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58
ALBIERO AND BOLDI
(A)
(B)
(C) (D)
Figure 15 Proximal cross versus distal cross and result after kissing balloon inflation. (A) The case of proximal
cross (
arrow
displacement inside the main branch stent (
balloon: good side branch ostium scaffolding (
the carina level (
); (B) after kissing balloon: poor side branch ostium scaffolding (
long arrow
).
long arrow
short arrow
). (C) The case of distal cross (
) associated with expansion of the main branch stent at
short arrow
) associated with strut
arrow
); (D) after kissing
The Role of Adjunctive Devices
Rotational atherectomy (Rotablator) or the “CuttingBalloon” can be used incalcified or severely
fibrotic ostial side branch lesions to reduce the likelihood of side branch compromise after main
branch stenting. Directional atherectomy can be helpful in debulking the main branch lesion
before stenting in order to decrease the risk of excessive carina shift or occlusion, especially for
large branch-ostial lesions.
(A) (C)
(B) (D)
Figure 16 The case of “proximal cross” with and without the use of a spherical balloon during provisional T
stenting. (A) Final result with the use of the spherical balloon postdilation strategy. (B) If an additional stent is
required in the side branch, T stenting without neo-carina can be performed. (C) Risk of final result without the
use of the spherical balloon post-dilation strategy. (D) In case of provisional T stenting, the TAP (T And Protrusion)
with a neo-carina should be done to completely cover/scaffold the side branch ostium. This could increase the
risk of subsequent restenosis and/or stent thrombosis.
PROVISIONAL STENTING TECHNIQUE FOR NON–LEFT MAIN CORONARY BIFURCATION LESIONS
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0
1
0
(A) (B)
59
Figure 17 The case of false bifurcation (Medina 0,1,0). (A) Atherosclerotic plaque is mainly located on the
outer wall of the mother vessel; (B) after main branch stenting the carina is shifted (
possibility (due to the absence of disease in the side branch ostium) to rewire the side branch through a proximal
or a distal strut (proximal cross vs. distal cross).
short arrow
) and there is the
Stenting the Main Branch
The next step is stenting the main branch across the side branch by using a moderate inflation
pressure (
on average 12–14 atm) (Figure 11,3). The stent diameter should be chosen based on
the distal main branch size in order to decrease the risk of excessive carina shift or side branch
occlusion, leaving the side branch wire outside the stent (“jailed” guidewire technique). We use
the “jailed wire” technique in nearly all cases even when the side branch has a stenosis <50%,
because (a) this technique favorably modifies the angle between both branches by converting
a T-shaped to a Y-shaped angle; (b) this technique helps splinter the side branch open; (c) this
technique isa goodmarker ofthe sidebranch originin case ofbranch occlusionafter mainbranch
stenting; and (d) in this technique a “jailed wire” can be used to treat an occluded/dissected
large side branch by passing a balloon under the main branch stent and crushing it (crush
conversion).
The design of the main branch stent should allow side branch access and offer optimal
plaque scaffolding:A drug-elutingstent withan opencell designis the bestoption—for example,
the TAXUS Libert`e (Boston Scientific), the Xience V (Abbott), and the Endeavor (Medtronic)
stents are “bifurcation-friendly.” On bench testing, they provide good scaffolding of the side
branch ostium while openingthe strut of the stent placed inthe main branch. This phenomenon
has been called “stenting of both branches with the main branch stent.” Unfortunately, opening
the strut of the main branch stent toward the side branch causes secondary stent deformation
that results in the nonapposition of the main branch stent to the vessel wall opposite to the
entry of the side branch. The final kissing balloon is therefore recommended in order to correct
this deformation and restore adequate stent apposition of the stent on the main branch wall
while optimal opening of the stent strut toward the side branch is obtained simultaneously
(Figure 11,6).
Stent diameter selection depends on the stent maximal diameter that we want to achieve
in the mother-vessel (Dm) according to the Murray’s law by the formula
Dm = 0.678 (Dd1 +
Dd2). We recommend selecting stent diameter according to the main branch distal reference in
order todecrease the risk of side branch occlusiondue to excessive carinashift.
The stent design
should also allow further expansion in the mother-vessel (proximal to the carina) after kissing
balloon or using a larger (short) balloon inflation. The size of stent cells is another important
design parameterthat influences theresulting wall coverage. Thestent cell circumference varies
considerably between stents with different design, as demonstrated by Mortier et al. (39). The
maximal expandability of the stent cells should preferably be as large as the side branch ostium
circumference to allow vessel wall opposition after kissing balloon inflation.
60
ALBIERO AND BOLDI
SB Rewiring After Stenting the Main Branch
As previously discussed, after main branch stent implantation with a “jailed wire” in place, a
decision need to be made regarding the need for kissing balloon inflation.
If the angiographic
results in the main vessel and in the SB are satisfactory with normal flow and with residual
diameter stenosis lessthan 50% to 75% (5,6,40), the jailed SB wire is removed and the procedure
is completed (38).
determines that ther
If the result at the side branch ostium is not satisfactory or if the operator
e is a need for final kissing balloon inflation, then the side branch should
be rewired. Side branch rewiring can be performed by using the main branch wire by pulling
it back slowly from the main vessel or by using a third wire, and pointing the tip toward the
side branch ostium with the intention to cross into the side branch through the distal strut
closest to the tipof the flow divider(Figure 11,4). As previously mentioned, this “distal cross” is
facilitated in bifurcations with a side branch lesion (Medina 1,1,1 or 0,1,1 or 1,0,1) when the side
branch is not
predilated (Figs. 12 and 13). Thereafter, the “jailed wire” is withdrawn from the
side branch and pushed distally in the main branch trying to advance with the wire tip bended
(Figure 11,5). Pulling back the jailed wire should be performed with caution because it almost
always lead to the guide being pulled deep into the coronary artery, potentially resulting in
proximal coronary dissection.
For most operators who do not perform a systematic kissing balloon inflation after main
branch stenting, thetreatment ofbifurcations withminimal orno diseaseat the ostium of theside
branch (Medina 1,0,0 or 1,1,0 or0,1,0; also called “pseudo-bifurcations”) seems easier compared
to the treatment of bifurcation with a side branch lesion (Medina 1,1,1 or 0,1,1 or 1,0,1; also
called “true bifurcations”) because they stop the procedure after main branch stenting, without
dilating
the side branch ostium. On the contrary, more expert operators who adopt the strategy
of systematic kissing balloon after main branch stenting (9,11,41) are faced with the problem
of a “proximal cross” versus “distal cross” during guidewire exchange before kissing balloon
(Fig. 17). In other words, although side branch rewiring is done taking care to pull back slowly
the wire from the main vessel and pointing the tip toward the side branch ostium with the
intention to cross into the side branch through the distal strut closest to the tip of the flow
divider, this is not certain.
To assist operators in identifying a wrong “proximal cross” versus a correct “distal cross”
in pseudo-bifurcations,we are currentlyusing a new tool: a spherical oversizedballoon inflated
the carina after guidewire exchange and before the kissing balloon inflation (Fig. 18). This
at
spherical balloon is sized 0.5 mm larger than the proximal reference main branch diameter and
1 mm larger than the distal main branch diameter, as illustrated in Figure 18(B). After inflation
of this spherical balloon with the central marker positioned 1 mm proximal to the flow divider
[Fig. 19(D)], we perform two tests: (a) a check of the free movement of the guidewire in the
side branch and (b) a check of the free passage into the side branch of the balloon selected for
the kissing [Fig. 19(F)]. If one or both the tests fail, we still have the chance to rewire the side
branch. Duringthe next side branchrewiring, the probabilityto rewire the wrong proximal strut
(proximal cross) is minimized because with the prior spherical balloon inflation the proximal
stent strut was apposed against the outer wall of the side branch. We have therefore a very high
probability to cross into the side branchthrough the“right” distal strut (distal cross) [Fig. 19(G)].
Final Kissing Inflation (FKI)
The final step in the provisional stenting strategy is kissing balloon inflation (Figure 11,6).Some
operators perform final kissing balloon inflation systematically in all patients while others do
so only if required to correct the main branch stent deformation that results from side branch
dilatation. Thefinal kissing balloon inflation,when done correctly after rewiring the sidebranch
using “distal cross,” not only corrects the main branch stent deformation but also provides a
better scaffoldingof theside branchostium andfacilitates future accessto theside branch(12,42).
Kissing balloon inflation is usually performed with two balloons that are matched in diameter
and lengthto therespective vessels. To perform safekissing balloon inflation, the position of the
two balloons should be adjusted in order to avoid a barotrauma (and a possible late restenosis)
outside the proximal edge of the main branch stent (geographical miss). A subanalysis of
the provisional stenting group in the CACTUS trial has shown that final kissing balloon was
PROVISIONAL STENTING TECHNIQUE FOR NON–LEFT MAIN CORONARY BIFURCATION LESIONS
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(A)
61
(B)
(C)
Figure 18 Utility of a very short (spherical)
oversized, postdilation balloon to discover a
proximal cross. (A) The case of proximal cross
arrow
); (B) inflation of the spherical oversized
(
balloon (with a diameter 0.5 mm larger than the
proximal reference and 1 mm larger than the distal reference diameter) with the central marker
positioned 1 mm proximal to the flow divider.
After spherical balloon inflation, the guidewire
will be jailed and the balloon used for the subsequent kissing inflation will not cross easily in the
side branch. (C) Due to protrusion of struts into
the side branch ostium induced by the spherical balloon inflation, it will be easy to reposition
the wire between distal struts where the wire will
cross now on a wide front.
associated with better angiographic results and lower MACE rate (7). Furthermore, the final
kissing balloon inflation in Medina (0,1,0) lesions guarantees a good vessel wall apposition of
the proximal stent segment (Fig. 20). However, before reaching general consensus on the need
for systematic final kissing balloon inflation in the provisional stenting strategy, we should wait
for the results of the randomized NORDIC-
KISS trial, which is evaluating this issue.
Provisional Side Branch Stenting
Side branch stenting is not necessary in almost 70% to 80% of bifurcations that are suitable for
this technique.
stent,” which is feasible in clinical practice because side branch lesions are usually short (Table
This is related to the concept of “stenting both branches with the main branch
1) and for the fact that the flow divider (carina) is free of disease and only shifted after main
branch stent (Figs. 12 and 13). Therefore, a provisional side branch stent is required on average
in 20% of patients [between 2% and 51% of cases in five RCTs (3–7)] when results in the side
branch are unsatisfactory after final kissing balloon inflation (>75% residual stenosis, dissection,
TIMI flow grade <3inaSB≥2.5 mm or fractional flow reserve (FFR) <0.75) (40,43). Optimal
stent positioning is crucial to scaffold the ostium of the side branch to avoid an ostial gap that
will predispose to ostial side branch restenosis. Additional final kissing balloon inflation is then
performed to correct any possible main branch stent deformation. The T technique is the most
frequently used for side branch stenting (6): (a) “simple T” (without protrusion in the main
vessel) (Figure 11,7a), this technique is appropriate when the final kissing balloon inflation
flares the main branch stent struts to cover/scaffold the side branch ostium (the case of “distal
cross”); (b) “T And Protrusion” (TAP) (33) (Figure 11,7b), this technique is used when side
branch rewiring occurred through “proximal cross” and some operators use it in all patients.
A balloon inflated at low pressure (2–3 atm) placed in the main branch can help side branch
stent precise positioning. Provisional side branchcan also beperformed using theinternal crush
(36) (Figure 11,7c) or the inverted Culotte (35) (Figure 11,7d) techniques to be sure to provide
62
ALBIERO AND BOLDI
(A)
(D)
(B)
(C)
1
1
0
(E)
(H) (I)
(F)
(G)
Figure 19 Stent implantation in a false bifurcation (Medina 1,1,0). (A) Baseline angiogram of the LCx-OM
bifurcation; (B)3.0× 23 mm drug-eluting stent implantation at 12 atm with a jailed wire in the side branch;
(C) the flow divider (carina) is mildly shifted; guidewire exchange is performed trying to cross into the side branch
through the more distal strut closest to the carina (
with the central marker of the balloon positioned 1 mm proximal to the flow divider; (E) angiogram after spherical
balloon inflation; (F)a2.0× 15 mm new Maverick balloon failed to cross into the side branch; (G) the side branch
guidewire (probably jailed after the prior proximal cross) was removed and easily repositioned in the distal struts
where it crossed on a wide front; (H) final kissing balloon; (I) final result after kissing balloon with good side branch
ostium scaffolding associated with expansion of the main branch stent at the carina level.
complete stent coverage of the side branch ostium in case of a proximal cross or systematically
short arrows
); (D) spherical 3.5 mm balloon inflation at 18 atm
(independently from the main branch strut crossed: proximal or distal cross). The drawbacks of
the inverted Culotte technique are excess of metal (double layer) covering of the mother vessel
(proximal main branch) and the complexity of the procedure that requires many steps, each
potentially at risk of complications.
PROVISIONAL SIDE BRANCH STENTING STRATEGY: WHAT CAN GO WRONG?
The primary concern with provisional side branch stenting is side branch occlusion. Although
this is an uncommon event withthe current techniques in thehands ofexperienced operators, it
still can occur particularlywhen thistechnique isused in complex bifurcation anatomy (severely
angulated side branches and/or severe ostial involvement). Although an occluded side branch
after mainbranch stenting can often be salvagedby propertechnique, this is notalways the case.
When the side branch is small and does not supply large myocardial territory its occlusion in
inconsequential. However, occlusion of large side branches can result in myocardial infarction.
The cases in Figures 21 and 22 illustrate two different scenarios of side branch occlusion during
provisional stenting technique.
PROVISIONAL STENTING TECHNIQUE FOR NON–LEFT MAIN CORONARY BIFURCATION LESIONS
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63
(A) (B)
0,1,0 0,1,1
Figure 20 The role of final kissing balloon inflation in 0,1,0 and 0,1,1 bifurcations. (A) After main branch stent
implantation in a 0,1,0 or 0,1,1 lesion, the proximal stent segment is not apposed to the vessel wall; (B) after
final kissing balloon inflation the proximal stent segment is well apposed to the vessel wall (
additional scaffolding of the side branch ostium (
long arrow
).
short arrows
)with
TAKE HOME MESSAGE
1. A stepwise provisional side branch stenting strategy with drug eluting stents in suitable
bifurcation lesions is preferable to elective double stenting (
2. The
provisional stenting strategy consists of stenting the main branch first, followed, if
necessary, by stenting the side branch through the main branch stent in a classic
almost 70–80% of cases).
T, TAP (T
And small Protrusion), inverted Culotte, or Internal Crush configuration.
1
1
0
(A) (B) (C)
Figure 21 Side branch occlusion after main branch stent implantation using the provisional stenting strategy.
(A) Baseline angiogram of the PDA-PL bifurcation in the distal RCA. The angle PDI-PL is >70
stent implantation in the distal RCA toward the PDA without a jailed wire in the PL branch due to the unfavorable
SB take-off; (C) final angiogram after stenting showing side branch occlusion.
◦
;(B) drug-eluting
64
ALBIERO AND BOLDI
(A)
(D)
Figure 22 Side branch subocclusion after main branch stent implantation using the provisional stenting strategy.
(A) Baseline angiogram of the OM1-OM2 bifurcation; (B) drug-eluting stent implantation with a jailed wire in the
side branch; (C) angiogram after main branch stenting; (D) guidewire exchange: the tip of the main branch
guidewire was pulled-back and directed towards the SB ostium to cross through the stent into the side branch;
(E) the guidewire crossed into the SB but was subintimal due to a proximal cross; (F) final angiogram showing
ostial dissection and subocclusion.
(B)
(E)
(C)
(F)
3. Patient selection for provisional stenting is essential for success. There are four anatomic
elements to evaluate: (a) the angle between the two branches, (b) the side branch lesion
severity and length, (c) the observed/expected diameter, and (d) the plaque distribution.
4. The design of the main branch stent should allow side branch access and offer optimal
plaque scaffolding.
5. The “jailed wire” technique should be used in all cases of provisional stenting.
6. When final kissingballoon inflation is planned, we recommend avoidingside branch predilation.
7. A new adjunctive tool (a spherical oversized balloon inflated at the carina after guidewire
exchange and before the kissing balloon inflation) can be used to assist operators in identifying a wrong “proximal cross” versus a correct “distal cross” in pseudo-bifurcations.
8. Performing provisionalside branch stenting in “unsuitablebifurcation anatomy” carriesthe
risk of side branch closure.
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Physiologic Guidance of Provisional Stenting
in Coronary Bifurcation Lesions
Michael J. Lim
Saint Louis University, St. Louis, Missouri, U.S.A.
Bon-Kwon Koo
Seoul National University Hospital, Seoul, South Korea
INTRODUCTION
The treatment of bifurcationlesions utilizing a technique of provisional side branch (SB) stenting
fundamentally requires the operator to make bedside decisions regarding specific treatments
within theSB after thestent is placedin the mainvessel (MV). Forthe most part,current practice
dictates careful evaluation of the angiogram obtained after MV stenting to look for SB ostial
narrowing, reduced flow down the SB, or dissection. Although clear-cut evidence of decreased
flow or dissection mandates further therapy to preserve the patency of the SB, the majority of
cases do not possess these definitive findings.
Within the protocol of the NORDIC bifurcation study, operators were only allowed to
further dilate the SB in the provisional group if there was angiographic evidence of impaired
TIMI flow (1). Furthermore, stenting of the SB (in addition to the MV) was allowed only for
complete occlusion of that branch. This randomized study showed that there was no clinical
advantage seen for a more complex strategy of stenting both the MV and the SB in patients
enrolled in this trial (patients with moderate and focal lesions at the SB ostium).
However, many operators may be less comfortable leaving more subtle abnormalities
without angioplasty or stent treatment despite preserved TIMI flow, especially ostial SB angiographic stenoses that appear significant. Operators are also faced with the urge to utilize an
upfront two-stent strategy because of significant plaque burden within the MV and SB on
the diagnostic angiogram. This chapter discusses the utilization of fractional flow reserve to
guide decision making in the cath lab for patients with bifurcation disease. Invasive physiologic assessment of coronary stenoses utilizing fractional flow reserve (FFR) has proven to be
an extremely useful tool in determining coronary stenoses that require stenting versus those
that can be treated with medical therapy alone. These same tenets for intermediate epicardial
coronary lesions can be extrapolated for use in bifurcation lesions.
BACKGROUND ON FRACTIONAL FLOW RESERVE
Invasive physiologic assessmentof acoronary arterystenosis withFFR hasbeen verified as atool
for the interventional cardiologist to address the question whether performing an angioplasty
(PCI) in an intermediate coronary lesion is necessary. An intermediate lesion, usually reported
in the range between 40% and 70% narrowing, is the most frequently encountered stenosis
in patients with CAD and its treatment in the cardiac catheterization lab is highly variable.
Ultimately, PCI has the potential to remove the burden of myocardial ischemia and subsequent
anginal symptoms as a result of a coronary stenosis. Multiple studies have shown that an FFR
of >0.75 translates into low subsequent cardiovascular event rates. Furthermore, performance
of PCI on these non–ischemia-producing lesion did not lower event rates for these patients
(2–4).
Most of the data supporting the utilization of FFR in patients have been in single-vessel
stable disease. Recently, the FAME trial evaluated the utility of FFR in patients with multivessel
disease andPCI utilized drug-eluting stents (5). Utilizingan FFR thresholdof <0.80 tosignify an
ischemia producing lesion, this study confirmed the lack of benefit in performing PCI for non–
ischemia-producing lesions in over 1000 randomized patients. Specifically, this study utilized
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