Bifurcation PCI

Definition and classification

The European Bifurcation Club (EBC) has defined bifurcation lesions as lesions occurring at or adjacent to a significant division of a major epicardial coronary artery. What is “significant” remains subjective and is determined by the treating physician as branches that, if compromised during percutaneous coronary intervention (PCI), can cause symptoms or periprocedural myocardial infarction (MI). A recent computed tomography (CT) analysis by Kim et al. showed that only 20% of non-left main bifurcations supply at least 10% of the myocardium.

There are multiple classifications of bifurcation lesions, but one of the simplest and most commonly used currently is the Medina classification ( Fig. 7.1 ), which records any narrowing of 50% or more in each of the three arterial segments of the bifurcation in the following order: proximal main vessel (MV), distal main vessel, and proximal side branch (SB). The presence of significant stenosis is marked as “1” and the absence as “0.” A limitation of the Medina classification is that it does not account for other lesion characteristics, such as angulation, plaque location, length, and calcification.

Basics of bifurcation lesion percutaneous coronary intervention

PCI of bifurcation lesions can result in both acute (such as SB occlusion and periprocedural MI) and long-term (such as restenosis and/or stent thrombosis) complications. Several strategies for bifurcation PCI are summarized in the Main, Across, Distal, Side (MADS) classification based on how the first stent is implanted ( Fig. 7.2 ).

Large (such as 7 French [F] or 8F) guide catheters may facilitate bifurcation PCI because they allow more treatment options, especially for two-stent strategies or if a complication occurs. Nevertheless, 6F guides (with or without radial access) are adequate for most bifurcation PCIs and are used by most operators. Wiring both the MV and SB should be done for all bifurcations with important SBs. Keeping the wires organized (e.g., by using a towel to separate them and by using guidewires with different shaft color) can facilitate performance of the procedure. The most challenging branch to wire should be wired first, and the wires should be kept in the same position on the table as on the working projection to prevent twisting. Drug-eluting stents (DES) significantly reduce the risk of in-stent restenosis (ISR) and are preferred for bifurcation lesions. The minimum number of stents should be used, and intracoronary imaging should be used in most cases to optimize stent expansion and stent strut apposition and help detect tissue protrusion and stent edge dissections.

A practical approach for selecting a treatment strategy for bifurcation lesion PCI follows.

Algorithmic approach to bifurcation percutaneous coronary intervention

See Video 7.1 .