www.medscape.

com


Coronary Artery Bifurcation Lesion
Classifications, Interventional Techniques
and Clinical Outcome
Mohammad Reza Movahed
Expert Rev Cardiovasc Ther. 2008;6(2):261-274.
Abstract
Percutaneous coronary intervention for the treatment of bifurcation lesions is associated with a
lower success rate and increased risk of subacute stent thrombosis and restenosis. The goal of
this manuscript is to review the current classification of coronary bifurcation lesions and
techniques. An algorithmic approach for the treatment of bifurcation lesions based on the
recently published simplified and comprehensive classification is proposed in this manuscript.
Coronary Artery Bifurcation Lesion Intervention: A Challenge
Coronary artery bifurcation lesions pose a major challenge for interventional cardiologists.
Percutaneous coronary intervention (PCI) for the treatment of coronary artery bifurcation lesions
is associated with increased risk of complications.
[1]
Two-stent techniques in the era of bare
metal stents (BMS) were associated with increased risk of short- and long-term adverse
outcomes.
[1-3]
For this reason, the American College of Cardiology Task Force categorized
simple bifurcation lesions as type B lesions and complex bifurcation lesions with the risk of side
branch occlusion as type C lesions.
[4]
Despite higher utilization of multiple stents in the treatment
of coronary artery bifurcation lesions, stent restenosis rate has been lower in the era of drug-
eluting stents (DES).
[5-7]
However, higher risk for subacute and late stent thrombosis is of major
concern.
[5,8-13]
Currently, there is no guideline to address the choice of particular interventional
technique in regards to the specific anatomy of a given bifurcation lesion. There are few major
coronary artery bifurcation lesion classifications published in the literature.
[11,14-18]
Most of these
classifications are confusing, difficult to remember and not clinically oriented.
[18]
A
comprehensive, clinically oriented and simplified classification of coronary artery bifurcation
lesions and techniques has been published recently.
[17]
Based on this classification, an
algorithmic approach for the treatment of coronary artery bifurcation lesions is proposed in this
manuscript.
Coronary Artery Bifurcation Classifications
Currently, there are six major bifurcation lesion classifications described in the literature. Of
these, four classifications were published in the era of BMS.
[11,14-16]
They are all very similar in
describing a given bifurcation lesion. These classifications have not been adapted to the current
clinical practice of bifurcation intervention involving many complex interventional techniques,
such as the kissing stent technique (KST) or the crush stent technique (CRT). They are similar in
their nomenclature. Different lesion types are named using numbers or letters with a lack of
association between the given names and anatomical abnormalities seen in these lesions.
For instance, Sanborn's Type I and Type III lesions describe two bifurcation lesions as two
different types with the same technical relevance (Figure 1).
[15]
On the other hand, this
classification does not categorize technically important features of bifurcation lesions such as
angulation between the two branches or the size of the proximal healthy segment (important for
the KST). The Duke classification
[14]
is similar to the Sanborn classification, which does not
describe the bifurcation angle or the proximal healthy segment. Furthermore, many lesions with
different names have similar features that are not important for technical decision making. For
example, Duke type D or F lesions, involving both ostia, resemble Sanborn type B and C lesions
(Figure 1). For an interventionalist, there is no discernable difference between these lesions in
regards to choosing any specific technique. Therefore, it would be clinically and technically
irrelevant to distinguish between these types. The same redundancy occurs in separating
bifurcation lesions into different types without technical relevance, as can be seen in Safian type
IA and IIIA
[16]
and Lefevre type 1 and type 4 lesions
[11]
(Figure 1). Again, there is no description
of proximal segment or angulation between the two branches in any of these classifications,
which miss important technical information. Furthermore, there is no connection between the
lesion's types and the names, making it very difficult to memorize. These are the reasons why
these classifications have not found their ways into routine clinical practice.

Figure 1.

Summary of currently published major coronary bifurcation classifications.
Two new bifurcation classifications have been published recently in order to overcome some of
the limitations of previous classifications. The first attempt to simplify these classifications for
better memorization was successfully made by Medina et al.
[19]
(Figure 1). They divided
bifurcation lesions into three segments: proximal segment of the main branch, side branch ostia,
and distal segment of the main branch. Any involvement of each segment will receive the suffix
1, otherwise suffix 0 was assigned starting from left to right. For example, lesion 1,0,1 means
that proximal segment, and side branch ostia are diseased but the distal part of the main branch is
free of disease (Figure 1). This classification is easier to remember in comparison to older
classifications. For this reason, the European Bifurcation Club has endorsed this classification in
their publications.
[20]
However, the Medina classification has completely failed to include two
important features of bifurcation lesions: angulation of branches and the size of the proximal
healthy segment.
The European Bifurcation Club admits the importance of angulation as a prognostic feature of a
bifurcation lesion, which is not mentioned in the Medina classification.
[20]
Furthermore, similar
to other classifications, this classification has redundancy in describing two different lesions with
similar technical decision making. For example, lesions 1,1,1 and 0,1,1 (Figure 1) describe two
types of lesions with involvement of the main and side branch ostia. Therefore, these two lesions
are anatomically very similar in regards to technical decision making.
In order to overcome the limitations and shortcoming of these classifications, a new
classification was recently published by Movahed et al. eliminating the redundancy and adding
other technically important features of bifurcation lesions.
[17]
This classification is based on a
system that is composed of a single prefix to which up to four different suffixes are added
(Figure 1 & Figure 2). The description of this classification begins with the prefix B (for
Bifurcation lesion) to which four different suffixes can be added to obtain the final description of
the lesion. The nomenclature for true bifurcation lesions involves only two main subgroups for
each of the four suffixes. Each suffix describes a technically important feature of a given
bifurcation lesion in the context of currently advanced PCI techniques. Using suffixes that
directly describe the anatomically important features of bifurcation lesions makes this
classification very easy to remember. This classification is more complete because it addresses
two other important technical features of bifurcation lesions that are not mentioned in any other
classifications: the proximal healthy segment and bifurcation angles between the side and main
branch.

Figure 2.

Detailed structural description of the Movahed's coronary bifurcation classification with
modification of the 4th suffix. Reprinted with permission from The Journal of Invasive
Cardiology.
A large proximal segment is a requirement for the KST, an important feature of this
classification. The main requirement for performing KST is the presence of a large proximal
healthy segment that is at least as large as two-thirds of the sum of the diameter of both branch
vessels, which can accommodate two stents.
[7]
The first suffix of this classification addresses this
feature. If the proximal segment is large enough, it is assigned the first suffix of L (for Large
proximal segment), whereas if the proximal segment is small (less than two-thirds of the sum of
the diameters of both branch vessels) it is assigned the first suffix of S (for Small proximal
segment). Therefore, BL lesions are suitable for the KST, whereas BS lesions are not.
[7]

The second suffix in this classification describes a very important feature of coronary artery
bifurcation lesions, which is the involvement of branches. If the ostia of both bifurcation
branches are involved in the significant atherosclerotic disease process, the suffix number 2 is
used. It is well known that significant atherosclerotic involvement of both ostia dramatically
increases the risk of side branch occlusion during PCI or stenting of the main branch. In the
randomized trial comparing the new intravascular rigid-flex stent to the Palmaz-Schatz stents,
atherosclerotic involvement of both branch ostia was associated with 40% occurrence of
myocardial infarction. However, if the side branch was not involved, myocardial infarction
occurred in only 4.7%.
[21]
In an analysis of angiographic predictors of side branch occlusion, side
branch closure occurred in 65% of lesions if both ostia were diseased versus 4% in lesions
without the side branch involvement.
[22]

If only the main branch is diseased regardless of whether it is in the proximal or distal segment,
suffix 1m is used. For involvement of the side branch only (or anatomically less important
branch), suffix 1s is used. This distinction is important for technical decision making, which is
discussed later in detail.
The third important suffix in this classification describes the angulation of bifurcation branches,
which has been ignored in other classifications. Steep angulation makes access to the side branch
difficult after main branch stenting and is significantly associated with adverse outcome. Dzavik
et al. found that there was a significant increase in the long-term mortality in patients with highly
angulated lesions who were treated with the CRT.
[23]
Furthermore, a steep angle is significantly
associated with the risk of abrupt vessel closure
[24]
or side branch occlusion.
[22]
Therefore, it is
very important that bifurcation classifications incorporate this important feature into
classification as has been done in the recent simplified classification. The suffix V is given for
shallow angles less than 70 (which looks like a V) and suffix T is given for a bifurcation with a
steep angle of more than 70 degree (which looks look like a T). For example, a BS2T lesion is a
bifurcation lesion (B for bifurcation) that has a small proximal segment (S for small, which is not
suitable for KST) with involvement of two ostia (2 for both ostia) in the disease process with a
steep angulation (T for steep angulation since it looks like a T) of the branches. An example of
BL2V lesion can be seen on Figure 3.

Figure 3.

An example of a BL2V lesion. A bifurcation lesion with a large proximal segment and
involvement of both ostia (2) with an angle of less than 70 (V) between the branches that was
successfully treated using the kissing stent technique.
This classification adds optional suffixes for other high-risk features at the end of the
classification symbols (in this classification LM was used for left main and CA for calcium).
However, an expansion of this classification can easily be done by adding an abbreviation of
other high-risk features to the end of the lesion description such as 'TO' (for total occlusion) or
'TR' (for thrombus-containing lesion). For example, for better communication and more detailed
description of a bifurcation lesion, an interventionalist could describe a heavily calcified
thrombus containing lesion involving LM with small healthy proximal segment, involvement of
both left anterior descending arterty and circumflex ostia, and steep angulation as: BS2T-LM-
CA-TR lesion. However, for simplicity, an interventionalist could just use the important
anatomical features of this bifurcation lesion and describe it as BS2T lesion or only utilize the
most important suffix for a given technique and describe this lesion as BS, B2 or BT lesion.
A summary of currently available classifications can be seen in Figure 1. A more detailed
structural explanation of the newest comprehensive simplified classification can be seen in
Figure 2.
Interventional Techniques in the Treatment of Bifurcation Lesions
Several techniques have been described and used successfully in the treatment of bifurcation
lesions. Different names for similar bifurcational techniques have caused confusion in the
past.
[11,14-16,25-28]
For example, the KST has also been described as 'V' stenting if proximal
overlap of both stents is too short.
[7,25]

Recently, the European Bifurcation Club has divided bifurcation interventions into categories
depending on the location and timing of the first stent implantation. If the first stent is planted in
the main branch, it is called 'M' (for Main branch), if it crosses the bifurcation, it is called 'A' (for
Across) and if the stent is placed in the side branch first, it is called S (S for Side branch).
[20]
This
nomenclature describes the location and sequential timing of bifurcation stenting. However, it
does not describe technical aspects of important interventional techniques using one or two
stents. Therefore, for simplification, the most common bifurcation techniques with regards to
stenting have been recently classified into six categories
[17]
: the one-stent technique (OST), the
stent with balloon technique (SBT), the KST, the T stent technique (TST), the CRT and the
cullotte stent technique (CUT) (Figure 4).

Figure 4.

Interventional bifurcation techniques. CRT: Crush stent technique; CUT: Cullotte stent
technique; KST: Kissing stent technique; OST: One-stent technique; SBT: Stent with balloon
technique; TST: T stent technique.
When to Choose One- or Two-stent Techniques?
The simplest technique is one-stent technique (the OST or the SBT). The long-term outcome of
the OST has been at least as good as or even better than two-stent techniques regardless of stent
type. The only two-stent technique that has shown better long-term outcome in comparison to the
OST with regards to stent restenosis has been published by Sharma et al.
[7]
using KST. Earlier
trials comparing two-stent techniques have shown an increase in adverse outcomes in
comparison to the OST in the BMS era. Restenosis rate (57 vs 21%) and target lesion
revascularization were higher for stenting both vessels (43 vs 8%).
[29]
This finding has been
confirmed by other studies.
[1,3,30]
In order to decrease the restenosis rate, DES have been studied
in comparison to BMS. DES has consistently been found to be superior to BMS in the treatment
of bifurcation lesions with lower in-stent restenosis or target lesion revascularization.
[31,32]
Using
two-stent techniques in the era of DES did not improve restenosis rate. Apart from the KST in
two large trials,
[7,33]
other two-stent techniques have not been superior to OSTs. The first
randomized trial comparing two stent to OSTs showed no significant difference between the two
approaches.
[5]
Various bifurcation techniques were used in this trial such as the TST and the
KST. A modified TST was used in the majority of the cases (63.5%). With advancement in the
bifurcation interventions, stent restenosis rates have been lower using one- or two-stent
techniques. It usually depends on the disease burden of the side branch.
[34]
For example, in the
Nordic study,
[34]
the presence of over 50% lesions in the side branch was associated with a
restenosis rate of 11-19%, whereas less than 50% side branch disease was associated with an in-
stent restenosis rate of 4.6-5%. The two randomized Nordic Bifurcation II and Bifurcations Bad
Krozigen studies were presented at the Trans Catheter Therapeutics meeting in November 2007
confirming the previous findings that the restenosis rate is not better using two stents.
Furthermore, the risk of subacute stent thrombosis has been higher using two-stent techniques in
the majority of trials.
[5,35,36]
Conversely, provisional side branch stenting in B2 lesions (both ostia
are diseased) poses a high risk for side branch occlusion and increases procedural complication
rate, as described earlier. The risk of side branch occlusion in B2 lesions can be as high as 65%
depending on the side branch angle.
[21,22]
Based on these trials, there is a general consensus that
if a bifurcation lesion does not have high-risk features for side branch occlusion, such as
involvement of both branch ostia (B2 lesions) or steep angulations (BT lesions), using one stent
techniques (the OST or the SBT) with provisional side branch stenting in the case of
unsatisfactory results in the side branch is the preferred technique. Otherwise, two-stent
techniques offer safer access to both diseased branches in the high-risk lesions. For easier
advancement of two stents in the bifurcation lesions, balloon predilation is recommended before
stenting. Any bifurcation intervention poses a high risk for acute side branch occlusion, which
may require changes in the initial technique to a more complex interventional technique. This
may require larger guide catheter size and stronger guide support. Therefore, in high-risk
bifurcation lesion interventions, it is recommended to use a 7-Fr sheath size.
Technical Features
One-stent Technique
The OST is based on a simple technique using one stent. This is the best technique in bifurcation
lesions with a small side branch that can be ignored. This is also the best technique that is
suitable for BC (close to bifurcation) and BN (not a significant side branch) lesions or B1m
lesions when the side branch ostia is not involved (as the risk of side branch occlusion is small
when the side branch is not diseased).
[22]
After the initial stent deployment in the main vessel, the
side branch will be left alone if no significant stenosis or plaque shift occurs at the side branch
ostium.
Stent Balloon Technique
The SBT uses one stent in the main branch and balloon angioplasty of the side branch ostium
when the side branch ostium is compromised after main branch stenting or the side branch has
significant disease. This technique is also very simple, but can be associated with a higher risk of
side branch occlusion in the high-risk lesions such as B2 lesions with difficulty to access the side
branch in BT lesions. B1m lesions are best suited for this technique if the side branch ostium is
compromised. It is important to use a short balloon for side branch angioplasty in order to
decrease trauma to the side branch vessel.
Kissing Stent Technique
The KST requires simultaneous advancement of two stents that are positioned side by side into
each bifurcation branch with the creation of a new carina. This technique is also known as V
stenting.
[7,19,37]
The major advantage of this technique is the ability to maintain access to both
branches at all times. However, the occurrence of an edge dissection or the presence of
additional stent struts in the main vessel poses a theoretical risk of stent thrombosis.
Nevertheless, based on the two recently reported studies,
[7,33]
the subacute stent thrombosis rate
for this technique has been low in the DES era. The most important anatomical requirement of
this technique is the presence of a large proximal segment in order to accommodate the proximal
ends of the two stents. Therefore, BL lesions with the proximal healthy segment of at least two-
thirds of the sum of the diameters of both bifurcation branches are best suitable for this
technique. Furthermore, steep angulations may cause difficulty in advancing two stents
simultaneously, making BT lesions more risky with this approach. It is important to perform
final kissing inflation of both stents at a low pressure for optimal stent deployment. The sequence
of this technique is as follows. First, both stents will be deployed at a low pressure (6-8
atmospheres). Next, both stent balloons are deflated and each balloon is inflated sequentially to a
high pressure (14-16 atmospheres) followed by final inflation of both stent balloons at a low
pressure again at the end of the procedure. Figure 3 demonstrates one example of this technique
used in a BL2V lesion. The main drawback of this technique is the occurrence of proximal edge
dissection, which could be difficult to treat. In such cases, the KST can be converted to the CRT
by crushing the side branch stent with the ability to stent the proximal segment. A long proximal
disease segment may require initial simple stenting of the proximal segment in order to avoid
creating a long carina. This technique has the disadvantage of requiring a large at least 7 Fr
sheath size in order to advance two stents simultaneously.
T Stent Technique
The TST requires positioning of two stents in a 'T' fashion. This technique has many other names
such as 'modified T technique' or 'classic T technique'
[25,27,28,38]
and there are many different
variations. The easiest and safest approach is a pullback technique where a stent is placed in the
side branch and a balloon in the main branch, which is inflated to a low pressure.
The side branch stent is then pulled back to the side branch ostium while a balloon is inflated at
low pressure in the main branch, protecting the main branch from excessive side branch stent
malposition into the main branch. After the stent deployment in the side branch, stenting of the
main branch is then performed if the main branch is compromised or has a significant lesion. A
different approach is also described as mini crush. In this approach, after initial balloon
predilatation, two stents are positioned simultaneously in both branches. Next, the side branch
stent is inflated with minimal stent overhang in the main branch. After the removal of the side
branch stent balloon, the main branch stent is deployed. This will clear and push the minimal
side branch stent overhang back to the side of the vessel wall. Final kissing balloon inflation will
conclude the procedure.
It is also possible to stent the main branch first and then stent the side branch through the stent
struts with the risk that advancement of the side branch stent could be difficult. This is the best
suitable bail-out technique when after the initial main vessel stenting and side branch balloon
angioplasty, the side branch result remains suboptimal or major dissection of the side branch
requires additional stenting.
The loss of direct side branch access after the main branch stenting in comparison to the KST is a
major drawback of this approach. This technique can be best utilized in bifurcation lesions with
small proximal segments that are not suitable for the KST such as BS2 lesions. Other two-stent
techniques such as the CRT or the CUT can be used in B2 lesions based on operator expertise.
Crush Stent Technique
The CRT, pioneered by Colombo et al.,
[27]
lost initial enthusiasm due to a high rate of subacute
thrombosis and difficulty to rewire the side branch for final kissing balloon angioplasty. It
consists of advancing two stents simultaneously into both bifurcation branches. The proximal
segment of the side branch stent is first deployed in the main branch and is then crushed to the
main branch vessel wall after stenting of the main branch. Modification of this technique is
called reverse crushing, which is done in the reverse fashion.
[13,39]
If after the one-stent technique
the side brach ostium has significant lesion despite balloon angioplasty, reverse crush technique
can be used as a bail-out technique. In this situation, a second stent is advanced into the side
branch though the main stent struts. Then, a balloon in the main branch is positioned at the level
of bifurcation. Next, the proximal part of the side branch stent is retracted into the main branch
and deployed. After the removal of the side branch balloon, main branch balloon inflation will
crush the proximal side branch stent strut. Then, the final kissing balloon is performed. The main
advantage of this technique is that it is compatible with a 6 Fr size system. At the end of the
procedure, the side branch will be rewired and final simultaneous kissing balloon inflation is
performed. Although this technique can be utilized for most bifurcation lesions, steep
angulations such as T lesions could make it difficult to rewire the side branch. Furthermore,
subacute stent thrombosis and side branch restenosis rates have been high.
[9,10,13]
This technique
can be technically challenging, since rewiring of three stent layers could be difficult. For these
reasons, this technique has fallen out of favor. The CRT has a major limitation related to the
difficulty in rewiring and advancing an angioplasty balloon across three layers of stents. In order
to overcome this limitation, a modified version of the CRT, known as the sleeve technique, is
successfully utilized clinically.
[9,40]
This technique utilizes an angioplasty balloon first (as
opposed to a stent) in the main branch after stenting of the side branch in order to crush the
proximal part of the side branch stent. Using only a balloon in the main branch for crushing has
the distinct advantage of having only two layers of stent in the side branch ostium for rewiring.
Before final stenting of the main branch, the side branch ostium is rewired and ballooned
together with main branch balloon inflation (first kissing balloon) creating an open side branch
ostium. The side branch is now like a new sleeve giving the name of the sleeve technique. After
main branch stenting, rewiring of the side branch ostium is much easier since only one stent
layer needs to be recrossed for the final kissing balloon inflation. Using this technique,
successful final kissing balloon inflation could be performed in all patients in a small trial.
However, subacute stent thrombosis rate remains high at 2.4%.
[9]
Furthermore, this modification
adds substantial time, cost and complexity to the CRT procedure and there are no long-term
follow-up data available at this time. A modified TST, which is described in the previous section,
is called mini crush, which is now utilized by many interventionalists in order to avoid
positioning many layers of stents in the main vessel. The CRT, similar to the KST has the
disadvantage of requiring a large at least 7 Fr sheath size in order to advance two stents
simultaneously, unless reverse crush or sleeve technique is utilized.
Cullotte Stent Technique
The CUT, also described as Y stenting or 'trouser legs',
[25,38,41]
was associated with high
restenosis rates in the past. However, it is gaining popularity in the era of DES. A small trial of
23 patients showed an encouraging low restenosis rate of 18% without any stent thrombosis.
[42]

This positive result was confirmed in a recent trial comparing the provisional CUT with the TST.
The CUT revealed a lower rate of target lesion revascularization of 8.9% in comparison with the
TST.
[43]
Based on these two encouraging trials, the CUT may become the preferred technique.
This technique is useful as a bailout technique. In case of an unsatisfactory side branch result
after main branch stenting using BST, the CUT can be utilized to resolve the problem. With this
technique, the operator should first stent the less angulated or most diseased branch vessel, and
then rewire the other branch through the stent struts. Next, the second stent is positioned across
the second branch with positioning of the proximal stent segment in the proximal part of the
previously stented segment in the other branch. Final simultaneous kissing balloon inflation
should be performed in order to expand stent struts. This technique is suitable for T or V lesions
when both ostia of the bifurcation branches are diseased. The technique is best suitable for the
lesions when the size of the side and main branches are similar. Otherwise, the proximal part of
the smaller stent could float in the larger branch making the rewiring for final kissing balloon
difficult.
Algorithmic Approach to the Treatment of Bifurcation Lesions
A proposed algorithm for lesion specific techniques is illustrated in Figure 5. It is important to
visualize the bifurcation branches in order to assess if a lesion is a true bifurcation. If there is a
small space between the main and the side branch, the lesion will be categorized as BC lesion
(close to bifurcation). These lesions are not true bifurcation lesions and should be treated with
careful positioning of one stent in the main branch before the bifurcation site. If the operator is
convinced that a bifurcation lesion is a true bifurcation lesion, then the next question is the
importance of the side branch vessel size. If the side branch vessel is small (usually less than 2-
2.25 mm) or supplies small territory, the lesion should be classified as BN (nonsignificant
bifurcation). In this case, the side branch should be ignored and stenting of the main vessel
should be performed using the OST. In the case of side branch occlusion, a short attempt of side
branch balloon angioplasty may be warranted if the patient is symptomatic.

Figure 5.

An algorithmic approach for the treatment of coronary artery bifurcation lesions based on the
lesion type.
If the side branch is found to be important, the operator needs to evaluate atherosclerotic disease
involvement of the main and side branches. If only one ostium is involved, it is important to
know which branch is diseased. If the main branch is not involved, the operator should
reconsider intervening on the side branch with a potential risk of injuring and compromising the
main branch. If the intervention can not be differed due to large side branch size, a OST with
pullback protection of the main branch should be used by positioning an inflated balloon at low
pressure in the main branch before ostial side branch stenting. This approach may prevent main
branch compromise. Any major compromise to the main vessel will require further intervention.
If only the main branch ostium is involved in the disease process, the OST is the easiest preferred
technique with provisional side branch angioplasty or stenting if the side branch is compromised
after main branch stenting.
If the interventionalist realizes significant involvement of both branch ostia, the OST poses a
high risk for side branch occlusion. In the majority of cases, operators prefer two-stent
techniques in order to decrease the risk of side branch occlusion. The choice of two-stent
technique depends on the operator's expertise and preference. Based on simplicity and good
long-term outcome, the KST can be used in suitable lesions. Therefore, the proximal segment of
a bifurcation lesion needs to be assessed. If the proximal segment is large enough to
accommodate two stents in BL lesions, the KST can be used. If the proximal healthy segment is
small, other techniques need to be utilized depending on the branch angles.
If the branch angle is over 70, advancement of two stents into the side branch could be difficult.
Furthermore, the CRT is technically more challenging in angulated lesions and is associated with
increased adverse outcome in these lesions.
[23]
Therefore, the operator should avoid the CRT in
angular BT lesions. If the branch angulation is less than 70, the TST runs the risk of missing the
side branch ostium. Therefore, the CUT or the CRT should be considered initially. If the TST is
used, the pullback technique, also known as the mini crush technique, would be a better choice in
order to avoid missing the side branch ostium. An overview of this suggested algorithmic
approach to bifurcation stenting and intervention is shown in Figure 3. A summary of advantages
and disadvantages of each technique can be seen in .
Table 1. Summary of Advantages and Disadvantages of Different Bifurcation
Interventional Techniques
Technique Advantage Disadvantage
Best suitable
lesions Not suitable lesions
One stent
technique/
stent with
balloon
technique
Easiest and
simplest initial
techniques by
advancing only
one stent in the
main branch
Risk of side branch
occlusion is higher,
particularly in B2
lesions Rewiring of
the side branch can be
difficult if side branch
balloon angioplasty or
stenting is necessary
after main branch
Close to
bifurcation but
not true
bifurcation
lesions
Bifurcation
lesion with a
nonsignificant
side branch Only
B2 lesions pose a
high risk for side
branch occlusion and
rewiring difficulties
if further
intervention is
needed Particularly
B2T lesions which
make side branch
stenting main branch
ostium is
diseasedOnly
side branch
ostium is
diseased
rewiring very
difficult
Kissing
stent
technique
Least risk of side
branch occlusion
as side branch
access is
maintained
throughout the
procedureOstial
side branch
coverage is
guaranteed
Requires large
proximal healthy
segmentRquires 7
Fr sheath size Long
main branch lesion
may require stenting
proximal main branch
disease first to avoid
long new carina
containing two stents
in the main vessel
Proximal or distal
dissection can be
difficult to treat and
may require changing
the technique to more
complex crush
technique to treat
proximal dissection
Two stents in the
main branch may be a
problem for future
intervention and may
pose unknown risk for
thrombosis
Preliminary trials
have shown the least
risk of late or
subacute stent
thrombosis with the
KST
Only BL lesions
can be treated
Particularly
BL2V lesions
with both ostial
disease and short
proximal main
branch disease
with shallow
angle are best
suitable for the
KST
Long main branch
lesion will cause a
creation of a long
new carina with two
stents in the main
branch. This may
increase the
theoretical risk for
stent thrombosis or
increases difficulty
for future distal
interventionBT
lesions with steep
branch angulation
can make it difficult
to advance two
stents
simultaneously
T stent
technique
Can be easily used
as bail out
technique Easiest
technique for
simultaneous
advancement of
two stents Can be
easier using
Risk of difficulty or
inability to advancing
second stent across
the main stent struts if
the main branch is
stented first Difficult
for precise stent
position in the side
B2 lesions with
steep angle (B2T
lesions). Steep
angle makes it
easier to position
the side branch
stent in the side
branch ostium
BV (shallow
angulated) lesions
make it difficult to
position the side
branch stent
balloon protection
in the main branch
branch and risk of
missing the side
branch ostium Risk of
side branch stent
overhand in the main
branch Increased
overall risk for
subacute stent
thrombosis
Crush stent
technique
Can be easily
perform in most
bifurcation lesions
initially Ostial side
branch coverage is
guaranteed
Poses difficulty for
rewiring the side
branch for final
kissing balloon
angioplasty (the
sleeve technique, a
modification of the
CRT, can make the
side branch access
easier, see text)
Higher risk for stent
thrombosis and
restenosis Requires a
large at least 7 Fr
sheath size unless the
reverse crush or the
sleeve technique is
used
B2V lesions BS
lesions (lesions
with small
proximal healthy
segments making
them not suitable
for the KST)
BT lesions have
shown worse long-
term outcome with
this technique
Cullotte
stent
technique
This technique can
be used as bail out
technique if the
side and main
branches have
similar sizeVery
easy for side
branch stent
positioning once
the second stent
crosses the side
branch
Long-term results are
not well studiedCan
not be easily
performed if the side
branch is much
smaller than main
branchMany stent
struts in the main
branch may increase
the risk of subacute or
late stent thrombosis
Rewiring the main
branch can be
difficultAfter main
branch stenting, side
branch could be
difficult to rewire in
BT lesions
All B2V
lesionsBoth
branches are
similar in size
BS lesion
If both branches are
markedly different in
size BT lesions pose
the risk for side
branch rewiring and
stent crossing failure

B2: Both ostia are significantly diseased; B2T: Lesions with ostial disease and steep angle; BS:
Lesions with small proximal healthy segments making them not suitable for KST; BT: Steep
angulation; B2V: Both ostia are diseased with shallow angulation; KST: Kissing stent technique.
Other Technical Aspects of Bifurcation Intervention
Wiring Technique
It is very useful to maintain side branch access during PCI of bifurcation lesions. In the KST,
wire access to both branches is maintained at all times. Therefore, this technique poses the
lowest risk of side branch occlusion. All other techniques require removing the side branch wire
at some point during the course of intervention. Some interventionalists advocate keeping and
jailing the side branch wire throughout the procedure after main branch stenting in order to have
a road map to the side branch for rewiring. This could be extremely helpful in the case of side
branch occlusion after main branch stenting. On the other hand, there is a theoretical risk and
concern of inability to remove the jailed wire at the end of the procedure. However, this risk
appears to be small.
[38]
Many interventionalists remain uncomfortable with this approach. There
are no data in the literature to systematically evaluate and compare the jailed wire technique
versus removing the side branch wire before the main branch stenting. There is currently no
consensus about these two wiring approaches.
Final Kissing Ballooning
In order to optimize stent geometry in the main and side branches, a final kissing ballooning is
recommended in procedures that require additional side branich intervention. This
recommendation is based on many trials indicating improvement in the long-term outcome using
this technque.
[11]
The superiority of final kissing balloon angioplasty has been clearly
demonstrated in many trials using the CRT.
[28,35,36,44]
However, there is no randomized trial or
consensus statements to evaluate balloon sizing or balloon overlap for the kissing balloon
angioplasty. It is recommended to avoid significant stretching and upsizing of two balloons
during final kissing inflation in order to prevent trauma or perforation to the vessel walls.
Selection of balloon diameter should be made based on the distal diameter of each branch. Short
balloons should be used in order to avoid inflation outside the stent preventing edge dissection.
In the side branch, the use of short balloons could reduce distal vessel injury. Inflation pressure
should be guided by the technique. Sequential high-pressure balloon inflation before final kissing
balloon angioplasty may be necessary for optimal stent expansion. For example, after initial
deployment of two stents using KST, each stent balloon should be inflated to high pressure
sequentially before final simultaneous low-pressure kissing balloon angioplasty. As mentioned
earlier, coronary bifurcation intervention is associated with increased procedural risk. The
majority of acute complications are related to the side branch occlusion. The use of glycoprotein
IIb/IIIa inhibitors has been shown to decrease the risk of side branch closure in the Evaluation of
Platelet IIb/IIIa Inhibitor for Stenting (EPISTENT) trial using abciximab.
[45]
Therefore, the use
of glycoprotein IIbIIIa inhibitors is encouraged during coronary bifurcation interventions.
Special Stents Designed for Bifurcational Intervention
Many new bifurcation specific stents have been developed for safer use in coronary bifurcation
lesions. None of these stents are approved in the USA. Some of these stents are combined with
delivery systems that allow permanent access to the side branch. This approach can potentially
decrease procedural time and reduce the risk of the side branch occlusion. Bifurcated stents, such
as BRAD XT Carina (Figure 6), new intravascular rigid flex-Side Royal and AVE stents, have
been studied in a small number of patients.
[46]
In France, the DBS stent (Cordis) has been
implanted in 34 patients with a procedural success rate of 94% and stent restenosis rate of
33%.
[38]
Recently, several manufacturers have designed stents with delivery systems that allow
simultaneous stenting of the main and side branch ostium with a single stent. Main branch stent
can be deployed while maintaining access to the side branch with a bifurcated balloon. However,
these stents are not drug eluting and have high risk for stent restenosis. The earliest trial using
SLK-View stents (Advanced Stent Technologies, Inc. CA, USA) has been promising in eight
patients.
[47]
The SLK-view stent is a scaffolding device incorporating a side aperture that allows
access to the side branch of a bifurcation lesion after stenting of the main branch. Ease of
deliverability of this stent with 100% successful side branch access was confirmed in a larger
trial of 81 patients with an acceptable 6-month restenosis rate of 37.7%.
[48]
A new bifurcation-
specific Multi-Link Frontier stent (Guidant Corp.) has been successfully tested in a small trial of
105 patients.
[49]
This stent allows stenting of the main branch and the side branch ostium
simultaneously with a single stent. The success rate was lower in comparison to SLK-view stent
at 91% with a higher overall restenosis rate of 44.8%. Successful delivery of this stent using
radial approach has been reported in a small number of patients.
[50]
A similar stent-delivery
system, the AST petal-side access bifurcation stent (Advanced Stent Technology, CA, USA), has
been tested in animal models
[51]
and successfully implanted in a small trial of 13 patients.
[52]
A
high stent restenosis rate using these bifurcation specific stents has lead to the design of
dedicated bifurcation-specific DES. Devax AXXESS DES is an example of this new design.
This stent is a nitinol-based stent with a biodegradable polymer and a drug called Biolimus A 9.
Preliminary data on this stent from AXXESS plus a trial in 139 patients that was presented at
meetings is encouraging in reducing in-stent restenosis rate. However, at this time, long-term
safety data and larger randomized trials are needed before these stents can be approved for
routine use.

Figure 6.

An example of bifurcated XT stent.
Summary & Conclusions
Coronary artery bifurcation lesion intervention is challenging with higher risk for stent
thrombosis, stent restenosis and procedural complications. With the availability of DES,
coronary artery bifurcation interventions are increasing in numbers. A therapeutic algorithm
based on the newly proposed simplified classification is presented in this manuscript with the
aim of guiding the interventional cardiologist to a better selection of a particular technique for a
given bifurcation lesion. In general, one stent should be used if possible. However, bifurcation
lesions involving both ostia (B2 lesions) are at high risk for side branch closure. Therefore, other
complex techniques such as two-stent techniques may be the preferred approach in this setting in
order to reduce the rate of acute complications. There is no consensus statement about using
specific techniques for a given bifurcation lesions requiring two stents. The choice of two-stent
technique remains at the discretion of interventional cardiologist depending on expertise and
lesion anatomy.
Expert Commentary
Coronary intervention in the setting of bifurcation lesions is challenging. There are no clear
consensus statements with regards to different techniques in the treatment of coronary
bifurcation lesions. With a recent introduction of a simplified classification of coronary
bifurcation lesions and techniques,
[17]
communication and the choice of technique for a given
bifurcation can be made easier. There is no long-term advantage in using two stents versus one
stent in a bifurcation lesion. Therefore, bifurcation lesions without side branch involvement
should be treated by using one stent. The choice of different bifurcation techniques in lesions
with the involvement of both ostia (B2) remains to the discretion and expertise of the treating
interventionalist. Lesions with large proximal healthy segments are suitable for the KST. Large
randomized trials using different techniques for different types of bifurcation lesions are required
in order to study the advantage of one technique over any others for a given bifurcation lesion.
Future DES designed for coronary bifurcation lesions may improve the procedural outcome.
Five-year View
There are many recent advances in the design of new DES and in the design of bifurcation
specific stents that can dramatically change our approach to the bifurcation stenting. Stents with
side branch access can significantly reduce the risk of side branch occlusion. Newly designed
bifurcation-specific DES will soon be available with the potential to reduce stent restenosis rate.
New steerable wires, lower profile balloons and stents are in development for better side branch
access. Based on rapid advancement in stent technology, we will have better treatment options
for coronary artery bifurcation intervention in the next 5 years.
Sidebar: Key Issues
The new simplified and clinically relevant coronary bifurcation lesion classification and
technique will improve communication between clinicians and researchers.


Intervention in the setting of coronary bifurcation lesions remains challenging and is
associated with increased adverse outcomes.


Whenever possible, one stent should be used for the treatment of coronary artery
bifurcation lesions (lesions without the side branch involvement such as 1m lesions are
best suited to one stent technique).


Coronary bifurcation lesions with a large proximal segment and involvement of both
ostia are best suitable for the kissing stent technique.


Coronary bifurcation lesions with a small proximal segment and involvement of both
ostia are best suitable for the T stent, the crush stent or the cullotte stent techniques.


Future drug-eluting bifurcation-specific stents for the treatment of coronary artery
bifurcation lesions will hopefully improve the procedural outcome.
References
1. Al Suwaidi J, Berger PB, Rihal CS et al. Immediate and long-term outcome of
intracoronary stent implantation for true bifurcation lesions. J. Am. Coll. Cardiol. 35(4),
929-936 (2000).
2. Cervinka P, Stasek J, Pleskot M, Maly J. Treatment of coronary bifurcation lesions by
stent implantation only in parent vessel and angioplasty in sidebranch: immediate and
long-term outcome. J. Invasive Cardiol. 14(12), 735-740 (2002).
3. Assali AR, Teplitsky I, Hasdai D et al. Coronary bifurcation lesions: to stent one branch
or both? J. Invasive Cardiol. 16(9), 447-450 (2004).
4. Ryan TJ, Faxon DP, Gunnar RM et al. Guidelines for percutaneous transluminal
coronary angioplasty. A report of the American College of Cardiology/American Heart
Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular
Procedures (Subcommittee on Percutaneous Transluminal Coronary Angioplasty).
Circulation 78(2), 486-502 (1988).
5. Colombo A, Moses JW, Morice MC et al. Randomized study to evaluate sirolimus-
eluting stents implanted at coronary bifurcation lesions. Circulation 109(10), 1244-1249
(2004).
6. Pan M, de Lezo JS, Medina A et al. Rapamycin-eluting stents for the treatment of
bifurcated coronary lesions: a randomized comparison of a simple versus complex
strategy. Am. Heart J. 148(5), 857-864 (2004).
7. Sharma SK, Choudhury A, Lee J et al. Simultaneous kissing stents (SKS) technique for
treating bifurcation lesions in medium-to-large size coronary arteries. Am. J. Cardiol. 94
(7), 913-917 (2004).
8. Vigna C, Biondi-Zoccai G, Amico CM et al. Provisional T-drug-eluting stenting
technique for the treatment of bifurcation lesions: clinical, myocardial scintigraphy and
(late) coronary angiographic results. J. Invasive Cardiol. 19(3), 92-97 (2007).
9. Jim MH, Ho HH, Chan AO, Chow WH. Stenting of coronary bifurcation lesions by using
modified crush technique with double kissing balloon inflation (sleeve technique):
immediate procedure result and short-term clinical outcomes. Catheter Cardiovasc.
Interv. (2007).
10. Iakovou I, Schmidt T, Bonizzoni E et al. Incidence, predictors, and outcome of
thrombosis after successful implantation of drug-eluting stents. JAMA 293(17), 2126-
2130 (2005).
11. Lefevre T, Louvard Y, Morice MC et al. Stenting of bifurcation lesions: classification,
treatments, and results. Catheter Cardiovasc. Interv. 49(3), 274-283 (2000).
12. Movahed MR, Vu J, Ahsan C. Simultaneous subacute stent thrombosis of two drug-
eluting stents in the left anterior descending and the circumflex coronary arteries. Case
report and review of the literature. J. Invasive Cardiol. 18(7), E198-E202 (2006).
13. Ormiston JA, Currie E, Webster MW et al. Drug-eluting stents for coronary bifurcations:
insights into the crush technique. Catheter Cardiovasc. Interv. 63(3), 332-336 (2004).
14. Popma JJ, Leon MB, EJ T. Strategic approaches in coronary intervention. In: Atlas of
Interventional Cardiology. WB Saunders Company, PA, USA (1994).
15. Spokojny AM, Sanborn TM. The bifurcation lesion. In: Strategic Approaches in
Coronary Intervention. Ellis SG, Holmes DR (Eds). Williams and Wilkins, MD, USA,
288 (1996).
16. Safian RD. Bifurcation lesions. In: The Manual of Interventional Cardiology. Safian RD,
Freed M (Eds). Physician's Press,MI, USA, 222 (2001).
17. Movahed MR, Stinis CT. A new proposed simplified classification of coronary artery
bifurcation lesions and bifurcation interventional techniques. J. Invasive Cardiol. 18(5),
199-204 (2006).
18. Medina A, Suarez de Lezo J, Pan M. A new classification of coronary bifurcation lesions.
Rev. Esp. Cardiol. 59(2), 183 (2006).
19. Melikian N, Airoldi F, Di Mario C. Coronary bifurcation stenting. Current techniques,
outcome and possible future developments. Minerva Cardioangiol. 52(5), 365-378
(2004).
20. Louvard Y, Thomas M, Dzavik V et al. Classification of coronary artery bifurcation
lesions and treatments: tme for a consensus! Catheter Cardiovasc. Interv. (2007) (Epub
ahead of print).
21. Baim DS, Cutlip DE, O'Shaughnessy CD et al. Final results of a randomized trial
comparing the NIR stent to the Palmaz-Schatz stent for narrowings in native coronary
arteries. Am. J. Cardiol. 87(2), 152-156 (2001).
22. Aliabadi D, Tilli FV, Bowers TR et al. Incidence and angiographic predictors of side
branch occlusion following high-pressure intracoronary stenting. Am. J. Cardiol. 80(8),
994-997 (1997).
23. Dzavik V, Kharbanda R, Ivanov J et al. Predictors of long-term outcome after crush
stenting of coronary bifurcation lesions: importance of the bifurcation angle. Am. Heart J.
152(4), 762-769 (2006).
24. Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morphologic determinants of
coronary angioplasty success and complications: current experience. J. Am. Coll.
Cardiol. 25(4), 855-865 (1995).
25. Melikian N, Di Mario C. Treatment of bifurcation coronary lesions: a review of current
techniques and outcome. J. Interv. Cardiol. 16(6), 507-513 (2003).
26. Lefevre T, Louvard Y, Morice MC, Loubeyre C, Piechaud JF, Dumas P. Stenting of
bifurcation lesions: a rational approach. J. Interv. Cardiol. 14(6), 573-585 (2001).
27. Colombo A, Stankovic G, Orlic D et al. Modified T-stenting technique with crushing for
bifurcation lesions: immediate results and 30-day outcome. Catheter Cardiovasc. Interv.
60(2), 145-151 (2003).
28. Ge L, Iakovou I, Cosgrave J et al. Treatment bifurcation lesions with two stents: crush
versus T stenting - one year angiographic and clinical follow-up. Heart (2005).
29. Saucedo JF KE, Talley JD et al. Long term outcome of patients with true bifurcation
coronary lesions undergoing new devices angioplasty. Insights from the New Approaches
to coronary Intervantions Registry (abstr) Circulation (Suppl. I) (1998).
30. Yamashita T, Nishida T, Adamian MG et al. Bifurcation lesions: two stents versus one
stent - immediate and follow-up results. J. Am. Coll. Cardiol. 35(5), 1145-1151 (2000).
31. Kang S, Yang YJ, Xu B et al. Comparison of drug eluting stents with bare metal stents in
daily practice for bifurcation lesions in Chinese patients. Chin. Med. J. 119(14), 1157-
1164 (2006).
32. Thuesen L, Kelbaek H, Klovgaard L et al. Comparison of sirolimus-eluting and bare
metal stents in coronary bifurcation lesions: subgroup analysis of the Stenting Coronary
Arteries in Non-Stress/Benestent Disease Trial (SCANDSTENT). Am. Heart J. 152(6),
1140-1145 (2006).
33. Kim YH, Park DW, Suh IW et al. Long-term outcome of simultaneous kissing stenting
technique with sirolimus-eluting stent for large bifurcation coronary lesions. Catheter
Cardiovasc. Interv. 70(6), 840-846 (2007).
34. 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
114(18), 1955-1961 (2006).
35. Ge L, Airoldi F, Iakovou I et al. Clinical and angiographic outcome after implantation of
drug-eluting stents in bifurcation lesions with the crush stent technique: importance of
final kissing balloon post-dilation. J. Am. Coll. Cardiol. 46(4), 613-620 (2005).
36. Hoye A, Iakovou I, Ge L et al. Long-term outcomes after stenting of bifurcation lesions
with the 'crush' technique: predictors of an adverse outcome. J. Am. Coll. Cardiol. 47(10),
1949-1958 (2006).
37. Gobeil F, Lefevre T, Guyon P et al. Stenting of bifurcation lesions using the Bestent: a
prospective dual-center study. Catheter Cardiovasc. Interv. 55(4), 427-433 (2002).
38. Louvard Y, Lefevre T, Morice MC. Percutaneous coronary intervention for bifurcation
coronary disease. Heart 90(6), 713-722 (2004).
39. Ormiston JA, Webster MW, El Jack S et al. Drug-eluting stents for coronary bifurcations:
Bench testing of provisional side-branch strategies. Catheter Cardiovasc. Interv. 67(1),
49-55 (2006).
40. Jim MH, Ho HH, Miu R, Chow WH. Modified crush technique with double kissing
balloon inflation (sleeve technique): a novel technique for coronary bifurcation lesions.
Catheter Cardiovasc. Interv. 67(3), 403-409 (2006).
41. Chevalier B, Glatt B, Royer T, Guyon P. Placement of coronary stents in bifurcation
lesions by the 'culotte' technique. Am. J. Cardiol. 82(8), 943-949 (1998).
42. Hoye A, van Mieghem CA, Ong AT et al. Percutaneous therapy of bifurcation lesions
with drug-eluting stent implantation: the Culotte technique revisited. Int. J. Cardiovasc.
Intervent. 7(1), 36-40 (2005).
43. Kaplan S, Barlis P, Dimopoulos K et al. Culotte versus T-stenting in bifurcation lesions:
immediate clinical and angiographic results and midterm clinical follow-up. Am. Heart J.
154(2), 336-343 (2007).
44. Colombo A. Bifurcation lesions. Ital. Heart J. 6(6), 475-488 (2005).
45. Marso SP, Lincoff AM, Ellis SG et al. Optimizing the percutaneous interventional
outcomes for patients with diabetes mellitus: results of the EPISTENT (Evaluation of
platelet IIb/IIIa inhibitor for stenting trial) diabetic substudy. Circulation 100(25), 2477-
2484 (1999).
46. Cervinka P, Foley DP, Sabate M et al. Coronary bifurcation stenting using dedicated
bifurcation stents. Catheter Cardiovasc. Interv. 49(1), 105-111 (2000).
47. Toutouzas K, Stankovic G, Takagi T et al. A new dedicated stent and delivery system for
the treatment of bifurcation lesions: preliminary experience. Catheter Cardiovasc. Interv.
58(1), 34-42 (2003).
48. Ikeno F, Kim YH, Luna J et al. Acute and long-term outcomes of the novel side access
(SLK-View) stent for bifurcation coronary lesions: a multicenter nonrandomized
feasibility study. Catheter Cardiovasc. Interv. 67(2), 198-206 (2006).
49. Lefevre T, Ormiston J, Guagliumi G et al. The Frontier stent registry: safety and
feasibility of a novel dedicated stent for the treatment of bifurcation coronary artery
lesions. J. Am. Coll. Cardiol. 46(4), 592-598 (2005).
50. Aziz S, Morris JL. Transradial treatment of bifurcation coronary disease using the Multi-
Link Frontier bifurcation stent system. J. Invasive Cardiol. 17(10), E1-E3 (2005).
51. Ikeno F, Buchbinder M, Yeung AC. Novel stent and delivery systems for the treatment of
bifurcation lesions: porcine coronary artery model. Cardiovasc. Revasc. Med. 8(1), 38-42
(2007).
52. Ormiston J, Webster M, El-Jack S, McNab D, Plaumann SS. The AST petal dedicated
bifurcation stent: first-in-human experience. Catheter Cardiovasc. Interv. 70(3), 335-340
(2007).

Acknowledgments
I would like to thank Dr Mehrnoosh Hashemzadeh for her support and editing of this manuscript.
Reprint Address
Mohammad Reza Movahed, Associate Professor of Medicine; Director of Coronary Care Unit;
and Medical Director of Heart Transplant Program, Section of Cardiology, Department of
Medicine, University of Arizona Sarver Heart Center; and the Southern Arizona VA Health Care
System, 1501 North Campbell Avenue, Tucson, AZ 85724. E-mail:
rmovahed@email.arizona.edu .
Expert Rev Cardiovasc Ther. 2008;6(2):261-274. 2008 Expert Reviews Ltd.