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Approach to Bifurcation PCI:A Step By Step Refresher
Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I.Director, Peripheral Interventions
Director, Interventional Cardiology Fellowship Program
Division of Cardiology
Scripps Clinic
La Jolla, CA
SCRIPPS CLINIC
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PCI Bifurcation Techniques:
How to Decide?
• Provisional Stent Technique
• Crush Techniques
• Simultaneous Stent Techniques
SCRIPPS CLINIC
• Simultaneous Stent Techniques
• T Stent Techniques
• Culotte Technique
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STEP 1:Which Ostia are Involved?
SCRIPPS CLINIC
RULE OF THUMB:If the ostium is ½ the size (orsmaller) than the proximalvessel, then it is involved
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STEP 2:What are the vessel sizes?
• Provisional Stent Technique
• Crush Techniques
• Simultaneous Stent Techniques
Requires a large enoughproximal vessel(2/3 of the sum of the 2 branchstent diameters)
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• Simultaneous Stent Techniques
• T Stent Techniques
• Culotte Technique
Requires similar sized vessels
NOTE:Any vessel less and 2mmshould be ignored forpurposes of PCI planning
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• Provisional Stent Technique
• Crush Techniques
• Simultaneous Stent Techniques
Side branch ostium is notsignificantly diseased
Side branch ostium isseverely diseased and youare concerned it will close
STEP 3:Is There a Specific Need for a Particular Technique?
SCRIPPS CLINIC
• Simultaneous Stent Techniques
• T Stent Techniques
• Culotte Technique
Need to minimize ischemictime (ie: LM bifurcationdisease in crashing patient)
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• Provisional Stent Technique
• Crush Techniques
• Simultaneous Stent Techniques
Traditional Crush requires7Fr or larger guide catheter
“Step Crush” can beperformed with a 6Fr guide
STEP 4:What Equipment is Needed?
SCRIPPS CLINIC
• Simultaneous Stent Techniques
• T Stent Techniques
• Culotte Technique
Requires minimum of 7Frguide catheter
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STEP 5:Which Vessels Should I Wire?
So…. Why wire a side branch in the first place?
“To Protect the Side Branch”
But… what does that really mean?
If the side branch gets pinched after the main branch is stented,
SCRIPPS CLINIC
If the side branch gets pinched after the main branch is stented,then the side branch wire will need to be removed and the vesselrewired before any PCI can be performed
If the vessel completely occludes, then the wire serves as amarker of where the vessel is so you can rewire it, or the wire canbe used to convert to a reverse crush
SO… the only reason to really wire a side branch is if youthink you are going to completely close it when the mainbranch is stented
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Bifurcation Techniques
•Provisional Stent Technique
•Crush Techniques
•Simultaneous Stent Techniques
SCRIPPS CLINIC
•Simultaneous Stent Techniques
•T Stent Techniques
•Culotte Technique
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Provisional Stent Technique:Use when the side branch ostium is not significantly diseased
MainBranch
Wire main vessel
Pre-dilate as needed
SCRIPPS CLINIC
SideBranch
Stent main branch
Rewire and balloonside branch if needed
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Provisional Stent Technique:Plan B
• If a second stent is needed after provisionalstenting is performed (ie: dissection orcompromise of the side branch) thefollowing techniques can be used:
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following techniques can be used:
•Culotte Technique
•Reverse Crush Technique
•TAP Technique
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Provisional Stent Technique
• Simple
• Less Metal
• Potentially easier to
• Residual stenosisat side branch
• If side branch stent
ADVANTAGES: DISADVANTAGES:
SCRIPPS CLINIC
• Potentially easier totreat restenosis
• Less thrombosis?
needed, it can bemore difficult toinsert it throughfirst stent
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If I Use a One Stent Strategy and the Side Branchisn’t Compromised, Do I Need to do a FinalKissing Inflation?
SCRIPPS CLINIC
Meta-analysis of all published studies that included kissingballoon inflation vs. no kissing balloon inflation when using asingle stent strategy
Kissing balloon inflation was associated with a higherrestenosis rate of the main branch and no difference in overallclinical outcome
PLoS One. 2018; 13(6)
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Commonly Used BifurcationTechniques
•Provisional Stent Technique
•Crush Techniques
•Simultaneous Stent Techniques
SCRIPPS CLINIC
•Simultaneous Stent Techniques
•T Stent Techniques
•Culotte Technique
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The Classic Crush Technique
MainBranch
Wire both vessels
Pre-dilate as needed
Position stents
Deploy side branch stent,remove balloon/wire
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SideBranch
remove balloon/wire
Deploy main branch stent-‘crushes’ side branch stent
Rewire side branch andperform kissing ballooninflation
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The Crush Technique
SCRIPPS CLINIC
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The Evolution of the ‘Crush’ Technique:Post-Crush Kissing Balloon Inflation
After KissingBalloon Inflation
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Before KissingBalloon Inflation
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Crush Technique:Variations
• Classic Crush
• Mini Crush
• Double Kissing Crush (DK Crush)
• Reverse Crush
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• Reverse Crush
• Step Crush
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SCRIPPS CLINIC
Classic Crush Technique Mini Crush Technique
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DK Crush Technique
SCRIPPS CLINIC
• Position side branch stent as if performing a Mini Crush, in conjunction with aballoon in the main branch
• Deploy side branch stent, withdraw side branch stent balloon slightly, thenreinflate to high pressures to “flare” the proximal side branch stent
• Remove side branch balloon and wire• Crush side branch stent with main branch balloon• Rewire side branch and perform a kissing balloon inflation
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DK Crush Technique
SCRIPPS CLINIC
• Remove side branch wire and balloon• Position stent in the main branch and deploy it• Rewire side branch and perform final kissing balloon inflation
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Reverse Crush Technique
SCRIPPS CLINIC
Performed as a bailout strategy if provisional stenting of the main branch issuboptimal
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Crush Stent Technique
• Assures coverage ofside branch ostium
• Prevents loss of side
• More complex
• Time consuming
• More costly (additional
ADVANTAGES: DISADVANTAGES:
SCRIPPS CLINIC
branch
• Can be used if sidebranch and main branchare of significantlydifferent sizes
• More costly (additionalwires/balloons)
• Sometimes unable toperform the final kiss-destined for a worseoutcome
• More difficult to treatrestenosis
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Commonly Used BifurcationTechniques
•Provisional Stent Technique
•Crush Techniques
•Simultaneous Stent Techniques
SCRIPPS CLINIC
•Simultaneous Stent Techniques
•T Stent Techniques
•Culotte Technique
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The Simultaneous Kissing Stent(SKS) Technique
MainBranch
Wire both vessels
Pre-dilate as needed
Position stents
Deploy stentssimultaneously
SCRIPPS CLINIC
SideBranch
simultaneously
Perform kissing balloonpost-dilatation
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Simultaneous Kissing StentTechnique (SKS)
• Simple
• Maintain wireaccess to both
• Can be difficult totreat later due toneocarina
ADVANTAGES: DISADVANTAGES:
SCRIPPS CLINIC
branches at alltimes
• Minimal ischemictime
• Requires largervessels of similar size
• Treating proximaldissection or residualdisease highlyproblematic
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Simultaneous V StentingTechnique
• Identical to theSKS technique,but without the
SCRIPPS CLINIC
but without thecreation of anew carina
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Simultaneous V StentingTechnique
• Simple
• Maintain wireaccess to both
• Only works ifproximal mainbranch is free ofdisease
ADVANTAGES: DISADVANTAGES:
SCRIPPS CLINIC
branches at alltimes
• Minimal ischemictime
disease
• Plaque shift moreproximally can bedifficult to treat:
Add a stent proximally andpotentially leave a gap vs.convert to SKS
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Commonly Used BifurcationTechniques
•Provisional Stent Technique
•Crush Techniques
•Simultaneous Stent Techniques
SCRIPPS CLINIC
•Simultaneous Stent Techniques
•T Stent Techniques
•Culotte Technique
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Traditional TStent Technique
PROBLEM:
Almost NEVER is therea perfect 90 degreeangle between main
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angle between mainbranch and sidebranch!
Use of the traditional Tstent technique isassociated with highrisk of missing the sidebranch ostium
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The TAP Technique
T stent And Protrusion
MainBranch
Wire both vessels
Pre-dilate as needed
Position and deploy mainbranch stent
Rewire side branch andballoon dilate
SCRIPPS CLINIC
SideBranch
balloon dilate
Position side branch stent soproximal edge protrudesslightly into main branch,‘backstop’ balloon inmain branch
Deploy side branch stentfirst, then inflate mainbranch balloon to kiss
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TAP Technique
• Relatively simple
• Assures coverage ofside branch ostium
• Less metal at side
• Excessive stentprotrusion can leadto troubleaccessing distal
ADVANTAGES: DISADVANTAGES:
SCRIPPS CLINIC
• Less metal at sidebranch ostiumcompared to Crushtechnique
• Works when vesselsare different sizes
accessing distalmain branch in thefuture
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Commonly Used BifurcationTechniques
•Provisional Stent Technique
•Crush Techniques
•Simultaneous Stent Techniques
SCRIPPS CLINIC
•Simultaneous Stent Techniques
•T Stent Techniques
•Culotte Technique
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The Culotte Technique
MainBranch
Wire both vessels
Pre-dilate as needed
Position and deploy stent inmost angulated branch
Remove first wire, wiresecond branch and
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SideBranch
second branch andballoon dilate
Position second branch stentso proximal portion equalwith previous stent edgeand deploy
Rewire initially stentedbranch and performkissing post-dilitation
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Culotte Technique
• Assures sidebranch ostiumcoverage
• Complex
• Vessels must be ofsimilar size
ADVANTAGES: DISADVANTAGES:
SCRIPPS CLINIC
• Excellent radialstrength in mainbranch
• Somewhat timeconsuming
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What is POT?
Proximal Optimization Technique
Dilatation of the stent within theproximal vessel to an appropriate
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proximal vessel to an appropriatesize to achieve proper appositionto avoid rewiring behind the stentand causing inadvertent crush ordistortion of the stent
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Does it Really Matter WhatTechnique I Use?
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A registry of unprotected left main bifurcation lesions treatedwith T-stenting, mini-crush, and Culotte techniques
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SCRIPPS CLINIC
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DK Crush vs. Provisional Stentingfor Left Main Bifurcation Lesions
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Chen et al. JACC Volume 70, Issue 21, 28 November 2017, Pages 2605-2617
482 patients from 26 centers in 5 countries with true distal LMbifurcation lesions (Medina 1,1,1 or 0,1,1) randomized to provisionalstenting (n = 242) or DK crush stenting (n = 240)
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DK Crush vs. Provisional Stentingfor Left Main Bifurcation Lesions
SCRIPPS CLINIC
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Conclusions
• Multiple techniques have been developed toeffectively treat bifurcation lesions
• Each has unique advantages anddisadvantages and details of why you would
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disadvantages and details of why you wouldwant to use one over the other
• Being proficient with multiple techniqueswill assure that you are able to perform PCIregardless of varying patient anatomy withexcellent technical success
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Thank You
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