1. BY DR D MANJUNATH

2.  Coronary bifurcations are prone to develop
atherosclerotic plaque due to turbulent blood flow
and high shear stress.
 Bifurcation lesions account for approximately 15%
of all percutaneous coronary interventions (PCI).
 In comparison to other PCIs, bifurcation
interventions have lower rates of procedural
success, higher cost, higher resource utilization,
longer hospitalization, and higher rates of clinical
and angiographic restenosis

3.  Coronary bifurcations have been classified
according to the angulation between the MV and
the SB, and according to the location of the plaque
burden
 A Y-angulation is less than 70 degrees and allows
easy wire access to the SB, but plaque shifting is
potentially more pronounced and precise stent
placement with complete ostial coverage is often
difficult or geometrically impossible.

5.  Any > 50 % stenosis adjacent (< 5 mm) to and/ or
 at the ostium of a side branch (> 2 mm of
diameter)

7.  15-20 % of all PCIs involve bifurcations of
importance
 Lower initial success rate
 Higher restenosis rate
 Higher thrombosis rate

16. A) If the side branch is significantly
diseased at its ostium or nearby, it is
sufficiently large to be stented, safety
and duration of PCI are an issue: 2
stents
B) In all other conditions 1 stents and
then evaluate

17. 1)Provisional
Mainvessel stenting ± sidebranch angioplasty
(Provisional) T-stenting, TAP,
REVERSE INTERNAL CRUSH, REVERSE CULOTTE.
2) elective
Culotte-stenting
Crush technique (reverse crush)
T TECHNIQUE AND TAP
V STENTING
Y STENTING(SKS technique)

19.  FINAL KISSING BALOON INFLATION:

23.  Dilate the main vessel stent at high pressure
 The original Universal Balance wire
 Prowater/ Rinato (Asahi Intech wire)
 Intermediate wire
 Pilot 50 or 150 wire
 Always perform high pressure inflation in the side
branch before doing kissing

24.  DIFFICULT ACCESS TO SIDE BRANCH:
OPTIONS

26.  Pt selection
◦ D.E.S. is considered default strategy for
E.D.S.technique.
◦ Should undergo at least 12 mnth antiplatelet
treatment.
◦ So avoided in pts non compliant with medications
and at high risk for bleeding.

36. 1. Inability to wire the SB.
 Make Sure That The Wire Is Directed Towards The
Distal Part But Not The Proximal Part.
 If The Primery Guide Wire Failes Try Hydrophilic
Wires. If They Also Fail Consider Tapered Tip
Wires(MIRACLE).
2. INABILITY TO PASS BALOON IN TO SB.
 USE COMPLIANT MONORAIL 1.5 MM BALOON.
 IF FAILS REWIRE SB THROUGH A DIFFERENT SITE
AND RE ATTEMT BALOON CROSSING.
 IF FAILS THEN USE FIXED WIRE BALOON SYSTEMS.

40. Provisional Bifurcation Crush Stenting
Rotablation prox/mid LAD burr
1.5mm
After Rotablation

41. Provisional Bifurcation Crush Stenting
IVUS controlled (Main Branch)
Post bifurcation stenting
After Rotabltor at MB,
before SB balloon dilatation

42. Provisional Bifurcation Crush Stenting
Final IVUS: from MB to SB
diagonal

43. Provisional Bifurcation Crush Stenting
Final IVUS: from MB and from SB
LAD dia
dia
LAD

44. 1.Nordic I: provisional T stenting as good as systematic side branch
stenting
2.Nordic II: Culotte better than Crush
3. Cactus: provisional T stenting not worse than crush
4 . BBC ONE: step wise approach with provisional T stenting
better than initial complex procedures
5.Bad Krozingen: no difference provisional vs systematic T
6.Double Kiss Crush Study: DK Crush better than conv. crush
Steigen Circulation 2006; 114:1955; Erglis TCT 2008; Hildick-Smith TCT 2008
Ferenc EHJ 2009; Chen J Interv Cardiol 2009; 22:121-27

45. Randomized Trial of Simple Versus Complex Drug-Eluting
Stenting for Bifurcation Lesions
The British Bifurcation Coronary Study: Old, New, and
Evolving Strategies
David Hildick-Smith, MD, FRCP; Adam J. de Belder, MD, FRCP; Nina Cooter,
MSc;
Nicholas P. Curzen, PhD, FRCP; Tim C. Clayton, MSc; Keith G. Oldroyd, MD,
FRCP;
Lorraine Bennett, MSc; Steve Holmberg, MD, FRCP; James M. Cotton, MD,
FRCP;
Peter E. Glennon, PhD, FRCP; Martyn R. Thomas, MD, FRCP; Philip A.
MacCarthy, PhD, FRCP;
Andreas Baumbach, MD, FRCP; Niall T. Mulvihill, MD; Robert A. Henderson,
DM, FRCP;
Simon R. Redwood, MD; Ian R. Starkey, BSc, FRCP; Rodney H. Stables, DM,
FRCP
Circulation. 2010;121:1235-1243

46. Conclusions
For treatment of coronary bifurcation lesions, a
systematic 2-stent technique results in
longer procedures, higher x-ray doses, more
procedural complications, and a higher rate
of in-hospital and 9-month MACE.
The provisional T-stent strategy should be the
default treatment for most bifurcation
lesions; however, there may be subtypes of
coronary bifurcation that nonetheless merit a
systematic 2-stent strategy.

47. Randomized Study of the Crush Technique Versus
Provisional Side-Branch Stenting in True
Coronary Bifurcations
The CACTUS (Coronary Bifurcations: Application of the
Crushing
Technique Using Sirolimus-Eluting Stents) Study
Antonio Colombo, MD; Ezio Bramucci, MD; Salvatore Saccà,
MD; Roberto Violini, MD;
Corrado Lettieri, MD; Roberto Zanini, MD; Imad Sheiban, MD;
Leonardo Paloscia, MD;
Eberhard Grube, MD; Joachim Schofer, MD; Leonardo
Bolognese, MD; Mario Orlandi, MD;
Giampaolo Niccoli, MD; Azeem Latib, MD; Flavio Airoldi, MD
(Circulation. 2009;119:71-78.)

48. Conclusions
In most bifurcation lesions with a significant
stenosis in
both branches, a strategy to stent the MB is
effective, with the need to implant a second
stent in the SB occurring approximately one
third of the time.
The implantation of 2stents does not appear
to be associated with a higher incidence of
adverse events, taking into account that the
follow-up was limited to 6 months and that
most patients were still on
dual-antiplatelet therapy.

49. Randomized Comparison of Coronary Bifurcation Stenting
With the Crush Versus the Culotte Technique Using
Sirolimus Eluting Stents
The Nordic Stent Technique Study
Andrejs Erglis, MD; Indulis Kumsars, MD; Matti Niemela¨, MD; Kari Kervinen, MD;
Michael Maeng, MD; Jens F. Lassen, MD; Pål Gunnes, MD; Sindre Stavnes, MD; Jan S.
Jensen, MD;
Anders Galløe, MD; Inga Narbute, MD; Dace Sondore, MD; Timo Ma¨kikallio, MD; Kari
Ylitalo, MD;
Evald H. Christiansen, MD; Jan Ravkilde, MD; Terje K. Steigen, MD; Jan Mannsverk,
MD;
Per Thayssen, MD; Knud Nørregaard Hansen, MD; Mikko Syvänne, MD; Steffen
Helqvist, MD;
Nikus Kjell, MD; Rune Wiseth, MD; Jens Aarøe, MD; Mikko Puhakka, MD;
Leif Thuesen, MD; for the Nordic PCI Study Group
Circ Cardiovasc Intervent. 2009;2:27-34.

50. Conclusions
In conclusion, excellent 6 months clinical
and 8 months angiographic results can be
obtained with the crush and culotte
stenting of de novo coronary artery
bifurcation lesions using SES.
Culotte-stented lesions tended to have
lower
angiographic restenosis rates making this
technique an attractive bifurcation stenting
technique in feasible bifurcation lesion
anatomies.

55. Indulis Kumsars, Matti Niemelä, Andrejs Erglis, Kari Kervinen, Evald H. Christiansen, Michael
Maeng, Andis Dombrovskis, Vytautas Abraitis, Aleksandras Kibarskis, Terje K. Steigen, Thor
Trovik, Gustavs Latkovskis, Dace Sondore, Inga Narbute, Christian Juhl Terkelsen, Markku Eskola,
Hannu Romppanen, Per Thayssen, Anne Kaltoft,Tuija Vasankari, Pål Gunnes, Ole Frobert, Fredrik
Calais, Juha Hartikainen, Svend Eggert Jensen, Thomas Engstrøm, Niels R. Holm, Jens F. Lassen
and Leif Thuesen
For the Nordic-Baltic PCI Study Group

56. Nordic-Baltic Bifurcation Study IV
The Nordic-Baltic PCI Study Group
• Provisional (simple) stenting is the preferred
strategy in treatment of most bifurcation
lesions
• It is unknown if this also applies to true
bifurcation lesions involving a large side
branch

57. Denmark
Aarhus University Hospital
(112 pts)
Aalborg University Hospital
(13 pts)
Odense University Hospital
(10 pts)
Rigshospitalet Copenhagen
(3 pts)
Latvia
P.Stradins University Hospital, Riga
(159 pts)
Sweden
Örebro Hospital
(11 pts)
Linköping
(3 pts)
Karolinska University Hospital
(1 pts)
Finland
Oulu University Hospital (75 pts)
Tampere University Hospital (8 pts)
Turku University Hospital (6 pts)
Kuopio University Hospital (2 pt)
Norway
Tromsø University Hospital (18pts)
Arendal Hospital (3 pts)
Feiring Heart Clinic
(2 pts)
Lithuania
Vilnius University Hospital (21 pts)
The Nordic-Baltic PCI Study Group

58. Nordic-Baltic Bifurcation Study IV
The Nordic-Baltic PCI Study Group
 To compare provisional stenting and two-stent
techniques for the treatment of true
coronary bifurcation lesions involving a large
side branch

59. Nordic-Baltic Bifurcation Study IV
The Nordic-Baltic PCI Study Group
• Open label, randomized, multicenter trial
• 1:1 randomization
• Clinical FU at 0, 1 and 6 months
• Angiographic substudy with 8 months FU
• Study stents:
– Sirolimus eluting Cordis Cypher Select+ (first 225
patients)
– Everolimus eluting Abbott Xience V (last 225
patients)

60. Combined endpoint after 6 months:
• cardiac death
• non-index procedure related myocardial infarction
• TLR
• definite stent thrombosis
Nordic-Baltic Bifurcation Study IV

61. Nordic-Baltic Bifurcation Study IV
Secondary endpoints
• Individual endpoints of:
• Total death
• Cardiac death
• Non-index procedure related MI
• Target lesion revascularization (TLR)
• Target vessel revascularization (TVR)
• Definite stent thrombosis
• Procedure related myocardial infarction
• 8-month angiographic follow-up results

62. Inclusion criteria
• Age≥18
• Stable Angina, UAP,
NSTEMI
• MV≥3.0mm
• SB ≥2.75mm
• Bifurcation stenosis
involving both MV and
SB
(≥50%DS by eyeballing)
Nordic-Baltic Bifurcation Study IV
Exclusion criteria
• STEMI
• Cardiogenic shock
• Other critical illness
• Relevant allergies
• Cr ≥ 200 μmol/L
• SB lesion length
>15mm

63. Nordic-Baltic Bifurcation Study IV
Provisional SB stenting
–Two wires
– Predilatation
– MV stenting
– If TIMI flow<III or >75%DS in ostial SB:
kissing balloon dilatation
– If SB TIMI flow <III after kissing balloon
dilatation, SB stenting using a T- or Culotte
technique

64. The Nordic-Baltic PCI Study Group
Two-stent techniques
– Two wires
Nordic-Baltic Bifurcation Study IV
– Predilatation of segments to be stented
– Culotte stenting recommended
• T-stenting and mini-crush allowed
– Final kissing balloon dilatation

65. Nordic-Baltic Bifurcation Study IV
Nordic Baltic Bifurcation study
IV
n=450
Provisional SB
stening
n=221*
Two stent
n=229*
1 lost to FU
1 excluded due to
protocol violation
Provisional
Completed 6M FU
n=220
Two stent
Completed 6M FU
n=227
1 withdrawal
*numbers not balanced due to block randomization and sites with less than 4 inclusions
The Nordic-Baltic PCI Study Group

66. Nordic-Baltic Bifurcation Study IV
1.8%
4.6%
p=0.09
The Nordic-Baltic PCI Study Group

67. Nordic-Baltic Bifurcation Study IV
The Nordic-Baltic PCI Study Group
• After 6 months, two-stent techniques for treatment
of true bifurcation lesions with a large side branch
showed no significant difference in MACE rate
compared to provisional side branch stenting
•
• Longer and more complex procedures in the two-stent
group did not translate into more procedural
myocardial infarctions
• Recommendations on optimal strategy for this
lesion subset should await longer term follow-up

68.  WHY WE NEED DEDICATED STENT.
 PROVISIONAL ASSOCIATED WITH S.B CLOSURE
 E.D.S . Is complex, time consuming, need one more
stent
 What are desired features
 Low profile
 Less cost
 Easy trouble

69. If the side branch is significantly diseased at
its ostium or nearby, it is sufficiently large
to be stented, safety and duration of PCI are
an issue: 2 stents
In all other conditions 1 stents and then
evaluate