New Approaches to Ostial and Bifurcation Lesions ANGELA HOYE, M.B., Ch.B., M.R.C.P., and WIM J. VAN DER GIESSEN, M.D., Ph.D. From the Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Percutaneous coronary intervention of bifurcation lesions is associated with lower procedural success rates, and an increased subsequent rate of major adverse cardiac events and restenosis. Currently, an array of stenting possibilities suggests a rational approach to treat various bifurcation lesions with appropriate techniques. This is howeever seldom the case. The main problems of treating bifurcation lesions remain plaque shift leading to (threatened) side branch occlusion, and either too much or insufficient side branch ostial stent coverage predisposing to impaired side branch access or restenosis, respectively. This paper reviews the available technologies and their relative merits. (J Interven Cardiol 2004;17:397–403) Introduction Percutaneous coronary intervention of bifurcation lesions is associated with lower procedural success rates, 1 an increased subsequent rate of major adverse cardiac events (MACE), and restenosis compared with nonbifurcated lesions. Various techniques and strate- gies have been applied in attempt to improve out- comes including double-wire technique, kissing bal- loon pre- and postdilatation, stent implantation in the main branch or both main and side branch by T-, Y-, culotte-, trousers-, skirt-, kissing-, crush-, or touching- stents technique. 2–5 This array of stenting possibilities suggests a rational approach to treat various bifurca- tion lesions with appropriate techniques. This is, how- ever, seldom the case. Usually, new inventions are ap- plied to most lesions in an attempt to treat bifurcations in general, and the most effective strategy for differ- ent anatomical variations is currently unknown. The present article attempts to familiarize the reader with the successive technical advances available to the inter- ventional community and discuss their successes and failures. Address for reprints: Wim J. van der Giessen, M.D., Ph.D., Thoraxcenter, Bd 412, Erasmus MC, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands. Fax: +31 10 4635341; e-mail: w.j.vandergiessen@erasmusmc.nl Coronary Bifurcation Anatomy Lesions at a coronary bifurcation may involve ei- ther the main vessel alone, and/or the ostium of a side branch. A classical scheme to categorize coronary bi- furcation lesions is the Duke classification (Fig. 1). However, even when only one of the two branches is significantly stenosed at baseline, plaque shift or the “snow-plough effect” can pose a problem. Following balloon dilatation or stent implantation, shift of athero- matous material may occur proximally, longitudinally, and/or circumferentially. 6 When treating the main ves- sel, such shift of material can lead to side-branch oc- clusion, particularly when the ostium of the side branch is itself diseased, the side branch is of relatively small diameter, or in the presence of thrombus in acute coro- nary syndromes. The clinical consequences of loss of the side branch are dependent on the vessel size, and are not usually serious with short-lived chest pain and only a modest rise in cardiac enzymes. In addition, follow-up evaluation frequently demonstrates restoration of pa- tency. 7 However, following PCI, a more than three-fold rise in cardiac enzymes above the upper limit of normal has been shown to have prognostic implications. 8 In the NIRVANA study of the NIR stent implanted across a side branch, side-branch occlusion occurred in 4.7% patients. Of these, occlusion was associated with acute myocardial infarction (creatine–kinase–MB ≥ 5 × nor- mal) in 40%, including Q wave infarction in 7%. 9 Vol. 17, No. 6, 2004 Journal of Interventional Cardiology 397