1. 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

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

3. Easy…..
Not so Easy!

4. 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

5. 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

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

7. 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

8. ? ? ?

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

10. 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

11. 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

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

13. 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

14. The Crush Technique

15. 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!

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

17. Kissing Balloons: Before and After

18. Classic Crush Technique
Mini Crush Technique
Also Reverse Crush Technique

19. 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

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

21. 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

22. 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

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

24. 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

25. 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

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

27. 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

28. 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?

29. 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

30. Thank You!