Contemporary approaches to bifurcation stenting

Figures

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  Figure 1.. The Medina classification is based on anatomic lesions, giving each bifurcation a 3 digit binary code. If there is a lesion >50%, it is classified as “1” and if <50% it is a “0”. The first figure represents the proximal main vessel, the second, the distal main vessel and the third the side branch. Each classification is demonstrated in the figure. Reproduced from Ali et al.2

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  Figure 2.. The DEFINITION study grouped bifurcation lesions into “complex” and “simple” lesions using criteria that predicted major adverse events post PCI. A complex lesion is defined as meeting the criteria in the first box and with at least two of the characteristics listed in the second box (adapted from Melikian et al.3).

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  Figure 3.. Importance of proximal optimization technique (POT). The POT balloon is sized 1:1 to the proximal MV. If the balloon is too proximal, there will be incomplete expansion of stent at the ostial SB and a risk of proximal edge dissection if the proximal balloon is outside of the stent. A too distal POT will deform the stent causing carina shift and reduction in the size of the ostial SB. The distal MV may be traumatized by the oversized balloon. There is also a risk of missing the proximal aspect of the stent which would then be under-expanded and unopposed to the vessel wall. Figure adapted from EBC.10

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  Figure 4.. OCT may be used to guide recrossing during bifurcation PCI. Here, a fly through image shows a proximal cell re-cross into the circumflex in a distal left main bifurcation.

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  Figure 5.. Provisional stent approach. A single stent is placed across the bifurcation. The proximal stent is optimised (POT) with a non compliant balloon sized to the proximal main vessel size. Rewiring of the side branch and kissing balloon inflation are commonly performed to optimize the ostium of the side branch but are not mandatory.

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  Figure 6.. The culotte technique. This is most suited to lesions where the SB and the distal MW are of similar caliber. The SB is stented first, followed by a POT and rewiring of the MV, aiming for a proximal cross of the stent struts. The stent struts are opened with a low profile balloon and the MV stented. A further POT is performed before rewiring of the SB to minimize the risk of abluminal wiring. KBI inflation is performed, sized to the distal vessels.

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  Figure 7.. T stent/TAP, treating MV first. The first 4 steps of this procedure are the same as provisional stenting so this can be used as a bailout technique if there is a large dissection in the SB or compromise of SB flow, converting the provisional strategy to a T stent/TAP strategy.

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  Figure 8.. DK crush technique. This is the most complex of the bifurcation techniques. It has the advantage of maintaining wire access in the MV throughout. Two KBI (unlike classic or mini-crush) are performed which increases the success of re-cross after MV stenting.