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The Bifurcation Issue: Treatment Strategies and Debates in Interventional Cardiology

Explore the complex topics and treatment strategies related to bifurcation lesions in cardiology, including debates on SB predilation, one vs. two stent approach, and more. Learn about the rational approach to bifurcation lesions and the role of functional evaluation.

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The Bifurcation Issue: Treatment Strategies and Debates in Interventional Cardiology

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  1. I Sheiban Director Interventional Cardiology University of Torino San Giovanni Battista Hospital Torino / Italy N. Valetova , Bifurcation European Bifurcation Club 16-17 October 2009 - BERLIN

  2. The Bifurcation Issue • The everlasting debates in bifurcation treatment: • Predilate SB ? • One stent or two stent approach or just keep it open ? • Which is the best approach in elective bifurcation stenting ? • Final kissing ( in one or two stents strategies ) always ?

  3. The Bifurcation Issue Bifurcation is heterogeneous lesion • Variable vessels ( branches ) size • Variable Morphology • Variable plaque distribution • Variable angulation • VariableExtent of side branch disease • Variable functional values ( FFR) for same angiographic stenosis

  4. The Bifurcation Issue • Despite all these variables and debates , it is largely accepted that most bifurcational lesions can be safely and effectively treated with single stent ( Provisional T stenting ) in nearly 70% of cases • In the other 30 % of cases an elective stenting for bifurcation lesions treatment is needed ( “true bifurcations” )

  5. SYNTAX Trial : Bifurcation / Trifurcation Subset PCI Arm ( 903 patients ) Incidence Treatment Modalities Colombo A , TCT 2008, Washington , October 14, 2008

  6. The Bifurcation Issue • Consequently , the debate on one nvs two stents seems to be obsolete . • The real question is how can we identify those bifurcation lesions where elective two stent strategy is the intention to treat ?

  7. For any BL treatment modality we should we keep in mind :

  8. The proximal reference diameter is always larger than distal reference diamater D mother D daughter 1 D daughter 2 D mother = 0,678 ( D daughter 1 + D daughter 2 ) Finet et al , Eurointervention 2007

  9. Plaque distribution in BL • Atherosclerosis occurs predominately close to bifurcation • Carinal involvement by atherosclerotic process is extremely unusual Renu Vermani

  10. Jailed SB can be compromised by carinal shift Carinal Shift

  11. Final Kissing Balloon can restore SB patency Distal Crossing and Kissing Balloon Final Result

  12. Influence of Bifurcation Angle Y-Shape T-Shape • Cush • MiniCrush • Culotte T Stenting • T Stenting Cush • MiniCrush Culotte

  13. Role of Functional of Evaluation of SB stenosis Basal FFR = 0.96 Following i.c. adenosine FFR = 0.84 B. A. , 56 yrs Male

  14. Correlation between fractional flow reserve and percent stenosis in Jailed SB Fractional Flow Reserve 40 50 60 70 80 90 100 Pecentage stenosis Bon-Kwon Koo et al , JACC 2005 ;43:633-637

  15. Correlation between fractional flow reserve and percent stenosis in Jailed SB Fractional Flow Reserve 27% 40 50 60 70 80 90 100 Pecentage stenosis Bon-Kwon Koo et al , JACC 2005 ;43:633-637

  16. Role of Final Kissing Balloon Non Randomized Milan Registry p<0.008 p<0.001 p<0.002 p<0.008 p<0.33 p<0.54 p<0.28 Ge L et al , JACC 2005;46:613

  17. Role of Final Kissing Balloon 231 consecutive pts , treated with Cruch Technique Late Loss ( mm) Binary Restenosis (%) P<0.001 P<0.00001 ns ns Hoye et al , JACC 2006;47:1949-1958

  18. FFR after kissing balloon inflation Side branch balloon/artery ratio: 0.9±0.1 Side Branch FFR p< 0.01 p< 0.57 Koo BK, et al. Eur Heart J 2008

  19. Safety & Efficacy of treatment

  20. TLR in Randomized and non randomized studies on: Provisional T Stenting ( with single stent ) vs Routine use of Two stents in the treatment of de novo bifurcation lesions Randomized Study TLR \ TVR ( % ) Colombo et al ,Circdulation 2004, PAN M et al Am H J 2004, Ge L at al AJC 2004,Tanabe K et al AJC 2004 Ge L et al JACC 2005,Ge L et al Heart 2005,Lefevre et al JACC 2005, Hoye et al , JACC 2006, Colombo et al Circulation. 2009 ;119 :71-8. Ferenc M et al , EHJ 2008; 2009 T.K. Steigen et al , Euro Interv 2008 ,

  21. Binary Restenosis on Side Branch in Randomized studies All p = ns Binary Restenosis Colombo et al Circulation 2004 , PAN M et al Am H J 2004 , T.K. Steigen et al , Euro Interv 2008 , Ferenc M et al , EHJ 2008; 29: 2858-2867 Colombo et al Circulation. 2009 ;119 :71-8.

  22. Stent Thrombosis in Randomized and non randomized studies on: Provisional T Stenting ( with single stent ) vs Routine use of Two stents in the treatment of de novo bifurcation lesions Randomized Study % Stent Thrombosis Colombo et al ,Circdulation 2004, PAN M et al Am H J 2004, Ge L at al AJC 2004,Tanabe K et al AJC 2004 Ge L et al JACC 2005,Ge L et al Heart 2005,Lefevre et al JACC 2005, Hoye et al , JACC 2006, Colombo et al Circulation. 2009 ;119 :71-8. Ferenc M et al , EHJ 2008; 2009 T.K. Steigen et al , Euro Interv 2008 ,

  23. Rational Approach to Bifurcational Lesions: Intention to Treat Step 1 : Side branch size < 2.5 mm Stent on Main Vessel , balloon PTCA on SB or any strategy to “ Keep It Open “ ( KIO )

  24. Treatment of Bifurcation Lesion with two stents Medina 1,0,1 - SB < 2.5 mm Baseline Treatment Stent in Main Vessel , POBA in SB

  25. Rational Approach to Bifurcational Lesions: Intention to Treat ( Side Branch > 2.5 mm ) Step 2 The bifurcation is a True Bifurcation (significant stenosis on the main and side branches) No Provisional T Stenting

  26. Treatment of Bifurcation Lesion with two stents Medina 1,1, 0 - SB > 2.5 mm Baseline Treatment Stent in Main Vessel , PTCA in SB + Final kissing balloon

  27. Rational Approach to Bifurcational Lesions: Intention to Treat ( Side Branch > 2.5 mm ) Step 3 The bifurcation is a True Bifurcation (significant stenosis on the main and side branches) No Yes The disease on the side branch is very focal, localized within 3 mm from the ostium of the side branch: Provisional T Stenting

  28. Treatment of Bifurcation Lesion with two stents Medina 1,1,1 : Focal disease on SB ( >2.5 mm ) Baseline Treatment Stent in Main Vessel , PTCA in SB + Final kissing balloon + FFR

  29. Treatment of Bifurcation Lesion with two stents Medina 1,1,1 : Focal disease on SB ( >2.5 mm ) Provisional T Stenting + Final Kissing Balloon , FFR = 0.68

  30. Rational Approach to Bifurcational Lesions: Intention to Treat ( Side Branch > 2.5 mm ) Step 4 The bifurcation is a True Bifurcation (significant stenosis on the main and side branches) No Yes The disease on the side branch is very focal, localized within 3 mm from the ostium of the side branch: Provisional T Stenting Diffuse disease on side branch Marked SB Tortuosity Difficult access to SB Risk of abrupt closure following Predilatation Hemodynamic instability ( Distal LM patients ) Elective stenting of Main Vessel and Side Branch

  31. Treatment of Bifurcation Lesion with two stents True bifurcation Medin 1,1,1 : very diffuse and severe disease on SB ( >2.5 mm ) Baseline Treatment Elective 2 stents – MiniCrush + Final Kissing Balloon

  32. Treatment of Bifurcation Lesion with two stents Medina 0,1,1 : Diffuse disease on SB ( >2.5 mm ) 1 2 Baseline Treatment Elective 2 stents – MiniCrush + Final Kissing Balloon

  33. Treatment of Bifurcation Lesion with two stents Medina 1,1,1 : Diffuse disease on LCX, Difficult access to LAD Baseline Treatment Elective 2 stents – Modified T Stenting + Final Kissing Balloon

  34. Treatment of Bifurcation Lesion with two stents Medina 0,1,1 : Tortousity in both branches ( both >2.5 mm ) Dissection is highly expected : plan for elective stenting

  35. Treatment of Bifurcation Lesion with two stents Medina 1,1,1 : severe dissection involving SB

  36. Treatment of Bifurcation Lesion with two stents Medina ? …. Complex anatomy , complex access . Intention to treat ? Might be Surgery

  37. In Conclusion : • Bifurcations without ostial SB involvement or those with only focal ostial SB narrowing can be successfully treated with single stent in MB and FKB in nearly 70% of cases • Elective bifurcation stenting as the intention to treat when : - Diffuse disease on side branch - Marked SB Tortuosity - Difficult access to SB - Risk of abrupt closure following Predilatation - Hemodynamic instability ( Distal LM patients ) • Functional Evaluating by pressure wire (FFR) can select those who need a second stent at SB. • Elective stenting in bifurcation, when needed, is safe and effective

  38. Thank you for your kind attention N. Valetova , Bifurcation

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