1. STRATEGIES OF HANDLING SIDE BRANCH
DURING PCI
Dr
manjunath

2. INTRODUCTION
 Coronary bifurcations are prone to develop atherosclerotic
plaque due to turbulent blood flow and high shear stress.
 Bifurcation lesions account for approximately 15% to 20% 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

4. ANATOMICAL CONSIDERATIONS
 Coronary bifurcations have been classified according to the
angulation between the MV and the SB, and according to
the location of the plaque burden

5. LOCATION OF ATHEROSCLEROTIC PLAQUE

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

11. LIMITATIONS OF
THE MEDINA CLASSIFICATION
 Does not take into account
1. Length of disease in the ostium of the SB
2. Length of the LMCA before the bifurcation
3. Trifurcation
4. Vessel angulation
 The LMCA differs from many other bifurcation
lesions due to the importance of the SB (LCx)

13. DUKE CLASSIFICATION OF BIFURCATION LESIONS

14. RISK
 The risk of side-branch closure with an ostial
narrowing approaches 15%
 PCI across an uninvolved side branch
carries a less than 1% risk of occlusion

15. PROVISIONAL OR ELECTIVE
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

16. GENERAL APPROACH OF BIFURCATION LESION

17. STENTING OF BIFURCATION LESIONS
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)

18. GUIDE CATHETER
 7 F or 8 F guiding catheter should be selected if the
operator anticipates using two stents
 A 6 F guiding catheter can accommodate only two
monorail balloon
 8 F guiding catheter can accommodate two stent
systems as well as other large-diameter PCI devices
such as the Rotablator or the Flextome Cutting
Balloon
 The maximum Rotablator burr that can be used with
a 6 F guiding catheter is 1.5 mm
 It may be prudent to “upsize” guiding catheters when
approaching any bifurcation lesion so that all options
remain available if trouble occurs during the
procedure

20. GUIDEWIRE
 To protect the side branch, two guidewires are
placed, one in the side branch and one in the main
vessel
 The order of inflation is relatively unimportant
 Wire markers or using two different wire types is
helpful to reduce confusion during balloon inflations
and wire repositioning
 When using a two-guidewire system, the guidewires
may become entangled after multiple wire
manipulations
 . Efforts should be made to avoid guidewire
entanglement, which will prevent advancement of the
balloon and may result in failure to recross the
stenosis.

21. BALLOON
 Standard balloon use
 Different balloon sizes may be required for each branch
 Sequential balloon inflations or simultaneous “kissing” balloon
inflations can be performed with elimination of plaque shifting
being the advantage of the latter
 It is important to make sure that the main vessel can
accommodate both balloon diameters when performing kissing
balloon inflations (proximal vessel should be at least two thirds of
the combined balloon diameters)
 After stent placement in the main branch and the side branch,
simultaneous kissing balloon inflations are critical to restore the
circular and fully expanded stent to each lumen
 Failure to perform final kissing balloon inflation will likely lead to
restenosis

23. PROVISIONAL STENTING OF BIFURCATIONS:
TECHNIQUE

26. - ? POSSIBLE PROXIMAL CROSS
UTILITY OF VERY SHORT OVER SIZED
BALOON TO DISCOVER PROXIMAL CROSS
FALSE BIFURCATION-POSSIBILITY OF PROXIMAL
CROSS IS MORE

27. AVOID PRE - DILATION OF SB

28.  FINAL KISSING BALOON INFLATION:

31. DIFFICULT ACCESS TO SIDE BRANCH: OPTIONS
1) dilating the main branch with baloon on the basis
of rationale that plaque modification and hopefully , a
favourable plaque shift will faciliatate access toward
SB
2)Performing rotational atherectomy
3) using venture wire control catheter – low profile
catheter with a tip that can be deflected to 90 degree.
4) Abort the procedure

32. ELECTIVE DOUBLE VESSEL STENTING

33. E.D.S.
 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.

35. SECOND STENT IN SIDE BRANCH AFTER
PROVISIONAL APPROACH
 T technique
 Modified T
technique—SB stent
first, when angle
between MB & SB is
near 90 degrees

38. CRUSH TECHNIQUE

39. REVERSE
CRUSH
TECHNIQUE
 Minimize
any
possible
gap b/w
MB & SB

41. STEP CRUSH

42. DK CRUSH
 In the DK crush, kissing balloon (KB) inflation
is performed after crushing the SB stent with
a balloon. This technique facilitates access to
the SB in addition to optimising stent
apposition at the SB ostium.
 It has been shown to perform favourably
against provisional stenting in a randomised
trial.

44. CULOTTE TECHNIQUE

48. THE V-STENTING TECHNIQUE

49. SKS TECHNIQUE

50. THE “SIMULTANEOUS KISSING STENTS” TECHNIQUE

51. POTENTIAL FAILURE MODES OF CRUSH AND SUGGESTED
SOLUTIONS
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.

52. L.M.C.A. BIFURCATION STENTING

53.  Double confirm about compiance of
antiplatelts.
 7/8 fr sheath.
 Elective I.A.B.P PUMP if required
 Low E.F
 HEMODYNAMIC SHOCK
 OLD AGE.
 FEMORAL ROUTE PREFFERED.

54. L.M.C.A. BIFURCATION STENTING

55. Role of intravascular ultrasound
Intravascular ultrasound (IVUS) is a useful modality
to help in selecting treatment strategies as well as
optimizing stent deployment and outcomes even in
the DES era
Role of fractional flow reserve
Physiologic flow assessment is a novel method to
assess reliably the functional flow in the SB.
FFR is measured when the functional severity of SB
stenosis is not adequately assessed by
morphological analysis.

56. RANDOMIZED TRIALS IN BIFURCATION STENTING SUPPORT
THE CONCEPT OF INITIAL SIMPLE PROCEDURES WITH ONLY
PROVISIONAL SIDE BRANCH STENTING
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

57. BRITISH BIFURCATION CORONARY STUDY
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

58. 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.

59. 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.)
CACTUS STUDY

60. 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.

61. 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.
NORDIC TRIAL

62. 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.

63. CORONARY ARTERY BIFURCATION LESIONS: A
REVIEW OF CONTEMPORARY TECHNIQUES
IN PERCUTANEOUS CORONARY
INTERVENTION
Felipe Fuchs, *Vladimír Džavík Peter Munk Cardiac Centre,
University Health Network, Toronto, Ontario, Canada
Citation: EMJ Int Cardiol. 2014;1:73-
80.

65.  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

88. CONCLUSION: PROVISIONAL OR ELECTIVE
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

89. Thank u