How to Handle a Complex Bifurcation Lesion Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I. Director of Peripheral Interventions Division of Cardiology Scripps Clinic and Research Foundation La Jolla, CA 1 1 1

Curtiss Stinis, MD Consulting: Abbott Vascular Medtronic, Inc. Honoraria: Cook Group Incorporated

Easy….. Not so Easy!

Background Bifurcation lesions have historically been associated with lower procedural success rates and higher complication and restenosis rates Various 2-stent techniques have been devised to ensure full coverage of the side-branch ostium in an attempt to improve acute and long-term outcomes Thus far, no single 2-stent technique has been truly proven to be superior Useful for the operator to know several techniques since there are certain advantages and disadvantages to each

Why Do Bifurcation Lesions Pose Such a Challenge? When treating the main vessel, shift of plaque or thrombus 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 sidebranch are dependant on vessel size and amount of myocardium

Bifurcation Intervention: The Problem of Plaque Shift (“Snow Plow”) Main Branch Side Branch 6 6

Bifurcation Lesion: Definition “A parent vessel with a side branch more than 2mm, with a lesion involving at least one vessel receiving PCI” – Antonio Colombo, MD

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Commonly Used Bifurcation Techniques Provisional Stent Technique Crush and Mini-Crush Techniques Simultaneous Kissing Stent Technique (SKS) TAP Technique Culotte Technique Provisional Stent Technique

Provisional Stent Technique: The ‘simplest’ way to treat a bifurcation lesion Main Branch Wire both vessels Pre-dilate as needed Stent main branch Rewire and balloon side branch (+/- kissing balloon inflation) Side Branch 10 10

Provisional Stent Technique Advantages: Disadvantages: ● Simple ● Residual stenosis at ● Less Metal sidebranch ● Easier to treat restenosis ● If sidebranch stent ● Less thrombosis? needed may be harder ● Less restenosis? to insert through stent

Commonly Used Bifurcation Techniques Provisional Stent Technique Crush and Mini-Crush Techniques Simultaneous Kissing Stent Technique (SKS) TAP Technique Culotte Technique

The Crush Technique Main Branch Side Branch Wire both vessels Pre-dilate as needed Position stents Deploy side branch stent, remove balloon/wire Deploy main branch stent- ‘crushes’ side branch stent Rewire side branch and perform kissing balloon inflation Side Branch 13 13 13

The Crush Technique

2 layers of stent separate side branch from the main branch… 2 layers of stent separate side branch from the main branch…. can be difficult to re-wire!

The Evolution of the ‘Crush’ Technique: Post-Crush Kissing Balloon Inflation After Kissing Balloon Inflation Before Kissing Balloon Inflation

Kissing Balloons: Before and After

Classic Crush Technique Mini Crush Technique Also Reverse Crush Technique

Crush and Mini-Crush Stent Technique Advantages: Disadvantages: ● Assures ostium coverage ● Complex ● Prevents loss of side branch ● Time consuming ● Can be used if side branch ● Difficult to rewire and main branch are ● Sometimes cant different sizes perform final kiss ● Difficult to treat restenosis

Commonly Used Bifurcation Techniques Provisional Stent Technique Crush and Mini-Crush Techniques Simultaneous Kissing Stent Technique (SKS) TAP Technique Culotte Technique

The Simultaneous Kissing Stent (SKS) Technique Wire both vessels Main Branch Pre-dilate as needed Position stents Deploy stents simultaneously Perform kissing balloon post-dilatation Side Branch 21 21

Simultaneous Kissing Stent Technique Advantages: Disadvantages: ● Simple ● Can be difficult to ● Maintain wire access to both rewire branches at all times ● Longer carinas can ● Minimal ischemic time cause trouble later ● Requires larger vessels of similar size ● Can be challenging to treat restenosis

Commonly Used Bifurcation Techniques Provisional Stent Technique Crush and Mini-Crush Techniques Simultaneous Kissing Stent Technique (SKS) TAP Technique Culotte Technique

The TAP Technique T stent And Protrusion Main Branch Side Branch Wire both vessels Main Branch Pre-dilate as needed Position and deploy main branch stent Rewire side branch and balloon dilate Position side branch stent so proximal edge protrudes slightly into main branch, ‘backstop’ balloon in main branch Side Branch Deploy side branch stent first, then inflate main branch balloon to kiss 24 24 24

TAP Technique Advantages: Disadvantages: ● Relatively simple ● Excessive stent ● Assures ostium coverage protrusion can cause ● Less metal at side branch main branch access ostium compared to crush problems later ● May be harder to treat restenosis

Commonly Used Bifurcation Techniques Provisional Stent Technique Crush and Mini-Crush Techniques Simultaneous Kissing Stent Technique (SKS) TAP Technique Culotte Technique

The Culotte Technique Main Branch Side Branch Wire both vessels Pre-dilate as needed Position and deploy stent in most angulated branch Remove first wire, wire second branch and balloon dilate Position second branch stent so proximal portion equal with previous stent edge and deploy Side Branch Rewire initially stented branch and perform kissing post-dilitation 27 27 27

Culotte Technique Advantages: Disadvantages: ● Complete coverage ● Complex ● Good radial strength ● Time consuming ● Can be challenging to treat restenosis ● Too much metal/drug in main branch?

In Conclusion… Various 2-stent techniques have been devised to treat complex bifurcation disease Each has unique advantages and disadvantages Having experience with a multitude of techniques can help to ensure clinical success in a variety of anatomical situations

Thank You!