Cardiology

Bifurcation Lesions

General description of procedure, equipment, technique

General

Coronary bifurcation lesions comprise approximately 20% of percutaneous coronary interventions (PCI). However, procedural and clinical outcomes associated with coronary bifurcation treatment are suboptimal due to the complexity of anatomy and the dynamic changes that occur during PCI.

Definition and Classification

A coronary bifurcation lesion occurs at or near a division of a major coronary artery. Characterizing bifurcation lesions involves assessing the lesion morphology in three important anatomic segments: (1) proximal main branch (MB); (2) distal MB; and (3) side branch (SB).

The carina is the inflection point at which the proximal MB bifurcates into the distal MB and SB. The European Bifurcation Club defines a bifurcation lesion as a significant stenosis (i.e., >50%) in a coronary artery adjacent to and/or involving the origin of an SB that is clinically significant.

Numerous classification schemes have been proposed to characterize coronary bifurcation lesions. The simplest and most widely used is the Medina classification. The Medina classification assesses plaque burden based on the presence ("1") or absence ("0") of stenosis in the proximal MB, distal MB, and SB (Figure 1).

Figure 1:

Medina Classification for Coronary Bifurcation Lesions. Reproduced with permission from Latib et al. JACC Cardiovasc Interv 2008;1:218-26.

For example, a lesion involving the proximal and distal MB without any SB involvement is classified as Medina "1,1,0". One distinction is to distinguish "true" or "complex" lesions from "nontrue" or "pseudo-" bifurcation lesions.

A "true" bifurcation lesion involves significant (>50%) stenosis in both the MB and the SB (i.e., Medina 1,1,1; 1,0,1; or 0,1,1), whereas all other lesion types would be classified as "nontrue." It is important to recognize that angiography may be limited in terms of its ability to appropriately classify bifurcation lesions, and adjunctive modalities such as intravascular ultrasound (IVUS) may be necessary to determine a lesion's true classification.

Indications and patient selection

The indications for PCI of coronary bifurcation lesions follow the same general principles for revascularization of nonbifurcation lesions. PCI is performed to reduce or eliminate symptoms secondary to stable or unstable coronary artery disease (CAD) or ischemic cardiomyopathy.

PCI vs CABG

No randomized studies have compared PCI with coronary artery bypass grafting (CABG) in a bifurcation-only patient population. The decision to pursue PCI or CABG should be based on the patient's preference and the complexity and severity of CAD. The SYNTAX score can be used to determine which patients may benefit from CABG over PCI.

Contraindications

Contraindications to PCI of bifurcation lesions would be any patient unwilling to undergo PCI, coronary anatomy that is not amenable to PCI (e.g., small caliber with diffuse disease), intermediate lesions in the absence of symptoms, and/or objective evidence of ischemia.

Details of how the procedure is performed

General approach

PCI of bifurcation lesions is technically challenging. Each lesion can vary incredibly based on a number of anatomic characteristics, including:

  1. Bifurcation site

  2. Plaque location

  3. Plaque burden and morphology

  4. Bifurcation angle between the MB and SB

  5. Vessel diameter

To complicate matters, bifurcation anatomy is dynamic and changes during PCI due to plaque or carina shift, bifurcation angle change, vessel spasm, and/or coronary dissection. The most important steps in PCI of coronary bifurcation are selecting an appropriate strategy based on the anatomic characteristics of the lesion and how to optimize the results of the intervention.

Treatment of bifurcation lesions with bare metal stents (BMS) has yielded suboptimal results. Thus, drug-eluting stents (DES) should be used for the treatment of bifurcation lesions.

One-Stent Versus Two-Stent Approach

An important clinical decision is to determine a priori if a lesion will be approached using a one-stent (i.e., provisional) or two-stent approach. In a one-stent approach, the MB is stented and the SB is stented provisionally only if clinical symptoms and/or angiographic (e.g., < TIMI 3 flow) or adjunctive features (e.g., FFR <0.80) warrant intervention. Whereas, a two-stent approach involves elective stenting of both the MB and SB.

Randomized and observational data suggest that provisional SB stenting compared with elective SB stenting is the preferred approach due to equivalent clinical outcomes in both approaches and shorter procedural time and less contrast with the provisional approach. However, the generalizability of the clinical data to all bifurcation lesions is not appropriate.

The heterogeneity and complexity of bifurcation lesions may warrant a one-stent or two-stent approach. No two bifurcations are alike, thus the therapeutic strategy should be determined in a lesion-specific manner. It is also important to remember that SB stenting is required in up to 30% of non–left main and 50% of left-main bifurcation lesions.

The decision to perform elective SB stenting as part of a two-stent approach should be determined based on certain lesion characteristics:

True bifurcation lesion

Typically, the two-stent approach has been reserved for lesions that have significant stenosis in both the MB and SB (i.e., Medina 1,1,1; 1,0,1; or 0,1,1), since the presence of two stents (versus just one stent in the bifurcation lesion) increases the risk of stent thrombosis. The SB length (see below) will help to determine if a two-stent approach is needed.

Bifurcation angle

The bifurcation angle is determined by the internal angle between the MB and SB. One-stent approaches are favored for bifurcation angles that are Y-shaped (<70 degrees), whereas the two-stent approach should be considered for T-shaped (70 to 90 degrees) or reverse-shaped (>90 degrees).

Higher bifurcation angles are associated with increased rates of adverse events and SB closure. Importantly, the bifurcation angle should be assessed both before and after MB stenting, as the angle can change after treatment necessitating SB stenting.

Side Branch Lesion Length

Isolated ostial or short SB lesions are less likely to occlude compared with long SB lesions. In the randomized trials comparing one-stent vs. two-stent techniques, the majority of SB lesions were short (<3 to 5 mm). The two-stent technique is generally preferred for SB lesions ≥10 mm, whereas provisional SB stenting is typically reserved for focal lesions (≤5 mm). If a SB lesion is between 5 and 10 mm, clinical judgment should be used to select the most appropriate stenting strategy.

Guide Catheter Selection

Vascular access can be performed through either transfemoral or transradial access and should be based on operator preference, yet transfemoral access is preferred given the catheter size limitations (i.e., >6 Fr) that one may encounter with transradial access. If a two-stent approach is undertaken or uncertainty exists as to the stenting technique, then a 7 Fr or 8 Fr guide catheter is preferred.

When using a 6 Fr guide catheter, it is important to remember that two stents can only be deployed sequentially. Thus a 6 Fr guide catheter should be used for lesions with a low-likelihood of SB stenting.

One-Stent Approach with Provisional Side Branch Stenting

The most common steps used for the one-stent approach are to:

1. Wire both the MB and SB with coronary guidewires (Note: a single MB wire should only be considered in a lesion confined to the MB where IVUS has confirmed that the lesion is on the contralateral wall from the SB)

2. Predilate the MB.

3. MB stenting sized to the distal MB reference diameter with jailing of the SB wire. (Avoid using SB wires with hydrophilic or polymer tip coating due to the risk of wire rupture.)

4. Assessment of the angiographic result in the MB and SB.

If the result is sufficient, remove the jailed SB wire gently and the case is finished. However, if the SB has < TIMI 3 flow and/or the patient has clinical symptoms, then with the SB jailed wire in place:

5. Attempt to rewire the SB through the distal MB stent strut to enhance SB scaffolding. (If successful, remove the jailed SB wire.)

6. After the SB is rewired, dilate the SB.

7. Assessment of the angiographic result in the MB and SB.

8. If the SB result is suboptimal, perform final kissing inflation (FKI) or preferably sequential side-main-side (SMS) balloon dilatation on the SB and MB with a noncompliant balloon or assess the hemodynamic significance of the SB with fractional flow reserve (FFR).

(Note: FKI or SMS should be performed to correct any MB stent deformation due to SB dilatation. FKI or SMS improve MB and SB stent apposition, SB scaffolding, and allow for easier SB access.)

9. SB stenting if the SB in ≥2.5 mm and has ≥75% stenosis, FFR ≤ 0.80, TIMI (thrombolysis in myocardial infarction) flow grade < 3, or plaque shift into the SB.

10. After SB stenting, repeat FKI or SMS.

Ways to overcome difficult SB access

Prior to treatment:

1. Use of a different wire.

2. Shape the tip curvature to the bifurcation angle (single bend for Y-shaped; double bend for T shaped).

3. Reverse wire technique for extreme bifurcations angles.

4. Use of a SuperCross microcatheter (Vascular Solutions, Minneapolis, MN) or a Venture Wire Control catheter (St. Jude Medical, Maple Grove, MN).

5. Jailed-balloon technique (JBT).

Note: The JBT (Figure 2) is a modified one-stent technique that involves jailing a long angiographically-sized SB balloon during MB stent deployment. If the SB is compromised, the jailed SB balloon is inflated and then removed. The MB stent balloon is inflated to correct for any MB stent deformation and then angiographic assessment of the result to determine if provisional SB stenting is required. The JBT is designed to maximize SB patency and access.

Figure 2:

Jailed-Balloon Technique. Reproduced with permission from Singh JS et al. J Interv Cardiol 2012;25:289-96.

After MB stent deployment:

1. Use of a different wire(s) such as Hi-Torque Whisper wire (Abbott Vascular, Abbott Park, IL), PT2 wire (Boston Scientific, Natick, MA), or Hi-Torque Pilot 50 and 150 wires (Abbott Vascular, Abbott Park, IL).

2. Change the tip curvature.

3. Proximal optimization technique (POT): using a short balloon to correct any proximal MB stent deformation that may be preventing SB access.

4. Use of a SuperCross microcatheter or a Venture Wire Control catheter.

5. Rescue jailed-balloon using the jailed SB wire to open the SB ostium to facilitate further attempts at recrossing.

6. Use of a second buddy wire, GuideLiner catheter (Vascular Solutions), or a low-profile 1.25 mm balloon can be helpful to recross SB through the MB stent struts.

Provisional SB stenting techniques

If SB balloon angioplasty yields suboptimal results (≥75% stenosis, FFR ≤0.80, TIMI flow grade <3, plaque shift into the SB, or clinical symptoms), then SB stenting is indicated. Regardless of the technique chosen, FKI or SMS should be performed. The following techniques can be used:

A. T-stent technique (also called "simple T")

The technique involves advancing a second stent into the SB and positioning the proximal end at the SB ostium without any stent protrusion into the MB. Invariably, a small gap in stent coverage is created at the SB ostium which may result in uneven drug coverage and a nidus for restenosis.

B. T and protrusion (TAP):

The TAP strategy is similar to a "simple T-stent" with the exception of the proximal SB stent is left extending slightly (1 to 2 mm) into the MB. A balloon is also advanced into the MB.

Both the MB balloon and SB stent balloon are simultaneously inflated and then removed. TAP allows for complete coverage of the SB without gaps. Intravascular ultrasound (IVUS) should be performed to assess for stent deformation and need for additional stenting in the MB or SB.

Other techniques such as the "reverse," "internal crush," or the "provisional culotte" have been described, yet the TAP technique should be considered as the preferred approach in cases of provisional stenting.

Two-Stent Approach

As described, an elective two-stent approach should be considered for "true" bifurcations lesions and the presence of high bifurcation angles (>70 degrees) or long SB lesions (≥ 10 mm). Several techniques have been described for the two-stent approach.

A. Classic T-stent and Modified T-stent Technique

1. Wire and predilate the MB and SB.

2. SB stent is advanced and positioned with (i.e., Modified T) or without (i.e., Classic T) SB protrusion.

3. SB stent is deployed and the SB balloon is removed.

4. Angiographic assessment looking at the SB result and any complications needing additional SB stenting.

5. If SB stent is satisfactory, remove the SB wire.

6. Advance and deploy the MB stent.

7. Rewire the SB through MB stent struts.

8. Postdilatation of the SB with a noncompliant balloon.

9. FKI or SMS with noncompliant balloons.

Both techniques are easy to perform and are ideal for bifurcation angles that are approximately 90 degrees. A drawback of the Classic T-stent is that incomplete stent coverage of the SB ostium can occur, which may result in restenosis. The Modified T-stent technique is limited by excess stent metal in the proximal MB.

B. TAP Technique

This technique is typically used with the provisional one-stent approach; however, it can also be used for the elective two-stent approach. A drawback of this technique as a two-stent approach is that recrossing the SB after MB stent deployment may not be possible and could result in a suboptimal result in the SB of a lesion that an operator intended on using two stents.

C. Culotte Technique (Figure 3)

Figure 3:

Culotte Technique. Reproduced with permission from Topol EJ, Teirstein PS, eds. Textbook of interventional cardiology. 6th ed. Philadelphia, PA: Elsevier Saunders

1. Wire and predilate the MB and SB.

2. In the most angulated branch (typically the SB), advance and deploy a stent with or without jailing the wire in the other branch (typically the MB).

3. Rewire the nonstented branch through the stent struts.

4. Dilate the nonstented branch with a noncompliant balloon.

5. Advance and deploy a stent in the nonstented branch.

6. Rewire the first stented branch through the second stented branch struts.

7. FKI or SMS of both branches.

The culotte technique allows for complete lesion coverage. It should preferably be performed with stent platforms that have an open cell design to allow for recrossing both branches.

A drawback of the technique is that it results in a double layer of stent in the proximal MB, which can limit the maximal achievable diameter. It also is not advisable to use this technique if the vessel diameters are significantly different as this could lead to malapposition in the proximal MB.

The culotte technique is associated with lower rates of periprocedural myocardial infarction (MI) and in-stent restenosis compared with the crush technique.

D. Mini-crush (Figure 4) and Step-crush Techniques

Figure 4:

Mini-crush Technique. Reproduced with permission from Topol EJ, Teirstein PS, eds. Textbook of interventional cardiology. 6th ed. Philadelphia, PA: Elsevier Saunders.

The original crush technique involves advancing a stent into both the MB and SB. The SB stent is deployed first and then crushed during MB stent deployment. The mini-crush technique has replaced the original technique by reducing the amount of overlapping stents in the proximal MB.

1. Wire and predilate the MB and SB.

2. Advance a stent into the SB and then the MB.

3. Pull the SB stent approximately 3 mm into the MB.

4. Deploy the SB stent.

5. Remove the SB stent balloon and then assess the SB angiographically to determine if additional SB stenting is required (If no additional stenting then the SB wire is removed).

6. Deploy the MB stent and remove the MB stent balloon.

7. Rewire the SB through the MB stent struts using the distal SB orifice.

8. Postdilate the SB with a noncompliant balloon.

9. Advance a second balloon into the MB and perform FKI or SMS.

Much like the culotte technique, the mini-crush technique allows for complete stent coverage of the lesion. An advantage over the culotte technique is the need to only recross the SB, instead of both branches using the culotte technique. One disadvantage of the mini-crush technique is that it creates three layers of stent in the proximal MB.

A slight variation of the mini-crush technique is called the "step-crush." This technique is most useful when an elective two-stent approach is needed and only a 6 Fr guiding catheter can be used (e.g., transradial cases). In the step-crush technique, the main difference is that the protruded SB stent is "crushed" with a noncompliant MB balloon.

Following a balloon crush, the MB stent is advanced and then deployed. Some operators will add an additional step using kissing balloon inflation prior to MB stent deployment and is termed the "double kiss step-crush" or "sleeve" technique.

E. V-stent and SKS Techniques

Both techniques employ simultaneous implantation of the MB and SB stents. The only difference between the two techniques is the amount of stent protrusion into the proximal MB. A small amount of protrusion is called the V-stent technique, whereas a significant amount of protrusion (≥ 5 mm) is termed the simultaneous kissing stent (SKS) technique.

1. Wire and predilate the MB and SB.

2. Position and advance the MB and SB stents with minimal (V-stent) or significant (SKS) protrusion into the proximal MB.

3. Simultaneous balloon inflation of the MB and SB stents to 12 atm (some operators may choose sequential inflation)

4. Postdilate both stents simultaneously with two noncompliant balloons.

The V-stent technique is particularly useful in patients with a Medina 0,1,1 bifurcation lesion. The techniques are easy to perform but have several disadvantages. Mainly, the creation of a neo-carina and the potential for malapposition in the proximal MB may yield suboptimal results. If further intervention is required in the proximal MB (e.g., restenosis or proximal MB dissection), a crush technique is required.

Though it is always difficult to determine which two-stent technique is the best for a given bifurcation lesion. The following guidelines can be used:

For Medina 0,1,1 lesions: Use the V-stent technique.

For true bifurcation lesions with a bifurcation angle approximately 90 degrees: Use the Modified T-stent technique.

For true bifurcation lesions with a bifurcation angle <70 degrees: Use a Mini-crush technique.

Left Main Bifurcation Lesions

The best approach for treatment (i.e., PCI vs. CABG) of an unprotected left main (LM) lesion remains controversial in the literature. CABG carries a significant risk of peri-procedural stroke, while restenosis rates with PCI are higher compared with CABG.

The decision to pursue PCI should be governed by the extent of surrounding CAD (e.g., isolated LM vs. triple vessel disease), as well as the patient's preference. The SYNTAX score can also be used to determine which patients may benefit from CABG over PCI for treatment of LM lesions.

For patients who undergo PCI of an unprotected left main bifurcation lesion, it is essential that the plaque burden of the lesion is clearly defined, and IVUS is very useful for this purpose.

The MB of an LM bifurcation lesion typically involves the LM and left anterior descending (LAD) artery. The left circumflex (LCx) artery is then considered the SB. The size of the LCx (or SB) and its plaque burden will determine if a one-stent with provisional SB stenting or two-stent technique is required.

A provisional one-stent technique is appropriate in patients with no or minimal (i.e., ostial only) LCx disease. It is also favored in patients with a LCx that is small (<2.5 mm), diffusely diseased, or supplies a small vascular territory. All other lesions favor a two-stent approach.

If the diameters of the LAD and LCx are identical and have significant disease, it is preferable to stent the more angulated branch first, including coverage of the proximal vessel (i.e., left main). This allows for easier recrossing of the stent struts and passage of a balloon or stent into the other branch for treatment (Note: this technique can be applied to non-LM bifurcation lesions where the branch vessels have the same diameter).

Dedicated Bifurcation Stents

Currently, a number of dedicated bifurcation stent platforms are undergoing investigation. The main goal of dedicated bifurcation stents is to allow for access to the SB after MB stent deployment without the need for recrossing. Currently, the efficacy of the dedicated bifurcation stents has not rivaled the current conventional bifurcation stenting techniques. However, it is likely that dedicated bifurcation systems will be become important tools for the future of coronary bifurcation treatment.

Interpretation of results

N/A

Performance characteristics of the procedure (applies only to diagnostic procedures)

N/A

Outcomes (applies only to therapeutic procedures)

Overall, the clinical outcomes associated with PCI of bifurcation lesions are suboptimal. Target lesion revascularization has been reported as high as 40% in studies with long-term angiographic follow-up.

Bifurcation lesions are an independent risk factor associated with stent thrombosis. The outcomes associated with PCI of bifurcation lesions reinforce the need for each operator to tailor the approach for each bifurcation lesion to optimize the final result. Use of adjunctive therapies, such as IVUS, FFR, and/or optical coherence tomography (OCT), may improve the clinical outcomes associated with the treatment of bifurcation lesions.

Alternative and/or additional procedures to consider

It is very important to recognize that angiography is very limited in its ability to characterize bifurcation lesions. The use of adjunctive techniques such as IVUS, FFR, or OCT are often necessary for tailoring the appropriate PCI strategy for a given bifurcation lesion.

Intravascular Ultrasound

No randomized trials support the use of IVUS for PCI of coronary bifurcation lesions in the DES-era; however, several observational studies have shown that IVUS is associated with a reduction in adverse cardiac events. IVUS has many important uses that can be used for treatment of bifurcation lesions.

Prior to PCI, IVUS can be used to:

  1. Assess plaque distribution and appropriately characterize the lesion ("IVUS Medina").

  2. Evaluate the extent of SB disease (especially for ostial lesions).

  3. Appropriately size the vessel diameters of the MB and SB.

  4. Recognition of the IVUS “eyebrow” sign (Figure 5): a prestenting marker for SB compromise.

Figure 5:

The IVUS "eyebrow" sign shown at the level of the carina (white arrow) between the left main and left circumflex coronary arteries. Reprinted from Stankovic et al. Eurointervention 2009;5:39-49, with permission from Europa Edition.

The information that IVUS provides when used prior to PCI allows for selection of stent size and length, type of stent, and the stenting technique.

After PCI, IVUS can be used to assess for:

  1. SB compromise.

  2. Stent deformation of the MB.

  3. Plaque shift in the MB or SB.

  4. Proximal or distal edge dissection.

  5. Stent malapposition.

  6. Stent underexpansion.

  7. Stent lesion coverage including gaps.

IVUS can optimize the result following PCI and has the potential to reduce adverse cardiac events.

Fractional Flow Reserve

FFR has the ability to assess the hemodynamic significance of a lesion. Given the importance of selecting the appropriate stenting technique for treatment of a bifurcation lesion, FFR can determine the ischemic potential of a given lesion and is most helpful for evaluating SB ostial disease.

An FFR value <0.75 is the best cut-off value for determining if a lesion is hemodynamically significant; however, an operator should use the cut-off value of 0.80 as established in the Fractional Flow Reserve versus Angiography for Multivessel Evaluation (FAME) trial to improve the specificity of FFR and determine if a lesion should be treated.

Another use of FFR during treatment of bifurcation lesions is to assess the significance of a jailed SB following MB stenting. One study found that only 27% of jailed SB had an FFR value <0.75 and a jailed SB with an FFR >0.75 that did not undergo further treatment had very low rates of adverse clinical events. Thus, FFR should be used to assess the significance of a jailed SB following MB stenting.

Optical Coherence Tomography

Similar to IVUS, OCT can be used to optimize treatment of bifurcation lesions both prestenting and poststenting. Compared to IVUS, OCT has a higher resolution, faster acquisition time, and smaller catheter size. It is limited by its tissue penetration, for which IVUS is superior. It can be particularly useful for evaluating lumen diameter, stent apposition and expansion, and lesion coverage.

Calcified or Fibrotic Lesions

Rotational atherectomy should be reserved for heavily calcified lesions, especially calcified ostial SB disease. Cutting balloons are also useful for calcified or fibrotic lesions. Both adjunctive therapies can improve SB access and allow for improved stent expansion.

Complications and their management

Tips and Tricks for Bifurcation Lesions: Our Generalized Approach and Algorithm

1. Use a 7 Fr or 8 Fr guide catheter, if possible.

2. Pretreatment IVUS and FFR is strongly encouraged.

3. One-stent approach with provisional SB stenting will suffice for most lesions with the use of JBT.

4. Two-stent strategy should be used in lesions that are true bifurcation lesions with high bifurcation angles and/or long SB lesions (≥10 mm).

5. If SB recrossing through MB stent struts is difficult, consider use of a second buddy wire, GuideLiner, or a low-profile 1.25 mm balloon.

6. FKI or SMS should be performed in all cases.

7. Posttreatment IVUS or OCT should be used to optimize the results.

Our algorithm for PCI of coronary bifurcation lesions is shown in Figure 6.

Figure 6:

Algorithm for percutaneous coronary intervention of coronary bifurcation lesions. Prior to percutaneous coronary intervention (PCI), all bifurcation lesions should ideally undergo assessment with intravascular ultrasound (IVUS) to further characterize the lesion. Fractional flow reserve (FFR) may also be used to assess the hemodynamic significance of any branches with intermediate lesions (i.e. stenosis 50-70%). If the side branch (SB) lesion length (L) is > 10 mm and the vessel diameter (D) is > 2.5 mm, then a two-stent strategy should be considered. Otherwise, the one-stent technique with provisional SB stenting should be used for all other lesions. If the bifurcation lesion contains: 1) a bifurcation angle > 70°; 2) a SB diameter > 2.0 mm; 3) the SB supplies a moderate or large area of viable myocardium; or 4) IVUS "eyebrow" sign, then the jailed-balloon technique should be considered to maximize SB patency. In the absence of these lesion characteristics, stenting of the main branch (MB) lesion using a jailed SB wire should be employed. Following MB treatment, if the patient experiences chest pain, has < TIMI 3 flow is the SB, or PCI is complicated by a flow-limiting dissection, then the proximal optimization technique should be used to increase the likelihood of successful recrossing of the SB followed by SB angioplasty and/or stenting. Finally, final kissing inflation (FKI) or side-main-side (SMS) inflation should be used in all cases followed by post-IVUS imaging to optimize the final result.

What’s the evidence?

Latib, A, Colombo, A. "Bifurcation disease: what do we know, what should we do?". JACC Cardiovasc Interv. vol. 1. 2008. pp. 218-26.

Latib, A, Colombo, A, Sangiorgi, GM. "Bifurcation stenting: current strategies and new devices". Heart. vol. 95. 2009. pp. 495-504.

Latib, A, Moussa, I, Sheiban, I, Colombo, A. "When are two stents needed? Which technique is the best? How to perform?". EuroIntervention. 2010. pp. J81-7.

Stankovic, G, Darremont, O, Ferenc, M. "Percutaneous coronary intervention for bifurcation lesions: 2008 consensus document from the fourth meeting of the European Bifurcation Club". EuroIntervention. vol. 5. 2009. pp. 39-49.

(The above articles are outstanding reviews on the treatment of bifurcation lesions, including a discussion of the IVUS "eyebrow" sign in the fourth article. )

Moussa, ID, Colombo, A. Tips and tricks in interventional therapy of coronary bifurcation lesions. Informa Healthcare. 2010.

Colombo, A, Stankovic, G, Topol, EJ, Teirstein, PS. "Bifurcations and branch vessel stenting". Textbook of interventional cardiology. Saunders. 2012. pp. 270-87.

(The above references provide a comprehensive review and very detailed descriptions about the techniques used for the treatment of bifurcations lesions.)

Medina, A, Suarez de Lezo, J, Pan, M. "A new classification of coronary bifurcations lesions". Rev Esp Cardiol. vol. 59. 2006. pp. 183.

(The original article describing the widely used Medina classification.)

Katritsis, DG, Siontis, GC, Ioannidis, JP. "Double versus single stenting for coronary bifurcation lesions: a meta-analysis". Circ Cardiovasc Interv. vol. 2. 2009. pp. 409-15.

Brar, SS, Gray, WA, Dangas, G. "Bifurcation stenting with drug-eluting stents: a systematic review and meta-analysis of randomised trials". EuroIntervention. vol. 5. 2009. pp. 475-84.

(The above articles represent the important systematic reviews/meta-analyses on the current evidence comparing one-stent with provisional side branch stenting versus the two-stent approach.)

Zamani, P, Kinlay, S. "Long-term risk of clinical events from stenting side branches of coronary bifurcations lesions with drug-eluting and bare-metal stents: an observational meta-analysis". Catheter Cardiovasc Interv. vol. 77. 2011. pp. 202-12.

(This reference represents an important systematic review/meta-analysis on the evidence for using drug-eluting stents for treatment of coronary bifurcation lesions.)

Singh, JS, Patel, Y, Depta, JP. "A modified provisional stenting approach to coronary bifurcation lesions: Clinical applications of the "Jailed-Balloon Technique"". J Interv Cardiol. vol. 25. 2012. pp. 289-96.

(This reference describes the jailed-balloon technique and its associated peri-procedural outcomes.)

Oviedo, C, Maehara, A, Mintz, GS. "Intravascular ultrasound classification of plaque distribution in left main coronary artery bifurcations: where is the plaque really located?". Circ Cardiovasc Interv. vol. 3. 2010. pp. 105-12.

(This reference compares the angiographic classification of left main bifurcation lesions with the plaque distribution found on IVUS, revealing that angiography is rarely accurate at classifying bifurcation lesions.)

Patel, Y, Depta, JP, Novak, E. "Long-term outcomes with use of intravascular ultrasound for the treatment of coronary bifurcation lesions". Am J Cardiol. vol. 109. 2012. pp. 960-5.

(This reference is a study on the clinical outcomes associated with IVUS use during PCI of bifurcation lesions.)

Rogacka, R, Latib, A, Colombo, A. "A IVUS-guided stent implantation to improve outcomes: A promise waiting to be fulfilled". Curr Cardiol Rev. vol. 5. 2009. pp. 78-86.

(This reference is a review article that discusses the use of IVUS for treatment of coronary bifurcation lesions.)

Koo, BK, Kang, HJ, Youn, TJ. "Physiologic assessment of jailed side branch lesions using fractional flow reserve". J Am Coll Cardiol. vol. 46. 2005. pp. 633-7.

(This study analyzed the FFR measurements of jailed side branches following main vessel stenting in bifurcation lesions.)

Koo, BK, De Bruyne, B. "FFR in bifurcation stenting: what have we learned?". Eurointervention. 2010. pp. J94-8.

(This reference is a review article that discusses the use of FFR for treatment of coronary bifurcation lesions.)

Bezerra, HG, Costa, MA, Guagliumi, G, Rollins, AM, Simon, DI. "Intracoronary optical coherence tomography: a comprehensive review of clinical and research applications". JACC Cardiovasc Interv. vol. 2. 2009. pp. 1035-46.

(This reference is a review article that discusses the use of OCT in PCI and for treatment of coronary bifurcation lesions.)
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