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
�������������� � ����� ���� � �������� �����
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 ?
