1. BIFURCATION LESIONS Dr. Tahsin.N
Review of Evidence
BIFURCATION LESIONS
Dr. Tahsin.N
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2. Introduction
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3. Definition of bifurcation lesion(EBC)
Coronary artery narrowing occurring adjacent to and /or involving origin of a significant side branch
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4. Bifurcation interventions lower rate of procedural success
higher procedural costs
longer hospitalization
higher clinical and angiographic restenosis.
No 2 bifurcations are identical
No single strategy to be used on every bifurcation
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5. Medina classification
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6. Provisional side branch stenting Vs Two stent strategy
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9. Nordic bifurcation study(circulation 2006)
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10. Randomized, multicenter trial Diameter of MV>2.5mm&SB>2.0 mm
MV grp
Stenting MV
Side branch dilatation if TIMI <3
Side branch stenting if TIMI=0 after dilatation
MV+SB grp
Crush technique in 50%,culotte technique in 21%, other techniques in 29%
Final kissing dilatation in 74%
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13. Procedure related biomarker elevation
18% of MV+SB grp Vs 8% of MV grp,p=0.01
Restenosis rates in MV
4.6% Vs 5.1% in MV &MV+SB groups,P=NS
Restenosis rates in SB
19.2% Vs 11.5%,p=NS
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14. Limitations Non blinded Underpowered Conclusions
simple stenting strategy procedure is as effective as complex stenting & a/w reduced procedure related biomarker elevation
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17. 9 mth FUP
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19. 2 year outcome
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20. CACTUS study(Circulation 2009)
Prospective, randomized, multicenter study
Compared elective “crush” stenting & stenting of only main branch with provisional side-branch T-stenting
SB T-stenting for
Residual stenosis 50%
Dissection
TIMI ≤ 2
Mandatory final kissing-balloon inflation
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21. provisional stenting,n=173
350 pts
elective crush,n=177
provisional stenting,n=173
Provisional group-additional stent on SB 31%
Primary clinical end point- MACE at 6 mth
crush group-15.8%
provisional group-15.0%
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22. Definite ST at 6 mth- 1.7% in crush grp 1.1% in provisional grp
Restenosis rate
MB 4% vs 8.7%
SB 14.6% VS 12.5%
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23. Second stent in the SB needed in 31% Limitations 6 mth FUP
Bifurcation lesions with significant stenosis in both branches, a strategy to stent the MB is effective
Second stent in the SB needed in 31%
Limitations
6 mth FUP
No functional assessment
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24. BBC ONE trial(Circulation 2010)
500 pts,9mth clinical and angiographic follow up
Simple or complex stenting strategy
MV>2.5 mm & SB>2.25 mm
Simple strategy(N=250)
MV stented F/B optional kissing balloon dilatation/T-stent
side branch Stenting
TIMI flow <3
90% pinching
Threatened side-branch vessel closure
dissection
Complex strategy(N=250)
Culotte or crush technique with mandatory kissing balloon dilatation
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26. BBC ONE Complex strategy Simple strategy (n = 250)
Trial design: Patients with bifurcation lesions were randomized to either a simple stepwise provisional T-stent strategy or a complex strategy involving either crush or culotte techniques. Clinical outcomes were compared at 9 months.
Results
(p = 0.009)
(p > 0.05)
MACE (death, MI, or TVF) was more frequent in the complex strategy arm (HR 2.0, 95% CI , p = 0.009), as well as MI (p = 0.001)
Incidence of mortality, TVF, and stent thrombosis was similar between the two arms (p > 0.05)
TIMI major bleeding was higher with the complex strategy (1.2% vs. 0.4%, p > 0.05) 20 20
15.2 15 15 % % 10 10
8.0
Conclusions 5 5
2.0
A simple stepwise T-stent strategy is superior to a more complex strategy involving crush or culotte techniques in patients with bifurcation lesions
0.4
MACE
Stent thrombosis
Complex strategy
(n = 250)
Simple strategy
Presented by Dr. David J. Hildick-Smith at TCT 2008
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28. Meta analysis of five RCT 1553 pts 777 treated with simple strategy
776 treated with complex strategy
PES in BBC ONE trial,SES in others
All pts treated with aspirin and thienopyridines(clopidogrel or ticlopidine)
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29. Endpoints clinical endpoints
cardiac death, myocardial infarction (MI), target lesion revascularisation (TLR) and stent thrombosis (ST)
binary angiographic restenosis
defined as >50% diameter stenosis of treated lesion at FUP of both MV and SB
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30. Results Risk of follow-up MI
lower in pts treated with the simple strategy Vs complex approach
RR 0.54, 95% CI 0.37 to 0.78, p=0.001
reduced early (in-hospital or 30-day) MI
RR 0.52, 95% CI 0.35 to 0.78, p=0.002
risk of non-Q-wave MI lower than that in the complex strategy
RR 0.63, 95% CI 0.39 to 0.99, p=0.049
no significant difference in the risk of Q-wave MI
RR 0.54, 95% CI 0.15 to 1.95, p=0.35
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32. No significant difference in risk of cardiac death at follow-up
RR 0.68, 95% CI 0.21 to 2.25, p=0.53
No significant difference in TLR at follow-up
RR 0.93, 95% CI 0.62 to 1.41,p=0.74
No significant difference in incidence of definite ST(0.6% Vs 1.4% ,RR 0.50, p=0.16)
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33. RR of definite stent thrombosis
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34. Restenosis rates of MV-no significant difference
RR 1.15, 95% CI 0.66 to 2.00, p=0.63
Restenosis rates of SB-no significant difference
RR 1.12, 95% CI 0.80 to 1.57, p=0.50
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37. CONCLUSION
Simple strategy a/w lower risk of early MI & similar rate of angiographic restenosis at FUP compared to complex strategy for bifurcation lesions
Simple strategy comprising MV stenting and provisional stenting for SB can be recommended as a preferred bifurcation stenting technique
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38. Final kissing balloon dilatation
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40. Acc.to final kissing balloon post-dilation (FKB) FKB group (n=116)
181 pts,Crush technique
Acc.to final kissing balloon post-dilation (FKB)
FKB group (n=116)
Non-FKB(n=65)
FUP at 9 mth,angiographic FUP in 80% of pts
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41. Black bars-without FKB
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43. Nordic III study(circulation 2011)
Randomized multicenter trial to compare final kissing balloon dilatation VS no FKBD
Vessel size
main vessel diameter ≥ 2.50mm
side branch diameter ≥ 2.25 mm
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45. Nordic-Baltic Bifurcation Study III
Trial design: Patients with coronary bifurcation lesions treated with a single stent in the main artery were randomized to kissing balloon dilatation post-stenting or conservative management. Patients were followed for a mean of 6 months.
Results
(p = 1.0)
(p > 0.05)
MACE at 6 months for kissing balloon vs. no kissing balloon: 2.1% vs. 2.5 (p = 1.0)
Stent thrombosis: 0.4% in both, TLR: 1.3% vs. 2.1%, mortality: 1.2% vs. 0% (p > 0.05 for all)
Procedure time, fluoroscopic time, and contrast use were higher in kissing balloon arm (p = ) 10 10 5 5 % %
Conclusions
2.5
Strategy of routine side branch kissing balloon dilatation was not associated with better outcomes at 6 months, with an increase in procedure and fluoroscopic times
Should be reserved in situations such as plaque shift with clinical changes or poor TIMI flow down side branch
2.1
1.2
MACE at 6 months
All-cause mortality
Kissing balloon
(n = 238)
No kissing balloon
(n = 239)
Niemela M, et al. Circulation 2011;123:79-86

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48. Restenosis rates MV+SB 11.0% Vs 17.3% ,p=NS MV alone-3.1% VS 2.5%,P=NS
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56. Conclusion
Provisional side branch stenting is the preferred bifurcation stenting strategy
Final kissing balloon dilatation is recommended in complex stenting technique,not routine in provisional stenting strategy
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57. FFR in Bifurcation Lesions
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60. Objectives This study was designed to assess the functional significance of side branches after stent implantation in main vessels using fractional flow reserve (FFR) Methods Between May 2007 and January 2011, 230 side branches in 230 patients after stent implantation in main vessels were assessed by FFR and were consecutively enrolled
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61. Results
After stent implantation in main vessels Only 41 (17.8%) side branches had functionally significant stenosis Among 67 side branches with > 50% DS by QCA, 19 (28.4%) had FFR < 0.80 Among 163 side branches with < 50% DS by QCA, 22(13.5%) had FFR < 0.80
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62. Conclusions
Most side branch lesions do not have functional significance after stent implantation in the main vessel, and quantitative coronary angiography is unreliable in assessing the functional severity of these lesions
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63. Bifurcation Dedicated Stents
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67. Nile Pax DES
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73. Thank You
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