an assessment of the importance and risk of side-
branch closure, and operator expertise and preference.
 Use two wires if side branch loss is important.
 Dilate smaller branch first or use Rotablator or cutting balloon.
 Dilate and stent main branch; reassess side branch.
 Redilate side branch.
 Stent side branch through main stent only when absolutely necessary; use FFR to assess physiologic significance of side
branch.
 If a two-stent technique is used, final kissing balloon inflation is necessary to optimize outcomes

32. SUBHA RATHAYATRA -2014