Bifurcation Stenting
Real-life Bifurcation – Challenges and Potential Complications Inga Narbute, Sanda Jegere, Indulis Kumsars, Dace Juhnevica, Agnese Knipse and Andrejs Erglis Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, Riga
Abstract
Together with calcified lesions, saphenous vein grafts, chronic total occlusions and unprotected left main lesions, bifurcation lesions are complex lesions that remain among the outstanding challenges of treatment with percutaneous coronary intervention. Bifurcation lesions are associated with increased rates of procedural complications, restenosis and adverse events than lesions in the body of the vessel. The introduction of drug-eluting stents for the treatment of bifurcation lesions has dramatically decreased restenosis rates, especially in patients suffering from diabetes. However, abrupt side branch closure, side branch ostial restenosis and stent thrombosis remain areas where further improvement is needed. Although a provisional T-stent strategy is most often used when side branch stenting is required, there are true bifurcation lesions where the selected use of more complex bifurcation approaches (such as the crush technique, T-stenting or the culotte technique) seem appropriate, particularly when the main branch and side branch are larger vessels with more diffuse side branch disease. The major challenge with any technique is to ensure that the side branch is protected and there is a satisfactory final result. Many technical questions rise in trying to ensure this outcome and lower the risk of intra- and post-procedural complications such as side branch closure and restenosis, stent thrombosis, dissection and fracture of a jailed wire: how can difficult side branch access be solved? How can unfavourable side branch anatomy be re-wired after main vessel stent placement? How can fracture of a jailed wire be avoided? Is side-strut dilation beneficial?
Keywords Bifurcation, complications, stent thrombosis, side branch closure
Disclosure: Andrejs Erglis has received grant research support from Abbott Vascular and consulting fees/honoraria from Boston Scientific, J&J Cardis and Abbott Vascular. The remaining authors have no conflicts of interest to declare. Received: 12 July 2011 Accepted: 30 July 2011 Citation: Interventional Cardiology, 2011;6(2):145–9 Correspondence: Andrejs Erglis, Chief, Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, Pilsoni Str. 13 LV1002, Riga, Latvia. E:
a.a.erglis@
stradini.lv
Coronary bifurcation disease is present in up to 15–20 % of lesions undergoing percutaneous coronary intervention (PCI) and remains one of the outstanding challenges of treatment with PCI.1,2
PCI for
coronary bifurcations is associated with more procedural complications and higher restenosis and adverse event rates than lesions in the body of the vessel.3–7
The introduction of drug-eluting
stents (DES) for the treatment of bifurcation lesions has dramatically decreased restenosis rates from, in some subsets, up to 60 %8,9 10 % and, in the latest trials,10–13
especially for patients suffering from diabetes.14 to 5–
even to 2.5 % in the main branch, However, abrupt side
branch closure and side branch ostial restenosis remain areas where further improvement is needed. A higher risk of subacute and late stent thrombosis is a major concern as well.7,10,15–18
Together with
and therefore require a longer procedural time, more radiation exposure and higher volumes of contrast material in comparison with non-bifurcation lesions.20 important questions about bifurcation lesions.
This article explores several
How Is a Bifurcation Lesion Defined and Which Classification Should be Used?
Many definitions of bifurcation lesions have been proposed, but the definition used by the European Bifurcation Club is that a bifurcation lesion presents as a coronary artery narrowing occurring adjacent to,
© TOUCH BRIEFINGS 2011
calcified lesions, saphenous vein grafts, chronic total occlusions and unprotected left main lesions, bifurcation lesions are complex lesions19
and/or involving, the origin of a significant side branch. A significant side branch is a branch that you do not want to lose in the global context of a particular patient (symptoms, location of ischaemia, viability, collateralising vessel, left ventricular function, etc.)21
There
are several major classifications of bifurcation lesions described in the literature,22–28
which are generally similar in describing specific bifurcation lesions and being sometimes difficult to memorise. The Medina classification is simple and practical; however, it does not include the description of angulation of branches and the size of the proximal healthy segment, as is the case in the classifications proposed by Movahed et al. and Shams et al. Nonetheless, the Medina classification has gained the highest popularity both in research and in clinical practice.29
Considering the increasing use and
more objective analysis of bifurcation lesions with intravascular ultrasound (IVUS), a more specific and clinically relevant classification should be developed based on IVUS results.
Which Technique Should Be Used? Coronary bifurcations are a unique and heterogeneous collection of anatomical variations. Different treatment strategies are employed based on plaque burden and the location and angulation of the bifurcated lesion. There have been many randomised studies (see Table 1) and analyses of non-randomised trials and registries30–33 published comparing different techniques and stents for the treatment of bifurcation lesions. Two meta-analyses of randomised
145
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69 |
Page 70 |
Page 71 |
Page 72 |
Page 73 |
Page 74 |
Page 75 |
Page 76 |
Page 77 |
Page 78 |
Page 79 |
Page 80 |
Page 81 |
Page 82 |
Page 83 |
Page 84 |
Page 85 |
Page 86 |
Page 87 |
Page 88 |
Page 89 |
Page 90 |
Page 91 |
Page 92 |
Page 93 |
Page 94 |
Page 95 |
Page 96 |
Page 97 |
Page 98 |
Page 99 |
Page 100