Coronary bifurcations stenosis: definition, classification of lesions,

classification of techniques, measurements

Y. Louvard, ICPS, Massy, Générale de Santé, France

European Bifurcation Club 10th anniversary meeting Bordeaux, France, October 17-18th 2014

Presented by Bernard Chevalier in the 1st EBC meeting, september 16th 2005

Definition of a coronary bifurcation stenosis

Fonctional hierarchy of coronary circulation: direct evidence of structure-fonction relation

Kassab, Am J Physiol Heart Circ Physiol 289: H2559-2565, 2005

Scaling laws of vascular trees: of form and function

Kassab, Am J Physiol Heart Circ Physiol 290: H894-H903, 2006

Scaling of myocardial mass to flow and morphometry of coronary arteries

Choy, Kassab, J Appl Physiol 104: 1281-1286, 2008

How to define a bifurcation lesion ?

•  A coronary artery narrowing occuring adjacent to, and/or involving, the origin of a significant side branch

•  A significant SB is a branch that you don't want to loose in the global context of a particular patient

Y. Louvard Catheter Cardiovasc Interv. 2008 Feb 1;71:175-83

Bifurcation or not ?

Classification of bifurcation lesions

Classifications of bifurcation lesions

Duke Sanborn Safian Icps-Lefevre

Chen - Gao Syntax classification

A New Proposed Simplified Classification of Coronary Artery Bifurcation Lesions and Bifurcation Interventional Techniques

Movahed, J Invas Cardiol 2006;18:199–204

A New Proposed Simplified Classification of Coronary Artery Bifurcation Lesions and Bifurcation Interventional Techniques

Movahed, J Invas Cardiol 2006;18:199–204

BL1sT-LM

BL2T-LM-CA ?

BL1nT-CA

Major Limitations of Randomized Clinical Trials Involving Coronary Artery Bifurcation Interventions: Time for Redesigning Clinical Trials by Involving Only

True Bifurcation Lesions and Using Appropriate Bifurcation Classification Suggested algorithmic approach for randomized clinical trials involving coronary bifurcation

intervention

Movahed. Journal of Interventional Cardiology 2011

Medina Classification

1,1,1 1,1,0 1,0,1 0,1,1

1,0,0 0,1,0 0,0,1

Medina et al. Rev. Esp. Cardiol 2006; 59(2): 183-4

0, 1

0, 1 0, 1

MB (Proximal)

MB (Distal)

SB

Name the bifurcation Why ?: - for Medina classification (which branch is the SB ?) - for stenting technique definition - for intention to treat analysis

Cx1,Mg1,Cx2 1,0,0 LAD1,LAD1,Dg1 1,1,1 RCA2,RCA2,Mgr 0,1,1 LM,LAD1,Ram,Cx1 1,1,0,1

LAD1,LAD1,Dg1,Dg2 0,1,1,1 Mg2,Br2,Br1 0,1,0 RCA3,PDA,PLA 1,0,0 LAD1,Dg1,LAD2 1,1,1

A B C D

E F G H

Louvard Y. CCI. 2008, 71: 175-83

What is our Medina classification ?

•  Simple •  Easy to remember •  Research classification •  Incomplete (angle, SB lesion length, Ca++ …) •  Can be completed by quantification •  Visual / base on quantification •  IVUS Medina, OCT Medina, FFR Medina …

Todaro, Burzotta, Rev Esp Cardiol. 2009;62(6):606-14

Evaluation of a Strategy for Treating Bifurcated Lesions by Single or Double Stenting Based on the Medina Classification

Todaro, Burzotta.Rev Esp Cardiol. 2009;62(6):606-14

Evaluation of a Strategy for Treating Bifurcated Lesions by Single or Double Stenting Based on the Medina Classification

Todaro, Burzotta, Rev Esp Cardiol. 2009;62(6):606-14

Quantification of a coronary bifurcation stenosis

D1

D2

D3

Structure-­‐func*on  s  caling  laws  of  vascular  trees  

Adapted from G. Kassab

Finet’s formula D1= (D2+D3) X 0,678

Murray’s law

D13*

= D23*

+ D33*

* 2.3 (Huo-Kassab)

Traditional QCA for coronary bifurcation quantification: reference, MLD, %

Dedicated bifurcation QCA

Bifurcation

Subsegment analysis demonstrating the various segments that should be analyzed and reported separately

Quantitative Angiographic Methods for Bifurcation Lesions: A Consensus Statement from the EuropeanBifurcation Group

Lansky, CCVI 73:258–266 (2009)

Classification of bifurcation stenting techniques

A B

C D

+

High Tech meeting 1997

Classification of Treatments

Classification of Treatments

A Technique B Technique C Technique D Technique

« Skirt » Technique

1 2

3 4

5 7

11

8

9

106

11

11

11

11

11

11

11

11

11

11

11

11

11

11

22

22

22

22

22

++ 22

++ 22

++ 22

++ 22

1 or 21 or 2

1 or 21 or 2

Y. Louvard, Heart 2004; 90 :713 –722

Exhaustive ? Simple ?

Schematic description of interventional bifurcation techniques: OST = one stent technique; SBT = stent with balloon technique; KST= kissing stent technique; TST = ”T” stenting technique; CRT = crush stenting technique; CUT = culotte stenting technique

Movahed. J Invasive Cardiol. 2006 May;18(5):199-204

M Main prox. first

A Main Accross side first

D Double first

S Side branch first

Extended V

Skirt

PM stenting

MB stenting across SB

MB stenting + kissing

MB stenting + SB balloon

Elective T stenting

Internal crush

Culotte TAP

DM stenting

Provisional SKS

V stenting

SKS

Trouser legs and seat

SB ostial stenting

SB minicrush

SB crush

Syst. T Stenting

Minicrush Crush

After balloon

2 stents

3 stents

1st stent

Skirt + DM

Skirt + SB

After balloon

2 stents

3 stents

1st stent

Inv. MB stenting across SB

MB to SB stenting + kissing

MB to SB stenting + DM balloon

Inv. Elective

T stenting Inv.

Internal crush

Inv. Culotte Inv. TAP

DM ostial stenting

DM minicrush

DM crush

Inv. Syst.

T Stenting Inv.

Minicrush Inv. Crush

Inv. Provisional

SKS

M Main prox. first

A Main Accross side first

D Distal first

S Side branch first

Two-stent strategies for bifurcation lesions: which vessel should be stented first, the main vessel or the side ranch? Adjusted incidences of cardiac death, MI and stent thrombosis using inverse probability weight (A) and standardized mortality/morbidity ratio weight (B)

Shin, J Korean Med Sci 2011; 26: 1031-1047

1st stent

2nd stent

MB stenting with protection MB stenting with SB balloon

Elective T stenting Internal Crush Culotte « Buchbinder ? »

MB stenting accross SB first1st stent 2nd stent 3rd stent

? Helqvist

Proximal MB stenting

Skirt technique

Proximal MB stenting first

V stenting V + proximal stenting

½ SKS SKS

1st stent 1st and 2nd stent 3rd stent

Distal branches stenting first

1st stent

2nd stent

SB ostial stenting SB Crush stenting

Systematic T stenting Minicrush Crush technique

SB stenting first

Inverted

e- CRF ?Wires

Balloons

Intention

DK-Crush technique, Chen, Eur J Clin Invest 2008; 38 (6): 361–371

Conclusions

•  Better definition of bifurcation stenosis ? Possible ? Useful ?

•  Do we need another classification than the Medina’s ? No…

•  Classification of treatments: how to take into account the complexity of techniques ?

•  What is missing ?