Percutaneous coronary intervention for bifurcation lesions: proposed statement from the 'Forum on bifurcation coronary artery disease' by Ran Kornowski & Goran Stankovic

The Forum on bifurcation coronary lesions will take place in room 7 - 16:00-19:00. For this forum, the chairpersons, Ran Kornowski, MD, FESC, FACC and Goran Stankovic, MD, FESC, FACC issued the following ten-point summary:

1. Symptomatic or silent atherosclerotic coronary artery disease is often related to bifurcation lesions. Bifurcation lesion treatment is complex and technical challenges remain.

2. Careful examination of the bifurcation lesion (both the main and side branches) using coronary angiography is critical for strategic planning of the PCI procedure.

3. Use of complementary imaging modalities such as IVUS, 3D angiography, FFR, and OCT may improve diagnostic accuracy for bifurcation lesions.

4. The 'Medina' classification (1/0) is still the simplest and most widely used method for defining and classifying the bifurcation type and the extent of atherosclerosis involvement.

5. Careful inspection of the side branch (SB) is mandatory for procedural planning and for planning a bailout strategy. The following SB features should be observed:

• Severity of ostial narrowing and narrowing beyond the ostium
• SB diameter (less than or greater than 2.5 mm) and lesion length
• SB angulation in relation to the main vessel (less than or greater than 50°)
• Extent of calcification of the bifurcation region
• Changes in SB angiographic and/or clinical findings during the course of PCI, such as plaque or carina shift, dissection, abrupt closure, flow limitation, chest pain, ECG, or hemodynamic changes.

6. In catheter-based bifurcation management, a key goal is to optimise the PCI result and assure the long-term bifurcation patency without making the procedure unduly complicated from a technical standpoint. This can be accomplished using either a single stenting technique (a provisional approach with an optional twostent bailout strategy, expected to be used in ~1/3 of cases when a large SB is at jeopardy) or using a priori a planned two-stent technique with one of several stenting options: mini-crush (or other 'crush' variants), modified T, Y/Culotte, V stenting, etc.

7. Drug-eluting stents yield substantially better long-term restenosis-free outcomes compared to earlier bare metal stents; drug-eluting stents should thus be considered a viable or even preferred interventional strategy in bifurcation PCI management.

8. Stent design and maximal stent cell size are important parameters in bifurcation stenting. The open cell stent design is associated with a lower risk of SB compromise and/or periprocedural myonecrosis.

9. Some preliminary conclusions can be drawn concerning the use of a single-stent versus a two-stent technique based on recent randomised studies such as NORDIC, CACTUS, BBC ONE, BBK, and others:

• In most cases, a provisional technique rather than an elective two-stent strategy involving the SB should be used.
• Provisional stenting alone, if feasible, appears to be simpler and less expensive. This procedure can be performed with less contrast utilisation and takes less time to perform.
• A dedicated two-stent strategy is advisable in carefully selected cases with complex bifurcation anatomy in which the SB is heavily affected by atherosclerotic disease. This calls for careful planning of the procedure by an experienced operator.
• The short- and long-term clinical and angiographic results of a two-stent technique (for example, the mini-crush technique or Culotte) are promising, and the MACE-free outcomes are equivalent to those achieved by the 'simplified provisional' approach.

10. Important challenges remain: What is the best way to identify, upfront, bifurcations that will need two stents, and how should one handle the technical difficulties encountered during implantation of two stents? Such difficulties may include SB access, re-wiring, re-crossing, full carina coverage, final kissing balloon inflation, optimised stent position, and expansion. Regardless of the technique, kissing balloon dilatation is recommended as a final step to improve short- and long-term angiographic, procedural, and MACE-free bifurcation-related outcomes

Selected reading list

Lansky A, Tuinenburg J, Costa M, et al. Quantitative angiographic methods for bifurcation lesions: a consensus statement from the European Bifurcation Group. Catheter Cardiovasc Interv 2009;73:258-66. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of coronary artery bifurcation lesions: the Nordic bifurcation study. Circulation. 2006;114:1955-61.

Colombo A, Bramucci E, Saccà S, et al. Randomized study of the crush technique versus provisional side-branch stenting in true coronary bifurcations: the CACTUS (Coronary Bifurcations: Application of the Crushing Technique Using Sirolimus- Eluting Stents) Study. Circulation. 2009;119:71-8.

Hildick-Smith D. British Bifurcation Coronary Study: Old, New and Evolving strategies (BBC ONE). Presented at the TCT Meeting 2008, Washington, DC. Louvard Y, Thomas M, Dzavik V, et al

Classification of coronary artery bifurcation lesions and treatments: time for a consensus! Catheter Cardiovasc Interv. 2008;71:175-83.

Ferenc M, Gick M, Kienzle RP, et al. Randomized trial on routine vs. provisional T-stenting in the treatment of de novo coronary bifurcation lesions. Eur Heart J. 2008;29:2859-67

Jensen JS, Galløe A, Lassen JF, et al; Nordic- Baltic PCI Study Group. Safety in simple versus complex stenting of coronary artery bifurcation lesions. The Nordic bifurcation study 14-month follow-up results. EuroIntervention. 2008;4:229-33.