How to Optimize Bifurcation PCI David Zhao MD

How to Optimize Bifurcation PCI David Zhao, MD, FACC, FSCAI Henry S. Miller Jr. Professor in Cardiovascular Medicine Professor of Medicine, Cardiothoracic and Vascular Surgery Chief, Section on Cardiovascular Medicine Executive Director, Heart and Vascular Center Wake Forest School of Medicine Winston Salem, NC

David X. Zhao, M. D. I have no relevant financial relationships pertinent to this presentation

Steps to Optimal Bifurcation PCI • Understand bifurcation anatomy and implication • Proficient in bifurcation PCI strategies and techniques • Always have a plan and be adaptable when anatomy and situation change (such as plaque shift) • Routinely consider Intra-vascular imaging modalities that can improve outcomes

Bifurcation Lesion Intervention Bifurcation Classification (Medina) § § Account for 15 -20% of PCI § § No two bifurcations are the same! Most of these lesions are complex (type C of ACC/AHA class) Technically challenging with higher learning curve ü Variation in anatomy: LM vs non LM, plaque burden and location, angle between the bifurcation, disparity in the sizes of two vessels ü Dynamic changes in anatomy during PCI: plaque shift, dissection, jailed branch

Strategies and Techniques for Bifurcation Lesions Side branch determines the bifurcation strategy § Provisional § Two stent strategies: § Culottes § Crush (Step crush, DK crush, Mini crush, Reverse crush) § V stenting § Simultaneous kissing stent (SKS) § T stenting (TAP)

Provisional versus Two Stents Zimarino et al JACC Intv 2013; 6: 687

Provisional Stent Techniques • Advantages: – Simple and less metal – Lower event rates • Disadvantages: – Residual stenosis at side branch – Potential difficulty to recross into SB – Potential difficulty to deliver stent to SB when needed

POT (Proximal Optimization Technique) Sawaya et al JACC Inv 2016; 9

Where to Re-cross Wire Matters Sawaya et al JACC 2016; 9:

Culottes Technique • • • Severe lesions in both main and side branches Lesions involve the ostium of SB: high risk to compromise SB MB and SB are similar in diameter – Exception: mini Culottes • • • Angulation: wide range, preferably <60 o Pre-treat both branches when necessary Stent the most angulated branch first (usually SB) Withdraw wire in the 1 st stent to avoid entrapment Final kissing balloon inflation: critical for long term outcome

Culottes: Advantage and Disadvantage • Advantages – Complete coverage of ostium and main branch – Suitable for wide range of angulation – Double stent layers (as compare to three layers in crush technique versus single layer in provisional) – Minimal strut deformity at SB ostium • Disadvantages – High procedure complexity and multiple rewiring – Risk of losing access to distal vessel

Crush Stenting Techniques Standard crush Step crush Double Kissing Crush

Crush Stenting Techniques • Advantages – Ensuring the patency and access of both branches – Relatively simple with need to rewire only one branch • Disadvantages: – Excessive metal near ostium of SB may complicate rewiring and balloon crossing

T Stenting Techniques &TAP JACC Intervention 2013; 6

T Stenting Techniques &TAP • Advantages: – Less metal at SB ostium (compare to crush) – Complete ostial coverage in SB (TAP) • Disadvantages: – Inadequate SB ostial coverage (T stent) – Stent protrusion in MB may affect MB access (TAP)

V Stenting Techniques • Advantages: – Simple – Maintain access to both branches • Disadvantages: Interventional Cardiology 2011; 3 – Does not apply if proximal vessel is diseased – Proximal vessel complication can be difficult to manage

Simultaneous Kissing Stenting Techniques JACC 2005; 46 • Advantages: – Ensure access to both branches – No need for rewiring • Disadvantages: – Presence of metallic “neocarina” – Stent mal-apposition – Difficult to manage proximal vessel if dissection occurs – Difficult in future reintervention

Dedicated Bifurcation Devices Abbott SB Axxess Tryton BSC Petal YMed Sidekick

Conclusions • Every bifurcation is different, careful planning is essential for every case • Side branch determines bifurcation approaches • Keep it simple: provisional versus two stents strategies • POT and Kissing balloons are essential in one or two stent approaches • Consider intra-vascular imaging modalities