Bifurcations

16.1.1

Does the side branch need to be preserved?

This depends on the size of the side branch (SB) (usually branches <2 mm in diameter do not need to be preserved) and the supplied myocardial territory. If a decision is made to preserve the SB, it must be decided whether to simply wire the SB to help preserve patency during provisional stenting of the main vessel (MV), or whether to perform an upfront dedicated two-stent bifurcation percutaneous coronary intervention (PCI) strategy. To help decide this, it is necessary to assess the likelihood of SB occlusion after MV stenting.

16.1.2

What is the likelihood of SB occlusion?

The likelihood of SB occlusion depends on:

• 1.

  Location of disease (Medina classification , Fig. 16.2 ).

  

• 2.

  Severity of SB disease.

• 3.

  Lesion morphology (calcification, thrombus, length). Use of intravascular imaging can help with lesion morphology assessment.

• 4.

  Bifurcation angulation (extreme angles may be challenging to wire).

16.1.3

If a provisional stenting strategy (Section 16.2.10.1) is implemented, is the SB compromised after MV stenting?

If an important SB becomes compromised after MV stenting (TIMI flow<3, diameter stenosis>70%, or NHLBI dissection B or more), efforts should be made to restore flow. The risk of SB compromise is reduced by sizing the MV stent according to the diameter of the distal MV. Balloon angioplasty often suffices to restore or improve flow in the SB, but sometimes SB stenting may be necessary.

16.1.4

What is the SB angulation?

The SB angulation is key for selecting the optimal two-stent bifurcation stenting strategy (either primary or in case of SB compromise after MV stenting).

For angulations between 70°–90° T-stenting ( Section 16.2.10.2 ) or T and Protrusion (TAP, Section 16.2.10.3 ) are usually used.

For angulation <70°, double kissing crush (DK crush) ( Section 16.2.10.5 ), culotte ( Section 16.2.10.6 ), and reverse crush ( Section 16.2.10.4 ) are commonly used, with DK crush being the preferred strategy in most cases.

16.1.5

Medina 0.1.1

V-stenting ( Section 16.2.10.7 ) can be performed in Medina 0.1.1 bifurcations.

16.1.6

Need for emergency stenting

When emergency stenting is needed and access to both MV and SB needs to be maintained, simultaneous kissing stents (SKS, Section 16.2.10.8 ) can be used. However, subsequent treatment and equipment delivery can be very challenging after SKS, due to formation of a long stent neocarina. SKS should not be performed in non-emergent bifurcation PCI.

16.2.1

Preparation

Planning for bifurcation PCI is performed as discussed in Chapter 1 : Planning. Some bifurcation stenting techniques, such as V-stenting and SKS require at least 7 French guide catheters (that have large enough lumen to accommodate two stents).

16.2.2

Monitoring

Monitoring for bifurcation PCI is performed as discussed in Chapter 2 : Monitoring.