1. Bifurcation Management Update:
CRT
Washington DC, February 
Bifurcation Management Update:
Choosing the Right Strategy and Technique
Eberhard Grube MD FACC, FSCAI
University Hospital Bonn, Germany
Stanford University, School of Medicine, Palo Alto, CA
Hospital Alemão Oswaldo Cruz, São Paulo, Brazil

2. Eberhard Grube, MD
Consulting: Medtronic CoreValve, Boston Scientific Corporation, Cordis Corporation, Johnson and Johnson and Abbott Vascular
Honoraria: Boston Scientific Corporation and Biosensors International
Stocks, Stock Options, other ownership interest: Medtronic CoreValve and Biosensors International
Off-Label: Off-label use of stents and valve prosthesis

3. Preamble
The main limitation of all randomized studies comparing provisional versus routine double stenting is that bifurcation lesions which are randomized are most of the times suitable for provisional. Bifurcation lesions which need to be treated with two stents are usually not randomized.
For bifurcation lesions, which are suitable for 1 stent or 2 stents, routine implantation of 2 stents does not give any advantage compared to routine implantation of 1 stent and cross-over to 2 stents when needed

4. My view
If you decide to implant two stents you take more responsibilities : an optimal result will give you a low restenosis on the SB, a suboptimal result may increase the risk of thrombosis of the SB and sometimes of the MB.
If you decide to implant one stent you are mainly responsible for the SB only: an incorrect decision may lead to SB closure
The final decision is a balance between the clinical relevance of the SB (risk of occlusion) and how confident is the operator to obtain an optimal result

5. This is not an ideal lesion for a
1 vs. 2 stents trial

6. Bifurcations
Provisional
Keep It Open (KIO)
Two stents

7. Provisional Wire both branches Dilate MB and SB if needed
When the SB has minimal disease or disease at the ostium AND when the SB is suitable for stenting
Wire both branches
Dilate MB and SB if needed
Stent MB leaving a wire in the SB
Re-wire SB and then remove jailed wire
Kissing balloon inflation
Stent SB if suboptimal result (TAP is my preferred strategy to cross-over to 2 stents)

8. Keep It Open (KIO) Wire both branches Dilate MB if needed
When the SB has ostial or diffuse disease AND when the SB is not suitable (too small) for stenting or clinically not relevant
Wire both branches
Dilate MB if needed
Stent MB and leave wire in the SB
Perform post-dilatation of the MB with jailed wire in the SB
Do not re-wire SB or postdilate or predilate SB

9. Two Stent Approach Cross over from Provisional: TAP: T and protrusion
2 stents as Intention to Treat:
Mini Crush, Culotte,
V: only for very suitable anatomy

10. non-left main bifurcations
Predictors of restenosis after one and two-stent techniques in left main and
non-left main bifurcations 9 9

11. Colombo A. et al Circulation 2009;119:71-78.10 10

12. If crush 2 step kiss ! 11 11

13. Inflate at high pressure only the SB balloon
We observed that two-step kissing was more effective than one-step kissing for improving metallic side-branch ostial area
No kissing
One-step kissing post-dilatation
Two-step kissing post-dilatation
SB ostial stenosis (%) with one step vs. two step kissing
58 crush deployments
Two steps:
Inflate at high pressure
only the SB balloon
2) Perform kissing inflation
Ormiston 12

14. Influence of Final Kissing in the CACTUS trial
YES Final Kissing
163 pts.
NO Final Kissing
14 pts. P
Myocardial infarction
7.5%
29%
0.001
TLR
6.3%
12.9%
0.25
MB restenosis
4.7%
16%
0.03
SB restenosis
11.9%
36%
Stent thrombosis
0.9%
6.5%
0.06

15. For the Nordic-Baltic PCI Study Group
Nordic-Baltic Bifurcation Study III Randomized Comparison of Final Kissing Balloon Dilatation vs. no Final Kissing Balloon Dilatation in Patients with Coronary Bifurcation Lesions Treated With Main Vessel stenting
Matti Niemela, Kari Kervinen, Andrejs Erglis,Niels R. Holm, Michael Maeng, Evald H Christiansen, Indulis Kumsars, Sandra Jegere, Andis Dombrovskis, Pål Gunnes, Sindre Stavnes,TerjeS teigen,Thor Trovik, Saila Vikman,Markku Eskola, Hannu Romppanen,Timo Makikallio, Knud N Hansen, Per Thayssen, Lars Åberge,Lisette Jensen, Anders Hervold, J Airaksinen, Mikko Pietila, Ole Frobert, Thomas Kellerth, Jan Ravkilde,Jens Aarøe,Steffen Helqvist, Iwar Sjögren, Stefan James,Heikki Miettinen, Jens F Lassen, Leif Thuesen
For the Nordic-Baltic PCI Study Group
Andis Dombrovskis. 14

16. (Re)stenosis at 8-months QCA: Entire bifurcation lesion%
p=0.11
17.3%
11.0%
Binary Restenosis: ≥50% diameter stenosis at follow-up

17. (Re)stenosis: Ostial Side Branch%
p=0.039
15.4%
7.9%
Binary Restenosis: ≥50% diameter stenosis at follow-up

18. True bifurcation subgroup MACE and TLR at 6 month clinical FU
2.5% %
(n=121)
(n=118)
1.7%
1.7%
P=0.68
0.8%
P=0.62

19. BIFURCATION ANGLE and TECHNIQUE TO USE WITH 2 STENTS
In general a small bifurcation angle gives a better result with mini-crush or culotte. A large angle with T or T and protrusion
With 2 stents an appropriately performed final kiss minimizes the effect of the bifurcation angle
Bifurcation angle
Dzavik et al Am Heart J 2006;152:

20. Bifurcation as predictor of DES thrombosis

21. Bifurcation and Thrombosis
The association of bifurcation with DES thrombosis has been frequent but not consistent across the studies with DES
Bifurcation has been related specially with early thrombosis or even with
late 1-12 months but not with very late thrombosis
The use of complex techniques (2 stents) could increase the risk of thrombosis, specially in the setting of ACS: operator dependent
In ESTROFA-2, bifurcation was an independent predictor for early thrombosis:
The treatment of bifurcations with ZES and with double stenting was associated with a trend for a higher risk (REGISTRY)
In cases with bifurcations a lower EF and smaller stent diameter were close to result independent predictors for thrombosis
In ACS, thrombosis was not significantly higher, though more frequently late

22. Dedicated bifurcation stents
At the moment for true bifurcations with short lesions in the side branch when the operator does not feel confident to recross an unprotected side branch
6 month FU
Cappella
sideguard
Tryton

23. Conclusions 1
The final result is far more important than the technique utilized
IVUS check on both branches every time 2 stents are implanted

24. Conclusions 2
Stenting coronary bifurcations requires more than deciding to implant 1 or 2 stents
The most important decisions should be taken by examining:
the clinical setting
the extent of the disease in both branches,
their size
the territory of distribution and
how confident is the operator with a specific approach