This document discusses strategies for percutaneous coronary intervention (PCI) of coronary artery bifurcation lesions. It outlines considerations for revascularization versus medical optimization and discusses stenting techniques including provisional stenting, T/V/Culotte techniques, crush techniques (classic, mini, double kissing crush), and the importance of final kissing balloon inflation. Guidelines, wiring sequence, predilation, and intravascular ultrasound guidance are also reviewed. Successful results and unsatisfactory results are defined.

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