1. Bifurcation coronary stenting: State 0f the Art Mazhar M Khan Consultant Cardiologist Royal Victoria Hospital Belfast, N.Ireland

2. Percutaneous intervention of coronary bifurcation lesion, like marriage, is easy to do but difficult to get out David Holmes

3. Problems of Bifurcation Stenting “Stent jail” of side branch “Snow plough” effect Stent deformity Difficult re-crossing Lower Success and higher complication rate High Restenosis Over all incidence of 15% of PCI

4. “ Stent Jail of the side branch is a low security prison” Caputo et al

6. Bifurcation lesion location remains a predictor of adverse late outcomes in multiple (DES) trials Controversies exist among differing strategies using standard stents: Is long term efficacy improved when a SB stent is placed? Is the SB compromised in provisional techniques? When 2 stents are needed, what is the safety impacts of multiple stent layers and mechanical distortions in T-, crush, culotte, V-, or SKS? Which technique is best? The Problem

8. Khan et al International J of Cardiovascular Intervent;2002 (1+1+1)* (1+1+0)*(1+0+1)* (0+1+1)* (0+1+1)

12. Need for stent?

18. Published in 2010 Circ.

21. PCI of Bifurcation coronary lesion One stent or two stents* 2 stentsOne stentsP value Procedure59% (T or Y) 41%0.13 Kissing Balloon 27 (94%)21 (75%)Ns success100%92% (8% Crossover) Ns TLR23%16%0.03 MACE6%8.3%Ns * Khan et al Int. Journal of cardiovascular intervention 2002

22. Duration of PCI Contrast Stress MI

23. And Keep it Safe Keep it Simple

27. And How

28. Khan et al Int J of Cardiovasc intervention:2001

35. p=0.26 p=0.12 p=0.47 p=0.34

44. Crush technique

45. (A) Crush stent SB stent first then main branch (B) final double balloon inflation

46. (A) Pre (B) Post crush

56. If you have a crush end with a kiss

61. MACE

67. GREAT!

69. Simple strategy with 5F Guide

72. Double vessel Stent

76. After TWO DES

78. Role of ”jailed” wire Identification of side branch ostium after Stent placement – a “road map” Favourable modification of side branch origin and angulations May maintain patency of side branch

79. New specific bifurcation stents View Stent (Advance Stent Technology) Double Driver on single shaft (Medtronic)? Devax system Invatec Bifurcation stent Clear Way Bifurcation Stent Free Path Bifurcation Stent Tryton Kapella

86. Key Message Recent studies and our own observation show that that there is no additional benefit of routine stenting of both arms Final double balloon (kissing) is essential to reduce the stent malformation and to improve long term outcome after side branch access through the stent Double stenting should be reserved for large branch, reduced flow or significant dissection of SB. While stenting side branch, keep balloon in main branch.

87. Conclusions Bifurcation coronary lesions are not uncommon (about 15%). Current technological advance with stenting offers a safe and efficient Revascularisation strategy for such complex lesion. New design of stents specific for bifurcation may be further helpful but have been disappointing so far due to anatomical variation.

88. Conclusions (cotd) Technical approach depending on the anatomy and the final use of double (kissing) balloon ensure immediate and long-term success for such lesions. Drug eluting stents covering both arms have reduced TLR but MACE is not reduced. Recent studies are also indicative of this approach. Double stenting should be reserved for selective anatomical sub set

90. ‘Light at the end of a tunnel may well be the headlight of the in coming train’ Murphy