How do I treat bifurcation lesions?
Bifurcation Lesion Intervention
• Bifurcation lesion intervention is performed in about 8-15% of PCI at most centers • Most of these lesions are complex (type C of ACC/AHA) • Technically challenging with higher learning curve
• PCI of these lesions requires greater number of
devices • PCI associated with higher MACE, higher
restenosis, and higher SAT
Bifurcation Lesion Intervention
Issues
• Plaque shift / displacement
• Elastic lesion / recoil • Disparity in the size of the parent vessel
and sidebranch
Bifurcation Lesion Classification Duke’s Sidebranch involvement ?
A
B
Prebranch
C
Postbranch Parent vessel only
D
Bifurcation
E
Ostial
F
Prebranch and ostial
1. Size of sidebranch 2. Presence of calcium 3. Angle with parent vessel
Optimal Treatment of Bifurcation Lesions Short & Long-term Results
Variable Angiographic appearance Acute complication Restenosis Technical challenge
Stent of parent vessel & PTCA ( stent ) of sidebranch Debulking of parent vessel & S of side-branch
Excellent for parent vessel, suboptimal for SBr
1-3%
High for SBr
+ ++ +++
High for main Excellent 0-1% vessel Simple approach with a single stent at High Stent of parent vessel & Excellent 2-13% bifurcatio may be adequate in many subsets n S of side-branch Debulking+S of parent Excellent for High for vessel & 2-4% parent vessel SBr PTCA of side-branch for SBr Debulking+S of parent vessel & Low for Excellent 1-5% both Debulking of side-branch
++++
+++++
The Bifurcation Study With Cypher Sirolimus-Eluting Stent
%
30
Segment Restenosis
Stent+Stent Stent+PTCA
25
Total Restenosis
p=0.20
20.3
20
Restenosis
10
10
5
0
2.3 1/44
3.1
11/44 2/20 2/64 13/64
1/20
Main branch
Side branch
Main Side branch
Colombo et al. Circulation 2004;109:1244.
Crush technique
Bifurcation Lesion Intervention “Crushed” T-Stent Technique
• Seems simple • Side branch may be difficult to recross • 30-day MACE rate of about 4-8% • Increased SAT
Thrombosis rates according to selected patient characteristics
35 % 30 25 20 15 10 5 0
Renal failure
29
Aspirin And Clopidogrel Stopped
Prior Brachytherapy Bifurcation
8.7 5.5 3.5
Bifurc
3.2
LM
2.6
DM
1.3
UA
*Iakovou et al JAMA 2005
Bifurcation Lesion Intervention “Crushed” T-Stent Technique
• Seems simple • Side branch may be difficult to recross • 30-day MACE rate of about 4-8% • Increased SAT • Restenosis issues especially of the crushed sidebranch • 8-16% TLR which seems to be lower with final kissing balloon dilatation
Main Branch
Side Branch
Bifurcation Lesion Intervention Using DES
“Simultaneous Kissing Stent” (SKS) Technique
Pre
Post
SKS Technique Bifurcation lesion involving LAD and Diagonal
LAD
Diagonal
1 or 2 stents?
A) 2 stents
The side branch is significantly diseased at its ostium or nearby, The side branch is sufficiently large to be stented,
B) 1 stent
in all other conditions and then evaluate
Predilatation
Baseline IVUS can suggest the need for predilatation and is helpful for strategy Dilate the side branch if critical Predilate if uncertain
If no predilation of the side branch…continue to re-evaluate the side branch following main branch predilatation; dilate is side branch if compromised
Case 2: Side branch management
74 yo wm with rest angina; troponin 1.0 Started on Plavix, Lovenox, Aspirin
Bifurcations:
Baseline
Bifurcations:
LAD stenting
after LAD stenting
Bifurcations:
Kissing
result after Kissing
Bifurcations
IVUS
CSA : 3.4 mm2 FFR : 0.80
Result after Kissing
Discrepancy between Angio & FFR
FFR
Angio
Conclusions
1 stent, when possible, when 2 stents are needed… crush with kiss or V/SKS
In complex bifurcations 2 stents as intention to treat
Perform optimal dilatation of the side branch
Always kissing balloon to end procedure
Failure to deliver DES stent: Use other DES, BMS or balloon only
Thrombosis is higher than in standard lesions
Ostial disease with proximal involvement
Ostial LAD with distal LM
IVUS
D1=4.0mm, D2=4.5mm
Distal LM
D1=2.9mm, D2=3.3mm
Ostial LAD
Baseline
LCSA = 5.6 mm2 LCSA = 3.4 mm2
Ostial LAD with distal LM
Result after stent implantation
IVUS
Cypher 3.5 x 33 mm
Distal LM D1=3.3mm, D2=2.8mm
Ostial LAD
D1=3.2mm, D2=2.9mm
LCSA = 7.6 mm2
LCSA = 7.0 mm2
Ostial LAD with distal LM
Result after 2nd inflation
IVUS
Powersail 4.0x8 mm 26 atm
D1=5.1, D2=4.4 mm
Distal LM
D1=4.0, D2=3.5 mm
Ostial LAD
12306/05
LCSA = 10.9 mm2
LCSA = 8.9 mm2
Left Main Lesion
Kissing Balloon
Final Result