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  1. Bifurcation: Anatomy, Classification,etc…. Bernard Chevalier, Philippe Guyon, Jean-Louis Sablayrolles, Thierry Royer Bernard Glatt CCN Saint-Denis, France

  2. Is it so complex..?

  3. Who is making the bifurcation lesion? The patient? The doctor? The company?

  4. The side branch size

  5. 2002 CCN procedures

  6. 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

  7. The angulation

  8. c p d p < c > d From 48°+-15° to 66°+-18° or >80% are 40°< <70°

  9. The disease location Classification

  10. Some are really unknown

  11. 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.

  12. Type 2 Type 1 Type 3 Type 4 The most well known Massy‘s classification

  13. Limitations Inter/intra observer variability Predictability

  14. 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%

  15. Protection wire NS 76% % 24% Total R. Koning et al.

  16. T Stenting p = 0,0004 % 76% 24% Total R. Koning et al.

  17. Final Kissing p = 0,026 % 54% 46% Total R. Koning et al.

  18. TLR p = 0,07 87% % 13% Total R. Koning et al.

  19. 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

  20. Is WYSWYG? What You See What You Get

  21. Anatomy may be different

  22. carina carina Courtesy of R Virmani

  23. Despite new tools

  24. Centre Cardiologique du Nord - Saint Denis - France

  25. Centre Cardiologique du Nord - Saint Denis - France

  26. Centre Cardiologique du Nord - Saint Denis - France

  27. Centre Cardiologique du Nord - Saint Denis - France volume plaque vs stenosis

  28. Centre Cardiologique du Nord - Saint Denis - France Diag. LAD

  29. Centre Cardiologique du Nord - Saint Denis - France LAD Diag. Diag. LAD

  30. Centre Cardiologique du Nord - Saint Denis - France LAD Diag.

  31. Centre Cardiologique du Nord - Saint Denis - France LAD I LAD LAD II Diag. LAD II LAD II LAD II Diag.

  32. Flow may be different

  33. Richter et al. JCI 2004

  34. Effect of flow on elution Edelman et al Circulation

  35. 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