BIFURCATION STENTING

DR MAHENDRASR, CARDIOLOGY

JIPMER

• Introduction• Classification • Techniques • Relevant study • Dedicated bifurcation stents• Conclusions

Introduction• Accounts for 20% of coronary angioplasty procedures. • European Bifurcation Club defines BIF as: “a coronary artery narrowing occurring

adjacent to, and/or involving, the origin of a significant SB".loss is significant SB lead to consequence in term of- • symptoms• location of ischemia • viability of the supplied myocardium • collateralizing vessel• left ventricular function

• Coronary bifurcations are at high risk for the development of atherosclerotic plaque

Classification• Based on degree of SB angulation.• Based on the location of the plaque burden.

Angulation and morphology

Y-shaped: access is easy but chances of plaque shift is moreT-shaped: access is difficult but chances of plaque shift is less

Based on location of plaque burden• Duke • Sanborn • Safian • Lefevre• SYNTAX • Medina

Medina classification

• Limitation of medina classification -does not consider • bifurcation angles• calcification• lesion length• functional significance of the lesions• plaque distribution and plaque burden when compared with IVUS.• fate of SB on dilatation of the MB.

Movahed classification

Technical aspect

Difficulties of Bifurcation PCI

Risk of periprocedural complication1. Side branch compromise ( ‘snow-plough’ effect).2. Incomplete coverage of side branch ostium with the stent.3. Stent distortion.

• Relatively high restenosis• Higher risk of stent thrombosis

Factors to be considered for bifurcation PCI strategy

• Anatomical factors• - LMCA bifurcation• - Location of plaque (Anatomical classification)• - Plaque or carina shift• - Angle btw SB and MB• - Dynamic change in bifurcation anatomy• Modalities for objective anatomical evaluation• - QCA, IVUS, FFR• Selection of devices and strategies• - DES vs. BMS• - Single vs. Double stent techniques• - Kissing balloon or not• - Dedicated bifurcation stent

Approach for side branch• How large and important is the side branch?• Does the side branch come out from the main at an acute angle?• Does the ostium or the proximal segment of the side branch have a

significant narrowing?• Is the side branch difficult to wire?• Is the patient a very high risk and does the side branch appears relatively

important?• Is the main branch severely narrowed with a considerable plaque burden?

General approach

PROVISIONAL SB STENTING STRATEGY

PROXIMAL OPTIMIZING TECHNIQUE

• SB- unsuitable for stenting (<2 mm), with normal flow, no angina, or ECG signs does not require intervention.

• SB ostium be dilated- • inadequate results are achieved, • antegrade flow is impaired (Thrombolysis In Myocardial Infarction flow grade <3)• severe ostial SB narrowing is present • fractional flow reserve of the SB is <0.80.

• series of recent studies, routine KBI after provisional bifurcation stenting has failed to provide clear clinical benefits.

• recommendations for KBI in provisional bifurcation stenting-• use of noncompliant balloons at least in unstented SB to prevent the occurrence

of dissection• short balloons to avoid oval distortion in the PM segment. • stent diameters adapted to the distal diameters of the bifurcation.

• advantage of the provisional strategy is that most techniques can be applied after MB stenting and SB opening:

• T-stenting • T-stenting and small protrusion (TAP)• culotte.

2-STENT TECHNIQUES• SB is >2.5 mm with >50% stenosis extending >5 mm beyond the SB ostium

Various techniques• V-stenting • SKS technique • Crush technique• T-technique• Y-stenting• Culottes technique• Skirt technique

Both branches are wired and dilated.

Step 3:

Figure 5. The “V” stenting technique

Final kissing balloon inflation using same pressure for both balloons.

a) Position two parallel stents covering both branches and extending into the main branch.

Cross Section

Step 1:

Step 2:

b) Inflate the first and then the second stent.

Crushing stenting technique

Step 1: Wire and dilate both branches

Step 2: Position both unexpanded stents.

Step 3: Dilatate the stent at the ostium of the side branch.

Step 4: Remove the wire and balloon from side branch and dilate the stent in main branch.

If necessary, step 5: Re-wire the side branch and final kissing balloon dilatation.

L.M.C.A. BIFURCATION STENTING

L.M.C.A. BIFURCATION STENTING

• many nonrandomized studies suggest provisional SB stenting strategy is superior for distal LM bifurcation in the majority of cases.

• subgroup of the SYNTAX trial, lower rate of cardiac death at 3 years and a lower 1-year major adverse cardiac events rate when performing a provisional approach.

DEDICATED BIFURCATION STENTS• currently 4 dedicated stents commercially available worldwide: • BIOSS stent • Stentys device• Axxess stent • Tryton stent• evaluated in the past 20 years but their superiority over the provisional strategy

has yet to be demonstrated.

IMAGING• provide essential information for the assessment and treatment of BIF• Better insight into plaque configuration and can diminish the unnecessary use of

a 2-stent procedure• After stenting, imaging modalities can be used to evaluate stent expansion, edge

dissection, or stent malapposition.

Result of various study

Stent thrombosis incidence in clinical trials comparing 1 stent (1S) with 2 stent (2S) strategies in treating coronary bifurcations

Major adverse cardiac event and TLR incidence in randomized trials comparing 1 stent (1S) with 2stent (2S) strategies.

• Majority of randomized trials comparing the 1 stent with 2 stent techniques have shown no advantage of implanting 2 stents regardless of the lesion type.

• both strategies resulted in similar outcomes in terms of risk of cardiac death, TLR, and stent thrombosis.

• rate of periprocedural MI significantly higher in the complex versus simple strategies on the basis of the patient level metaanalysis of the Nordic I and BBC 1 (British Bifurcation Club 1) trials.

• outcomes achieved with each individual technique, a simple strategy with provisional SB stenting has now become the preferred strategy.

CONCLUSION• major challenge for interventional cardiologists • treatment decision should depends on each patient and each lesion. • provisional SB stenting should be the default approach in the majority of cases• DES implantation has dramatically improved long term outcome of the main

vessel in the bifurcation lesion.• OCT and IVUS having important role in treatment strategy, assessment of

complication, optimization of stent.

THANK YOU