2. Bifurcation lesion
Definition:
-Lesions occurring at , or adjacent to, a significant division of a major epicardial
coronary artery.
True Bifurcation:
-Main branch(MB) and side branch(SB) are both significantly narrowed(>50%
stenosis)
Non-true Bifurcation:
-All other lesions that are involved in bifurcation.
3.
4. Epidemiology
15-20 % of all PCIs involve bifurcations of importance
Lower initial success rate
Higher restenosis rate
Higher thrombosis rate
5.
6.
7.
8. Why challenging?
• Difficulty in access to the side branch
• Plaque shift
• Lesion recoil
• Ineffective lumen expansion
• High periprocedural complication rate
• Sub optimal immediate and long term results
• Risk of side branch occlusion
11. Stenting of bifurcation lesions
Provisional:
Main vessel stenting ± side branch angioplasty
(Provisional) T-stenting, TAP,
REVERSE INTERNAL CRUSH, REVERSE CULOTTE.
Elective:
Culotte-stenting
Crush technique (reverse crush)
T TECHNIQUE AND TAP
V STENTING
Y STENTING(SKS technique)
12.
13. When a wire is needed in the SB?
The SB has a narrowing at its ostium.
The MB has severe stenosis with a large plaque burden and the SB
originates with an angle of <45°.
The ostium of the SB deteriorates after predilatation of the MB
14. SHOULD WE PREDILATE SB LESION OR NOT?
• Kissing balloon predilatation is not recommended because of risk of
extensive dissections in unstented segments.
• Predilatation of MB left to discretion of operator based on type of lesion.
• Predilatation of SB is subject of controversy – better avoid.
• DRAWBACKS - Because while dilating ostium dissection may develop
prevents access to SB across stent struts of MB stent.
15. PROXIMAL OPTIMISATION TECHNIQUE ( POT )
Provides solution to under deployment of proximal MB stent.
Carried out by short bigger NC balloon just proximal to Carina.
Changes the orientation of SB Ostium facilitating the insertion of
guide wire, Balloon & if necessary stent in the SB, as well as
projection of stents in the SB Ostium.
POT is useful in especially in bifurcation lesion with large SB.
16. IS KBI NEEDED AFTER SINGLE STENT DEPLOYMENT ?
• KBI allows SB ostium treatment & apposition of MB stent struts on SB
ostium.
• It also enables correction of stent distortion & inadequate apposition.
• Drawbacks : Procedural complexity , stent ovalisation, proximal dissection.
• Final KBI is strongly recommended after complex technique with two stents,
remains controversial in case of single stent.