Bifurcation Approaches: A Step By Step Refresher

Bifurcation Approaches:A Step By Step RefresherCurtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I.Director, Peripheral InterventionsDirector, Interventional Cardiology Fellowship ProgramDivision of CardiologyScripps ClinicLa Jolla, CASCRIPPS CLINIC

Background Bifurcation lesions are commonly encounteredin clinical practice (up to 30% of PCIs) In the DES era, clinical outcomes of bifurcationPCI are very good Various 2-stent techniques have been devisedto effectively treat bifurcations lesions The savvy interventional cardiologist needs tobe familiar with all techniques since there arecertain advantages and disadvantages to eachSCRIPPS CLINIC

PCI for Bifurcation LesionsSCRIPPS CLINIC

Why Do Bifurcation Lesions PoseSuch a Challenge? When treating the main vessel, shift of plaque orthrombus can lead to sidebranch occlusion,particularly if: The ostium of the sidebranch itself is diseased The sidebranch is of small diameter Thrombus from ACS is present Clinical consequences of loss of the sidebranchare dependent on vessel size and amount ofmyocardiumSCRIPPS CLINIC

Bifurcation Intervention:The Problem of Plaque Shift (“Snow Plow”)MainBranchSideBranchSCRIPPS CLINIC

Commonly Used BifurcationTechniques Provisional Stent Technique Crush Techniques Simultaneous Stent Techniques T Stent Techniques Culotte TechniqueSCRIPPS CLINIC

Provisional Stent Technique:The ‘simplest’ way to treat a bifurcation lesionMainBranchWire both vessels (ifneeded)Pre-dilate as neededStent main branchSideBranchRewire and balloonside branch ( /kissing ballooninflation)SCRIPPS CLINIC

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Provisional Stent Technique:Plan B If a second stent is needed after provisionalstenting is performed (ie: dissection orcompromise of the sidebranch) the followingtechniques can be used: Culotte Technique Reverse Crush Technique TAP TechniqueSCRIPPS CLINIC

Provisional Stent TechniqueADVANTAGES:DISADVANTAGES: Simple Less Metal Potentially easier totreat restenosis Less thrombosis? Residual stenosisat side branch If side branch stentneeded, it can bemore difficult toinsert it throughfirst stentSCRIPPS CLINIC

If I Use a One Stent Strategy, Do INeed to do a Final Kissing Inflation?Meta-analysis of all published studies that included kissingballoon inflation vs. no kissing balloon inflation when using asingle stent strategyKissing balloon inflation was associated with a higherrestenosis rate of the main branch and no difference in overallclinical outcomePLoS One. 2018; 13(6)SCRIPPS CLINIC

Commonly Used BifurcationTechniques Provisional Stent Technique Crush Techniques Simultaneous Stent Techniques T Stent Techniques Culotte TechniqueSCRIPPS CLINIC

The Classic Crush TechniqueMainBranchWire both vesselsPre-dilate as neededPosition stentsDeploy side branch stent,remove balloon/wireDeploy main branch stent‘crushes’ side branchstentSideBranchRewire side branch andperform kissing ballooninflationSCRIPPS CLINIC

The Crush TechniqueSCRIPPS CLINIC

The Evolution of the ‘Crush’ Technique:Post-Crush Kissing Balloon InflationAfter KissingBalloon InflationBefore KissingBalloon InflationSCRIPPS CLINIC

Crush Technique:Variations Classic Crush Mini Crush Double Kissing Crush (DK Crush) Reverse Crush Step CrushSCRIPPS CLINIC

Classic Crush TechniqueMini Crush TechniqueSCRIPPS CLINIC

DK Crush Technique Position sidebranch stent as if performing a Mini Crush, in conjunction with aballoon in the mainbranch Deploy sidebranch stent, withdraw sidebranch stent balloon slightly, then reinflateto high pressures to “flare” the proximal sidebranch stent Remove sidebranch balloon and wire Crush sidebranch stent with mainbranch balloon Rewire sidebranch and perform a kissing balloon inflationSCRIPPS CLINIC

DK Crush Technique Remove sidebranch wire and balloon Position stent in the mainbranch and deploy it Rewire sidebranch and perform final kissing balloon inflationSCRIPPS CLINIC

Reverse Crush TechniquePerformed as a bailout strategy if provisional stenting of the mainbranch issuboptimalSCRIPPS CLINIC

Crush Stent TechniqueADVANTAGES:DISADVANTAGES: Assures coverage ofside branch ostium Prevents loss of sidebranch Can be used if sidebranch and main branchare of significantlydifferent sizes More complex Time consuming More costly (additionalwires/balloons) Sometimes unable toperform the final kissdestined for a worseoutcome More difficult to treatrestenosisSCRIPPS CLINIC

Commonly Used BifurcationTechniques Provisional Stent Technique Crush Techniques Simultaneous Stent Techniques T Stent Techniques Culotte TechniqueSCRIPPS CLINIC

The Simultaneous Kissing Stent(SKS) TechniqueMainBranchWire both vesselsPre-dilate as neededPosition stentsDeploy stentssimultaneouslyPerform kissing balloonpost-dilatationSideBranchSCRIPPS CLINIC

Simultaneous Kissing StentTechnique (SKS)ADVANTAGES:DISADVANTAGES: Simple Maintain wireaccess to bothbranches at alltimes Minimal ischemictime Can be difficult torewire/retreat laterdue to neocarina Requires largervessels of similarsize Higher restenosisrates reportedSCRIPPS CLINIC

Simultaneous V StentingTechnique Identical to theSKS technique,but without thecreation of anew carinaSCRIPPS CLINIC

Simultaneous V StentingTechniqueADVANTAGES:DISADVANTAGES: Simple Maintain wireaccess to bothbranches at alltimes Minimal ischemictime Only works ifproximal mainbranch is free ofdisease Plaque shift moreproximally can bedifficult to treat:Add a stent proximally andpotentially leave a gap vs.convert to SKSSCRIPPS CLINIC

Commonly Used BifurcationTechniques Provisional Stent Technique Crush Techniques Simultaneous Stent Techniques T Stent Techniques Culotte TechniqueSCRIPPS CLINIC

Traditional TStent TechniquePROBLEM:Almost NEVER is therea perfect 90 degreeangle betweenmainbranch andsidebranch!Use of the traditional Tstent technique isassociated with highrisk of missing thesidebranch ostiumSCRIPPS CLINIC

The TAP TechniqueT stent And ProtrusionMainBranchWire both vesselsPre-dilate as neededPosition and deploy mainbranch stentRewire side branch andballoon dilatePosition side branch stent soproximal edge protrudesslightly into main branch,‘backstop’ balloon inmain branchSideBranchDeploy side branch stentfirst, then inflate mainbranch balloon to kissSCRIPPS CLINIC

TAP TechniqueADVANTAGES:DISADVANTAGES: Relatively simple Assures coverage ofside branch ostium Less metal at sidebranch ostiumcompared to Crushtechnique Works when vesselsare different sizes Excessive stentprotrusion can leadto troubleaccessing distalmain branch in thefutureSCRIPPS CLINIC

Commonly Used BifurcationTechniques Provisional Stent Technique Crush Techniques Simultaneous Stent Techniques T Stent Techniques Culotte TechniqueSCRIPPS CLINIC

The Culotte TechniqueMainBranchWire both vesselsPre-dilate as neededPosition and deploy stent inmost angulated branchRemove first wire, wiresecond branch andballoon dilatePosition second branch stentso proximal portion equalwith previous stent edgeand deploySideBranchRewire initially stentedbranch and performkissing post-dilitationSCRIPPS CLINIC

Culotte TechniqueADVANTAGES:DISADVANTAGES: Assures sidebranch ostiumcoverage Excellent radialstrength in mainbranch Complex Vessels must be ofsimilar size Somewhat timeconsumingSCRIPPS CLINIC

What is POT?Proximal Optimization TechniqueDilatation of the stent within theproximal vessel to an appropriatesize to achieve proper appositionto avoid rewiring behind the stentand causing inadvertent crush ordistortion of the stentSCRIPPS CLINIC

Does it Really Matter WhatTechnique I Use?A registry of unprotected left main bifurcation lesions treatedwith T-stenting, mini-crush, and Culotte techniquesSCRIPPS CLINIC

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DK Crush vs. Provisional Stentingfor Left Main Bifurcation Lesions482 patients from 26 centers in 5 countries with true distal LMbifurcation lesions (Medina 1,1,1 or 0,1,1) randomized to provisionalstenting (n 242) or DK crush stenting (n 240)Chen et al. JACC Volume 70, Issue 21, 28 November 2017, Pages 2605-2617SCRIPPS CLINIC

DK Crush vs. Provisional Stentingfor Left Main Bifurcation LesionsSCRIPPS CLINIC

Conclusions Multiple techniques have been developed toeffectively treat bifurcation lesions Each has unique advantages anddisadvantages Being proficient with multiple techniqueswill assure that you are able to perform PCIregardless of varying patient anatomy withexcellent technical successSCRIPPS CLINIC

Thank YouSCRIPPS CLINIC

Various 2-stent techniques have been devised . Step Crush . SCRIPPS CLINIC Classic Crush Technique . Mini Crush Technique . SCRIPPS CLINIC . DK Crush Technique Position sidebranch stent as if performing a Mini Crush, in conjunct