Bifurcation: Anatomy, Classification,etc…. Bernard Chevalier, Philippe Guyon, Jean-Louis Sablayrolles, Thierry Royer Bernard Glatt CCN Saint-Denis, France
Who is making the bifurcation lesion? The patient? The doctor? The company?
2002 CCN procedures
QCA and bifurcation location Main Branch reference diameter Tt : 3,08±0,46 mm nTt : 2,87±0,43 mm Side Branch reference diameter Tt : 2,38±0,78 mm nTt : 1,99±0,41 mm
c p d p < c > d From 48°+-15° to 66°+-18° or >80% are 40°< <70°
The disease location Classification
Many types of lesion… Type A: Prebranch stenosis not involving the ostium of the side branch. Type B: Postbranch stenosis of the parent vessel not involving the origin of the side branch. Type C: Stenosis encompassing the side branch but not involving the ostium. Type D: Stenosis involving the parent vessel and ostium of the side branch. Type E: Stenosis involving the ostium of the side branch. Type F: Stenosis directly involving the parent vessel and ostium of the side branch.
Type 2 Type 1 Type 3 Type 4 The most well known Massy‘s classification
Limitations Inter/intra observer variability Predictability
Type 1 Type 1 Type 3 Type 2 Type 2 Type 3 Type 4 Type 4 b Type 4 a Type 4 Type 4 b Type 4 a Three prospective french registries with central analysis (>1500 pts) 1 20 to 53 % 2 10 to 21 % 3 8 to 20 % 4 8 to 18 % 4a 10 to 19 % 4b 4 to 20%
Protection wire NS 76% % 24% Total R. Koning et al.
T Stenting p = 0,0004 % 76% 24% Total R. Koning et al.
Final Kissing p = 0,026 % 54% 46% Total R. Koning et al.
TLR p = 0,07 87% % 13% Total R. Koning et al.
To summarize as a consensus in real world registries • A bifurcation lesion involves • A side branch >/= 2 mm • With angulation between 40° to 70° • And at least two of the three parts • But you can expand the field as much as you want
Is WYSWYG? What You See What You Get
carina carina Courtesy of R Virmani
Centre Cardiologique du Nord - Saint Denis - France volume plaque vs stenosis
Centre Cardiologique du Nord - Saint Denis - France LAD Diag. Diag. LAD
Centre Cardiologique du Nord - Saint Denis - France LAD I LAD LAD II Diag. LAD II LAD II LAD II Diag.
Effect of flow on elution Edelman et al Circulation
Take home message • Disease is more diffuse but carena is less diseased than visual estimate • Classification usefulness is somewhere questionable • Is the role of angulation to predict oucome underestimated ? • Perfect anatomic result does not warranty flow normalization and could affect biological result of PCI