The document summarizes the Year Review of Bifurcation PCI by Ahmed Kamel. It discusses various techniques for bifurcation stenting including provisional side branch stenting, two stent techniques like T-stenting and culotte, and the DK crush technique. It provides guidance on assessing bifurcation anatomy and recommendations for treating different types of bifurcations including left main bifurcations. The consensus is that provisional stenting is generally the preferred approach, but planned two stent techniques like DK crush may be better for complex anatomies with long side branches.

1. The Year Review of Bifurcation PCI
By
Ahmed Kamel ,MD,FSCAI
National Heart Institute
Ischemia club
December 2018

2. Introduction
Percutaneous coronary interventions (PCI) affecting a bifurcation lesion
are encountered in 15-20% of cases in daily practice. The inherent
difficulty of bifurcation PCI stems from the fact that stent implantation
in the main branch (MB) may lead to acute impairment of coronary
blood flow in the side branch (SB)

4. Step by step approach
• A. Baseline assessment of bifurcation anatomy
Regardless of the stenting technique chosen, the initial step for
a successful bifurcation PCI strategy begins with a good understanding
of bifurcation anatomy. The main points when assessing bifurcation
anatomy may be summarised as follows:
• 1. Assessment of the three diameters of a bifurcation.
• 2. Assessment of the lesion length and plaque distribution.
• 3. Assessment of the bifurcation angle and SB ostium

5. Starting a bifurcational PCI procedure:
• Almost all bifurcation lesions – including the distal left main coronary
artery can be safely treated via the radial artery approach with a large
lumen 6 Fr guiding catheter. A 7 Fr guiding catheter may be required if
the planned strategy involves complex double stenting techniques or
three balloons for trifurcations. In very large vessels, 7 Fr guides are
also helpful when a kissing inflation using balloons larger than 3.5 mm
in diameter is needed.

6. Two stent technique or provisional SB stenting?

7. • Provisional SB stenting is the standard strategy
According to the EBC 12 th consensus on bifurcation PCI ,EBC 13 th
consensus on left main bifurcation PCI and ESC/ESCTS 2018 guidelines
for coronary revascularization ,except in some special situations when a
complex two stent strategy is indicated .
The long-term clinical outcomes are determined by the status of the
MB after bifurcation stenting. Ensuring optimal results in the MB
should be given priority over optimising the appearance in the SB if
there is a need for a choice between the two.

8. Summary of the provisional approach. Upper panel from left to right: two wires in place, main branch stent sized
according to the
distal reference, POT, keep it open. Lower panel: access towards the distal strut, guidewire exchange, kissing balloon
inflation with short
non-compliant balloons (not proximal to the polygon of confluence to avoid dilating the distal part of the stent too
much towards the side
branch). A final POT should be carried out if the two balloons are proximal to the polygon of confluence.

9. Predilatation of both branches?
• It is recommended to predilate the main vessel for proper stent sizing
but the side branch should not be predilated when a provisional
strategy is intended for fear of ostial side branch dissection.

10. Selection of the main vessel stent size
Stent diameter should be selected according to the reference diameter of the
MB distal segment , the potential drawback being inadequate apposition of the
stent on the proximal MB segment. However, this can be easily corrected by
POT and/or KBI.
The MB stent should extend at least 8-10 mm proximal to the carina
in order to prevent balloon trauma at the proximal stent edge during
the performance of the proximal optimisation technique (POT)
A provisional technique should always end by final POT with or without KBI

11. Bailout two stent strategy
If the side branch is pinched with >75% Sstenosis
TIMI flow <III it should be stented

12. Side branch salvage using the jailed wire if failed
to recross the main vessel stent struts

13. EBC recommendation of using upfront two stent technique
A planned two-stent technique may be indicated for bifurcations with long SB lesions, difficult SB access
or high risk of SB compromise.
-Vessel anatomy, vessel sizes, a need for stenting the SB first and operator proficiency affect the choice of
strategy.
- Recommended techniques include reverse provisional stenting, T-stenting, culotte and DK-crush.
– POT is recommended and ensures optimal stent expansion in both the MB and SB.
– Always finalise a double stent procedure with KBI, followed by POT.

14. What about the old crush technique
The crush technique reported by Colombo et al, has gained popularity
since it has the benefit of allowing stenting both the MB and SB
without rewiring through the stent struts. However, due to the low
success rate in finalising the procedures with KBI and suboptimal long-
term outcome in the absence of KBI, this procedure is not
recommended anymore.

15. The DK crush technique
Chen and colleagues modified the original crush technique as the DK-
crush technique. This modification made the procedure more complex
(since it requires the systematic performance of two kissing balloon
inflations),
but has been shown to reduce dramatically the risk of failures in
performing kissing balloon inflation and to be clinically effective and
safe in the long term in trials conducted by operators dedicated to the
technique.

16. Left main bifurcations
• When to treat the left main?
• According to the European guidelines, myocardial revascularisation
is indicated for patients with LM angiographic stenosis >50% and
documentation of myocardial ischaemia. However, in clinical practice,
evidence of myocardial ischaemia may be equivocal and LM disease is
sometimes difficult to assess with coronary angiography (lack of
appropriate angiographic views, possible absence of undiseased
reference segment

17. INTRAVASCULAR IMAGING ASSESSMENT
• There have been several important IVUS studies assessing LM
disease severity using different parameters. The traditional minimal
lumen area (MLA) cut-off value of 6 mm2 is usually regarded
as the most robust IVUS-derived threshold. A large multicentre,
prospective study supported the feasibility of treatment deferral
in patients with angiographically intermediate LM lesions and an
MLA >6 mm2

18. Left main coronary stenosis CABG Vs PCI

19. Noble
• Biomatrix,1201 patients
• Death, stroke, or procedural MI,
repeat revascularisation at 5
years: 29% vs. 19%, p=0.0066
Excel
• Xience 1905 patients
• Death, stroke, or MI at 3 years:
• 15.4% vs. 14.7%, p for non-
inferiority=0.02,
• p=0.98 for superiority

21. Left main bifurcation stenting technique selection
according to the EBC 13 th consensus
1- Non complex left main disease:
When the left main stem plaque involves one branch only (such as Medina 1,1,0 or
1,0,1), the stent strategy should aim to cover with a single stent from the most
relevant and diseased vessel (usually the LAD, in selected cases the LCX) back into
the main stem according to the provisional strategy. Then, POT is recommended
to be performed systematically. The selected stent should have sufficient length
(8-9 mm) in the LM to accommodate an appropriately sized balloon needed for
the POT postdilation.

22. 2- Complex left main disease:
The vast majority of true bifurcation anatomies can be approached using a
stepwise provisional technique which includes the potential to end with double
stenting if needed an acceptable result on both branches may often be achieved.
When this is not the case, a second stent can be implanted using a different
strategy. Expert consensus suggests that T/TAP or culotte techniques
are adequate techniques for bail-out side branch stenting

24. Methods
• The authors randomized 482 patients from 26 centers in 5 countries
with true distal LM bifurcation lesions
• (Medina 1,1,1 or 0,1,1) to PS (n ¼ 242) or DK crush stenting (n ¼ 240).
The primary endpoint was the 1-year composite
• rate of target lesion failure (TLF): cardiac death, target vessel
myocardial infarction, or clinically driven target lesion
revascularization.

25. Conclusion
• In the present multicenter randomized trial, percutaneous coronary
intervention of true distal LM bifurcation lesions using a planned DK
crush 2-stent strategy resulted in a lower rate of TLF at 1 year than a
PS strategy.

26. DK crush is a perfect illustration of the “no pain, no gain” concept: doing DK
crush in ULM bifurcation lesions will be more challenging than provisional
stenting, but will benefit the patients, which is what matters the most. It is
our strong belief that coronary interventionalists will demonstrate an
evidence based “growth mindset” and will adopt DK crush as their standard
strategy for treating ULM bifurcations

29. Is there any drawbacks for the technique?
1.It commits the operator to
adopt a two stent technique from
the start.
2.It has two many steps ,each step
offers a way to screw up.
3.The technique may cause
rewiring outside the stent area.

30. Wiring the side branch(ouside the stent) after the first crush

31. Finally this will be the side branch

32. What is expected in 2019-2020?

33. The EBC main study
• It will include 450 patients with complex left main disease ,they will
be treated by PCI with provisional versus 2 stent strategy .
• The technique will be left to the operator`s choice TAP, Culotte or DK
crush.
• The primary end point will be a composite of death,MI and TLR within
one year.
• So lets wait and see.