J Hermiller MD 1
Bifurcation Lesion Treatment Option:
Insights From Clinical Literature
James Hermiller, MD, FACC, FSCAI
St Vincent Medical Group
St Vincent Heart Center of Indiana
Indianapolis, IN
Presentation Theater: Tryton Pivotal: Randomized Trial and
Confirmatory Study – Implications for Everyday Practice
Tuesday, October 13, 2015
11:53 AM - 12:02 PM
Room: Moscone South, Exhibit Hall, Presentation Theater 4
Presentation Theater Programs

J Hermiller MD 2
Disclosure Statement of Financial Interest
• Grant/Research Support
• Consulting Fees/Honoraria
• Edwards, Medtronic, Abbott, St Jude,
BSC
• Edwards, Medtronic, Abbott, St Jude,
BSC
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship Company

J Hermiller MD 3
Key Points
• Bifurcation Lesions: Continues to be a problem – we don’t
have the right tools

J Hermiller MD 4
Key Points
• Bifurcation Lesions: Continues to be problem
Only Lesion Subset Not Routinely Stented
• Combined Literature:
Supports Provisional over 2 Stent Strategies
• Study Population Primarily Focused on Small SB
– BBC 1
– Nordic 1
• Studies with Large SB Favors 2 Stent Approach
– DK Crush
– 2 Stent ‘Simple’ Dedicated Stent
• Dedicated Side Branch Stent:
Focused on Providing Straight Forward 2 stent solution

J Hermiller MD 5
Bifurcation Lesions are Common
“All Comers” Studies % Patients % Lesions
Leaders Trial1,2 29.1% 21.6%
Nobori 23 17.5% 16.9%
xSearch4 22.2% N/A
Average 22.9% 19.3%
1. Windecker et al. Lancet 2008; 372: 1163–73
2. Wykrzykowska, EuroPCR ’09
3. Danzi, EuroPCR ‘09
4. Serruys, ACC ‘08

J Hermiller MD 6
Bifurcation Lesions Yield Complications
• Thrombosis Rate
– Incidence: 3.6-3.9%
– Hazard Ratio: 4.6-6.5
• Restenosis Rates
– Angiographic 20-40%

J Hermiller MD 7
Bifurcation Lesions:
Large Variation: Disease, Angle & Diameter
Case Courtesy of Drs Kutcher &
Holland, USA
Courtesy of P Brunel, France Courtesy of Dr. Dumonteil,
France
Courtesy of Prof. R. Kornowski,
Israel
Courtesy of Dr. Th. Lefèvre,
France
Courtesy of Dr. Schulze,
Germany
Courtesy of Dr. M. Lesiak,
Poland
Courtesy of Drs. E. Grübe - R.
Müller, Germany

J Hermiller MD 8
Multiple Treatment Strategies
Implementation: High Variability/Poorly Characterized

J Hermiller MD 9

J Hermiller MD 10
Forest plots from the included trials. Odds ratios of target vessel revascularization
(A), and main vessel restenosis (B) in the large side branch subgroup (patients with
side branch diameter ≥2.5 mm)
SB <2.5 mm: 1-stent
SB ≥2.5 mm: 2-stent

J Hermiller MD 11
Studies Involving Large Side Branches Favor 2- stent Strategy

J Hermiller MD 12
Tryton: Dedicated 2 Stent Approach
Baseline Tryton Final

J Hermiller MD 13
Key Points
• Bifurcation Lesions: Continues to be problem
Only Lesion Subset Not Routinely Stented
• Combined Literature:
Supports Provisional over 2 Stent Strategies
• Study Population Primarily Focused on Small SB
– BBC 1
– Nordic 1
• Studies with Large SB Favors 2 Stent Approach
– DK Crush
– 2 Stent ‘Simple’ Dedicated Stent
• Dedicated Side Branch Stent:
Focused on Providing Straight Forward 2 stent solution

J Hermiller MD 14
Thank You!!!!!!
Herms2@gmail.com