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STRATEGIES OF HANDLING SIDE BRANCH 
DURING PCI 
Dr 
manjunath
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
Strategies of handling side branch during pci
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
LOCATION OF ATHEROSCLEROTIC PLAQUE
Strategies of handling side branch during pci
EPIDEMIOLOGY: 
 15-20 % of all PCIs involve bifurcations of importance 
 Lower initial success rate 
 Higher restenosis rate 
 Higher thrombosis rate
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
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)
Strategies of handling side branch during pci
DUKE CLASSIFICATION OF BIFURCATION LESIONS
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
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
GENERAL APPROACH OF BIFURCATION LESION
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)
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
Strategies of handling side branch during pci
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.
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
Strategies of handling side branch during pci
PROVISIONAL STENTING OF BIFURCATIONS: 
TECHNIQUE
Strategies of handling side branch during pci
Strategies of handling side branch during pci
- ? POSSIBLE PROXIMAL CROSS 
UTILITY OF VERY SHORT OVER SIZED 
BALOON TO DISCOVER PROXIMAL CROSS 
FALSE BIFURCATION-POSSIBILITY OF PROXIMAL 
CROSS IS MORE
AVOID PRE - DILATION OF SB
 FINAL KISSING BALOON INFLATION:
Strategies of handling side branch during pci
Strategies of handling side branch during pci
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
ELECTIVE DOUBLE VESSEL STENTING
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.
Strategies of handling side branch during pci
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
Strategies of handling side branch during pci
Strategies of handling side branch during pci
CRUSH TECHNIQUE
REVERSE 
CRUSH 
TECHNIQUE 
 Minimize 
any 
possible 
gap b/w 
MB & SB
Strategies of handling side branch during pci
STEP CRUSH
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.
Strategies of handling side branch during pci
CULOTTE TECHNIQUE
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
THE V-STENTING TECHNIQUE
SKS TECHNIQUE
THE “SIMULTANEOUS KISSING STENTS” TECHNIQUE
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.
L.M.C.A. BIFURCATION STENTING
 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.
L.M.C.A. BIFURCATION STENTING
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.
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
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
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.
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
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.
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
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.
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.
Strategies of handling side branch during pci
 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
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
Strategies of handling side branch during pci
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
Thank u

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Strategies of handling side branch during pci

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