Two things. One is what bifurcation technique for a given bifurcation lesion. It's all individualized and the second thing is when we decide what technique, tips and tricks to execute this technique properly. Let's start with the technique. That's essentially a good comprehensive algorithm approach on what and when. And let's walk through this step by step. First things first, we look for the anatomy, the medina. It has to involve to be true bifurcation the main vessel, either proximal or distal, and the side branch. Only then it's true bifurcation and if so we have to consider the next step. If no true bifurcation then no worries. We just go ahead with one stand technique and we do provisional. So no true bifurcation, provisional. If it's a true bifurcation then the next question we need to answer is how big is the side branch. Because if it's a smaller, less than 2mm diameter, again there's no anxiety here. We just go ahead, we ignore this, essentially go ahead with provisional, one stand technique across the main vessel and we ignore the small disease but small side branch. And then the third question, if it's a sizable, more than 2mm side branch, the lesion length of the osteomyosite branch, if it's more than 5mm, usually 10mm, means extensive disease there, then it's more complex. And in that case, if very short disease of the osteomyosite branch, less than 10mm, then we go with one stand, provisional. If it's more than 10mm, then we start thinking about two stands. So to go up front with two stand technique, we need to have a true bifurcation involving main vessel and side branch, a sizable side branch, and a diseased side branch with more than 10mm disease lengthwise. Only then we go ahead with two stand technique. And then the question we need to answer, which two stand technique, is based on essentially the side branch risk to be lost if we stand the main vessel. If the risk to lose a side branch after the main vessel standing is not an issue, then we stand the main vessel first. And we have different techniques, T-tap and culotte. If it's a T configuration, then we go ahead with a T technique, two stand technique. If it's a Y configuration, usually less than 50-60 degrees of bifurcation angle, and the main vessel and side branch are sizable, comparable in size, less than a millimetre difference in diameter, then we go ahead with culotte, and then tap is in between. And of course, provisional, whenever it fails, we can convert, don't call it bailout, we can convert at any point to either T-tap or culotte as needed. Now, if we have a major concern that we're going to lose the side branch, if we fix the main vessel first, then what we do, we start with the first stand from the side branch. And we have four techniques, we have decay crash or T-tap and culotte, which is now called inverted. It's the same thing like T-tap and culotte, but now that we stand the side branch first, we call this inverted. So let me walk you through now some tips and tricks for each of those techniques, T-tap, culotte, and decay crash. And provisional first, of course. So we start with provisional. I'm going to show you here some videos. We always size the stand to the distal main vessel, always. And we leave some room here approximately to make sure that we have enough room for a nice pot, 6 to 8 millimetres at least. We deploy the stand. And then what we do, we do pot, approximate optimisation technique with the NC, usually balloon, inflate on high atmospheres to make sure that this balloon, the distal neck is at the carina. And then that's the result. This is coming from patient-specific simulations. To give you to illustrate the results, that's the side branch they are opening. And now, if we have any of the following conditions, the side branch is more than 80%, less than TME III flow, dissection or evidence of ischemia clinically or by EKG, then we convert to KISS. And to KISS, we rewire from distal struts, it's very important. And we use two NC balloons usually, centered around the carina. And then we inflate them simultaneously. And then we deflate them simultaneously, not in very high pressures. And then finally, always after KISS, it's a good habit to close with a pot and make sure that we have good optimisation of the proximal part and done. And then again, if after the KISS, we still have any of the following conditions, like a dissection or less than TME III flow or ischemia by EKG or clinically, then it's time now to convert this provisional to either T, TAP or CULOT. Now, I want to emphasise this. This is the kissing balloon inflation. And one more point, a footnote here. Now we propose a sequential KISS first, which means that we have an inflation of the main vessel balloon first, high pressures. Then we deflate this. Then we inflate the side branch balloon, very high pressures. And then we do the simultaneous KISS. We inflate both balloons at the same time, but now not on high pressures. We just make this, do this manipulation to restore the carina in the middle. And then we deflate them simultaneously. That's a nice trick to do sequential and then simultaneous KISS. Now, going to the T, again, in the interest of time, the first steps are always the same. Main vessel first. Then we go to the, hold on a sec. Here you go. So main vessel first. Then you go to pot. Always KISS before we do a T or TAP or CULOT. We have to KISS. That's mandatory there, very important step. And now it's time for the STENT. And the STENT is not protruding, it's just right. Where is the, also in the side branch, no protrusion to the main vessel. And we have a balloon uninflated in the main vessel. Then we take the STENT balloon back and do feather scaffolding of the STENT at the side branch. And then we KISS with the STENT balloon and the uninflated balloon of the main vessel as shown here. And then finally, always finish with a nice pot. And we don't need to be deep with this pot balloon, just approximately to make sure that we restore the circular configuration of the main vessel. And that's how it looks from the inside as well. As you can see here, again, we don't protrude with this STENT at all into the main vessel. Now, TAP is more or less the same philosophy, like a T, but now instead of having no protrusion, we protrude into the main vessel by a couple of millimeters. Again, pot, then KISS always before the second STENT. And now it's time for the second STENT. And you see here, the second STENT now protrudes by a couple of millimeters. Two struts if you want, if you go to STENT Boost. And then you have the uninflated balloon in the main vessel. So you take the STENT balloon back to feather scaffold the OST on the side branch. And then using the STENT balloon and the uninflated balloon, the main vessel, we do a nice KISS. And then finally, we close with a nice pot as shown here. Again, very important, avoid deep intubation of the balloon because you don't want to distort the metallic neocarina. So just the proximal part of the main vessel STENT. And if we go very deep, we're going to distort the neocarina and we're going to mess it up. And then that's how it looks from the inside. So essentially, TAP is a T with more protrusion into the main vessel by a couple of millimeters. And then also we have the CULOT. Actually, this is with a red blood cell, with a camera from the inside. You see how much we protrude with the side branch STENT into the main vessel. And we inflate it now. All is from the inside. This is like part of virtual simulation training we can do. You see how the metallic neocarina is pushed away to the main vessel. And now with the KISS, you're going to see it here, we restore the neocarina into the middle here. Okay. That's the reason of doing KISS with two non-NC balloons in low pressures. And then CULOT, as shown here, again, same scenario. It's the same configuration, the same steps. But now it's time to decide about the CULOT, positioning of the STENT. You see, CULOT is a TAP with lots of protrusion. And it protrudes just proximally to the polygon of confluence, as shown here. Make sure you take the wire out from the main vessel. After you do the side branch STENT, then you do a nice spot to the side branch STENT. And then, again, we rewire now from distal struts, and we do a nice KISS with two NC balloons centered at the middle of the neocarina. Inflate it. Again, we're going to do sequential and then simultaneous. That's a good trick. And then finally, we conclude with a nice pot. Again, avoid the deep intubation positioning of this balloon, just proximal part of the main vessel STENT. And you can tell essentially that T-TAP and CULOT is the same thing, same philosophy. It's a matter of how much you protrude. T, no protrusion, TAP, two millimeters, and CULOT all the way in. And then that's the final result from the CULOT. And then finally, DECAY CRUSH, which is a little more tricky, which is always side branch first. So you do this when you want to start with the side branch first, and make sure you have a nice uninflated balloon into the main vessel. You protrude by two, three, four millimeters of the side branch STENT to the main vessel. You inflate the side branch STENT, always side to the side branch. The side branch STENT always side to the side branch. And then now we CRUSH with the uninflated. We do actually a nice scaffolding of the side branch STENT with a bigger balloon, and then we CRUSH with the uninflated main vessel balloon. But you can tell here, believing you're seeing, you see from the inside, as you see down here, that this CRUSH is not enough, because the balloon is side to the main vessel. We need to do a better CRUSH with the second balloon side to the main vessel to have a complete CRUSH before we attempt the next step, which is rewiring the side branch from the proximal struts, and then do a nice KISS and see how nicely the STENT is now opposing to the CARINA. We need to CRUSH well before we do the KISS. And now time for the second STENT, which is the main vessel STENT now. And then again, we take the wire out from the side branch. We don't want to smash the wire between the two STENTS. And a nice spot always to optimize the main vessel STENT proximally. And now we rewire from distal struts the side branch. And as we know very well, time for a sequential and simultaneous KISS. And then we conclude with a nice POT. That's the KISS, the second KISS. It's double KISSing CRUSH, mini CRUSH. And then that's the main vessel POT. And then finally, I'm not going to show this to you, but inverted T-TAP and CLOT is the same thing like T-tap and colloid, but we start from the side branch first. So finally, technical messages, provisional versus upfront two-stands, it all depends on the bifurcation anatomy. If it's no true bifurcation, provisional. Side branch size is important. If it's small, less than two millimeters, provisional. And then length of disease in the side branch, if it's less than 10 millimeters, provisional. Provision is a philosophy, can be converted at any time to any two-stand technique, not decay-crush, of course. So don't worry, don't feel that provisional is going to kind of like oblige you to one stand. You can always do two-stands. And then when it comes to two-stand techniques, number one issue is risk of losing side branch after main vessel stand. If it's low risk, then go ahead with T-tap and colloid, stand the main vessel first. If it's a high risk to lose the side branch after main vessel because of angulation, calcification, and so on, then you go with inverted T, inverted tap, inverted colloid, or decay-crush where we stand the side branch first. Bifurcation angle, Y angle, colloid, T angle, T or tap. And then the size of the main vessel, comparable within a millimeter to the side branch. If so, then colloid. If no, it is mismatch between the proximal vessel and the side branch, then T or tap. And always mandatory IBUS or OCT to do fine job. You can see all those videos online in YouTube. If you hit CBBL, you can have access to all those tips and tricks for every technique. I think it's a good educational material. A big thank you to my group, to the international collaborators from ABC, and of course, to the funding sources all the way from industry, philanthropy, and NIH. Thank you so much for your attention. So, you just went through that quite quickly, a lot of information. Yes. And so, if an operator is performing maybe 100, 150 PCIs a year, and about 10 of those are going to be bifurcation, just a couple of key take-homes that I got from your talk is that one is the provisional is appropriate for many cases, and Medina is one classification, so we might extend that and say we can even do more complex that are non-definition criteria, bifurcation lesions. So, going for that, and that the T, TAP, and CULOT are all just variations and have a lot of the same steps. Absolutely. Yeah. Anything about the bifurcate app in helping people remember some of this, because everybody kind of learns these things, and we want to all agree with what you just said, but if someone is not doing them all the time, they may forget some of the steps, or many steps. So, that may be either you're going to pull the paper, or you're going to pull the app, or is there a website? You have a website? We have a website here, this thing here. You can check it out. Very important, because the question can happen any time, so we think we all remember it, but you know, afterwards, I think you've got to have something. To this point by Dr. Dangas, I think also a good idea, concept would be to have this on your plate, on the angiogram. So you don't need to be checking any website or any app, but have it as an autopilot on the angiogram, step by step to guide you, and recommend you now the next step, step two, step three, step five, as a reminder, and then you're free to follow it or not. Well, I'd like to make a few comments, questions from the audience. Yeah, so Juan, come to the microphone, please. Just a simple question. Could you just explain the logic about rewiring the distal strut and not the proximal one? And any tips and tricks, you know, in case you just can't get to the distal? Yeah. So, that's actually more important how we get there. So, the logic behind this, as you can see here very quickly, is that it is very important that we need to oppose as much as possible. So, you see now it's a main vessel stand, right? So, at this point, we need to go from a distal strut and oppose this part of the stand as much as possible to the side branch. Okay? And to achieve this, you have to go from a distal strut. So, it's coming now. So, you see this is after pot. And now it's time, we're not satisfied with the result, to move to the kiss. And these are the conditions when we move from provisional to kiss. And to achieve this, you need to go from a very distal strut. So, how you do this? There are two techniques. I have them here. One is a wire exchange. So, you take, you leave this jailed wire, right, into the side branch. And you take the main vessel wire and you pull it back on fluoro. And as you pull back, you make sure that it turns towards the side branch and jumps essentially from distal struts into the side branch. That's one technique. And then you take back the side branch jailed wire carefully, because if you just pull it back, it's jailed. So, you might deeply intubate the guide cut and dissect the left main or the RCA, whatever. So, you have to be very careful when you take the side branch jailed wire back. Why if it doesn't cross into the side branch of wire? Everything seems like all of these wires fly in and out so easily. But sometimes it doesn't cross. So, then why? I think it's going to cross. But if it doesn't cross, then we have different options. One option, and that's a very good question, is we can get a dual-lumen catheter, maintain the wire here, load it over the main wire, and then use the dual-lumen catheter to access to the side branch, having this side branch as the jailed side branch wire as a guide. Or you can get an undulated micro catheter and direct it. It is very undulated side branch to the side branch. And then one thing, we have the consensus paper from ABC just came out in parallel with EuroPCR. And the other good technique here is to, if everything fails, to go do another pot with a bigger balloon, hopefully to rearrange some struts there, and then find the hole to get through. Good evening, everyone. Thank you for the amazing talk. I have a few questions. Is any particular stent better or indicated for bifurcation? Like the Zions? Indicated bifurcation stent that hasn't been approved yet. Any FDA approved? That's a tricky question. But I'll be very fair. In my humble experience, and I think most of us will agree, there's no better stent in bifurcation. They all behave well. Actually, the FDA approval is only for one right now. But I think we have good results with most of the stents. But one point that you should keep in mind is that the stents, the struts of the stents, the scaffolding changes in different size of balloons depending on the manufacturer. So some companies, you have a 3-0 balloon that's supposed to go just to 3.5. So if your proximal vessel is bigger, maybe you could change the manufacturer for one that does a 3-0 balloon, a 3-0 stent that can expand to a higher size than 3.5 or so on. So pay attention not only to the chart for that particular case, for that particular balloon, but on the scaffolding ability to expand that changes from one company to the other. Thank you. Dr. Javik was to respond about this exact thing, I think. The only other thing I would say is that you just have to make sure, and this is more relevant in left main bifurcation PCI, is that the stent you're choosing and the size of stent you're choosing actually can be expanded, that its maximal expansion ability is to the left main, to the diameter of the left main vessel. Not all stents will do that. So, for example, a 3.5 LAD, proximal LAD, not all stents can get up to the size that you need in the left main, which is 4.5 to 5. So you just have to look carefully at the maximal expansion. Good point. Thank you. And the other question, any experience with like a jail balloon technique in provisional? I think Dr. Jassing, I think, maybe can also answer. Jass. Any question, Jass? Jail balloon. Jail balloon. We have a question about the jail balloon technique. Can we jail any balloon? Any experience with it? You have a preferred balloon to jail. No, and I'll show in my presentation. So, you know, in provisional stenting, there is a subset of people who are high risk of side branch closure. And I'll show it in my slides a little bit later on. And those are the probably five characteristics of a high risk bifurcation in provisional. Those are the ones that the wire is not optimal. So we trap the balloon behind it, modify the carina, because carinal shift is the main problem in those issues. So we trap it and then modify it. And so the side branch stays, the angle stays, and the plaque we don't really worry about in those scenarios. So it really works in high risk things. So it's a good technique. You don't use it in all the time. But in those high risk subjects, it really makes a big difference. Right. So don't they recommend that leave the jailed wire, take a third wire after you part it, go in there, parallel to it, or distance, and then pull out the thing? Instead of – we sometimes just pull out the LED wire, put in the diagonal wire to the LED, and isn't that safer to do? Number three wire, number three? It's a matter of how much you're in the mood to spend for wires. Yeah. It's good. Use a lot of wire. One of the things is difficulties when trying to get a wire into the side branch is going sub-intimal into the main stent. And what I've been doing is putting a guide liner in the central line stent and advancing the guide liner – well, it depends on how far the stent is – to the central of the stent. And then put the wire with – the second wire or the third wire he's talking about, I have already downloaded way distant to the tip of the guiding catheter. When I get the guide liner into the center, then I push it again to pass the side branch. Then I pull back the guide liner. Now, I guarantee that 100% my secondary wire is in the lumen of the stent, and I make sure that it doesn't go up in – I mean, under the stent. It's a poor manner to do a lumen catheter. Yeah, it is. Exactly. So, we save wires. With the two wires, pull back the wire exchange technique. If you have the luxury, get the third wire. Use a guide if you don't have a dual lumen catheter. And, again, don't forget wire escalation. We have the workhorse wires, and we have more hydrophilic wires, which can always make the trick and go through. So, don't – you can attempt this first before you escalate to more expensive microcatheters. George, just a quick question. You mentioned high-pressure inflation sequential in doing kissing balloon first at the side branch. That is, yes. Any reason for not doing also in the main branch high-pressure inflation? Yes. So, can you elaborate a little? So, it's sequential. Sequential. Sequential inside the branch. You said do high-pressure inside branch. Yes. But you didn't say high-pressure in the main branch. Any reason for doing just inside branch high-pressure? You know, you need to scaffold well. See how much better we scaffold to the side branch, the main vessel stand. And then we have just the simultaneous kiss to just restore the carana. The simultaneous kiss is only to restore the carana in the middle. But to scaffold – But sometimes you don't restore with simultaneous kissing low-pressure. That's my point. So, sometimes you have to do also high-pressure in the main vessel to get back your carana to the proper location. You can. You can.

bifurcation lesions

percutaneous coronary intervention

individualized technique

true bifurcation techniques

wire exchange

guidelines