Thank you, Tinvir. I assume everybody can see my slides. You'll let me know if you can't. It's a real pleasure to be in this. You know, I've had the fortunate, I've been very fortunate to be able to work with both Europeans and Americans on bifurcations and be able to share my experience of the both. But I have to admit, for many years living and working in Europe, I've gotten to learn so much from the European Bifurcation Club, from Yves, from Francesco, and the rest of the team. And so it's an honor for me to really talk about their document. I'm not an author of the document, but two of the senior authors are here, so they can comment on it too. What I love about the European Bifurcation Club is that every year they try and come up with a consensus document, which really highlights the important parts of what we need to know about bifurcations. And they always try and keep it very practical. And there's no sort of dramatic change from one year to another. It's always building on the previous year and what we've learned and how clinical data impacts our choices. So one of the most impactful ones I've read is the 15th Consensus, which was from two years ago, done by Francesco. And since then, from then to now, what's really changed? There have been a couple of really important papers that I think have impacted the guidelines and have impacted how we think about bifurcations. The first is the EBC Main Study. Yves Louvard is the senior author on that, and many members of the European Bifurcation Club are included on that. And we should maybe talk about that first. This was a randomized study, and I think a very important randomized study, because it was a randomized study evaluating a strategy in distal left main lesions that affect both the main and side branch. And I think what's different here is that these were important side branches that was part of being in the study with lesions in the side branch. So these were lesions, real lesions in the side branch. The true bifurcations were lesions in the side branch, and patients were randomized to either stepwise provisional strategy or upfront two-stem strategy with crossover allowed. There was about a 22% crossover rate to second stems, and the technique was used in half was TAP and the other half CULOT. The upfront two strategy, and I think this is interesting because it's a little bit different to what we see in the United States, that in Europe the preferred strategy in the study for upfront two stems was CULOT in more than half. In my experience having worked in the U.S., I think many operators prefer DK CRUSH, but I think both these strategies are good. You see DK CRUSH was only in 5%, TAP in 33%, but very importantly very high rate of final kissing balloon inflation in 93%. The primary outcome was at 12 months, and you see no difference again between a provisional approach and upfront two-stem strategy, which I think we've seen in many of these similar randomized studies. The other study which I think is important for you to know, and then I'll quickly go through what's changed in the document, is the definition study, definition two study. Here the authors try to really give us clear criteria of what a complex bifurcation is, looking at the complexity of the bifurcation, how much calcium, the severity of the disease, so not the typical bifurcation that we all know will do well with a provisional strategy. Here again the intervention was a two-stem approach, DK CRUSH in the majority, 78%. Remember most of these patients were treated in China, all of them were, and so that is the preferred two-stem strategy. The control group was a provisional approach in the rest of the patients, and again a similar rate of crossover, about 22%, which I think is for left main probably true, or for really complex bifurcations true. Probably in the most simple bifurcation that rate is probably lower, and the preferred strategy was TAP. And I think what's interesting about this study is that if you select out complex bifurcations with a lot of cyprimes disease, with a lot of complexity, we do see that in those patients they do better with a two-stem approach, and you see the target lesion failure rate here being about 37% lower with a two-stem approach. So the newest documents, the 16th expert consensus document, first authors are Remo and Jens. I cannot go through these documents with you online, they are really extremely thorough, and I would suggest if you're really interested in bifurcations, you want to know how to get yourself out of trouble, and what are the potential pitfalls for you to really read these documents. They have some amazing images inside of them that I think will really help you get great outcomes. I'll highlight maybe a couple of important things from both documents. So I think the first thing is the fact that most of us accept that the provisional approach is the best approach to deal with the majority of bifurcations, but we all need to also be saying the same things, in that the provisional approach is done in a very specific way. So I think we all agree now that to do a good provisional approach, you should wire both branches. If you think this bifurcation is important, the days of only putting a main branch wire are gone, we shouldn't be seeing side branches occlude because there's no wire in, and that we're systematically jailing the side branch or the side branch wire when we put the main branch stand in. We usually, in a provisional approach, mostly prepare the main vessel unless the side branch has a very tight stenosis. We don't usually dilate it, and then we have to also think about optimizing. So there's a great figure, which I love in this in this paper, which really goes to the provisional approach, and I think, you know, this is how we all should be performing the provisional approach, right? It starts after predilatation. We choose our main vessel stent based on the distal main vessel diameter, so based on that diameter, not the proximal diameter, and by doing that, we prevent carina shift, which is the most common cause of new side branch narrowing. When we do that, however, our stent is under-deployed or non-opposed in the proximal main vessel, and so we need to then, the next part of the step is to do a POT, a proximal optimization technique, where we use a small balloon. We should try not to cross the carina with that small balloon, and that small balloon will then oppose that stent and facilitate, if we need it, side branch access. In many cases, I think the procedure can end here. You're done if you have a good result in your side branch. If you have a suboptimal result in your side branch, or it's compromised, then usually what I do is really, you know, step three is I get another wire, I go with the wire into the distal main branch, I then pull back, and I rewire into the side branch, and then remove my gel wire, being careful about the guide catheter and not sucking it in, and then follow with a kissing balloon inflation. Some operators also prefer to re-POT after the kissing balloon inflation, just because of the concern that the two balloons will ovalize your stent, and so by using a doing a POT again, you circularize the stent, and then you assess what the result is. The result looks great, you're done. If you're concerned about the result, you may then think about crossing over to a second stent. I think one of the things that are most important, and these are some pictures from the visible heart, this really shows you the visible heart how stents look when we're in a bifurcation, and one of the things I think I've learned from being doing the visible heart and doing provisional on the visible heart, is the fact that it's really important to do the POT, because if you don't do the POT, your main vessel stent is really underposed, and you really then are challenged, and you risk doing this, where your wire is going to go outside the main vessel stent. And in the paper, there are a lot of these tables, which I think are really useful. What to do when you run into trouble, what to do when you're struggling to wire, you know, into the side branch, and you think you're getting stuck. How important it is then to redo your POT, maybe choose a third wire, and think about where you place your POT, or whether you would need a dual lumen catheter. So I would really, you know, suggest looking at the paper. I really like the approach to understanding what the pitfall is, what the mechanism is, and then troubleshooting it, and then how to prevent it, because I think many of these problems can be prevented. Then here's another example. I think that the paper covers very well. It's when your balloon does not cross, and why doesn't it cross. And many of these cases in provisional can really be prevented by doing a proper POT, placing the stent, placing the POT balloon in the correct place, using the correct size of the balloon, and really making sure that your balloon is well inflated. And so the whole paper really goes to through the sort of stepwise approach of how you do a approach, whether it's provisional or second-stem approach, where you potentially will have pitfalls, and understanding what those pitfalls would be. For example, you know, could it be a blue, you know, getting your wire stuck outside stent struts, not doing a proper POT. So troubleshooting that in your mind, and then what the solution is. Number one, usually the best solution is preventing it, but in case you haven't prevented it, how do you actually manage the problem? And so I really say it's great paper. The first paper covers provisional. The second paper covers double stenting. And it really goes through each of the approaches and where you can run into trouble. I would just maybe summarize the approach to two stents as I think the use of which technique you use should be selected according to the anatomy and your experience. Learn one approach first, and learn to do it well, and learn to do the steps well before trying to do three different approaches in a week in three different patients. When you think that bifurcation is complex because it has a large and very diseased side branch, usually an upfront two-stem strategy will give you a good outcome if you do it with meticulous technique, which also requires meticulous lesion preparation. I think the other thing to remember is when you're worried about the side branch, when you're worried about reaccess, about it occluding, that's when a two-stem strategy is useful because what's different between a two-stem strategy and a provisional is that you're really deciding that you're going to stent the side branch first. Remember that a provisional approach does not preclude crossing over to two stents. You can decide during the, even in a bifurcation that you may think will require two stents, you can start provisional and then cross over to two stents later. And then think about the pot. I think I often, you know, when I do a technique like a culotte, I probably do three pots during a culotte. You need to do often multiple pots, and also the importance of final kissing balloon inflation. When we do two-stem techniques, I used to do for some of my techniques, but I learned from Francesco that I probably need to do it in all my techniques, where before I do the kiss, probably it's worthwhile doing very high pressure inflation in each branch and then doing your kissing inflation. So really I'll end here with my key messages from the 16 Consensus. I think the most important thing when you do bifurcations, as much as possible, and this is probably for PCI in general, is keep it simple and safe. Try to limit the amount of metal. The provisional stent strategy, and I'm sure Eve and Francesco will talk about it, it's more philosophy and ease of philosophy. It's about trying to keep the procedure simple, safe, minimizing metal, but it's also dynamic and does allow you to cross over to two stents when you need to and when you need to get a good result. In order to get a great result, it's really important to understand what can go wrong so that in most cases you can prevent it. But sometimes if you can't at least understand the pitfalls will help you correct it and getting a fantastic optimal outcome in the end. So thank you for your attention and it's always a pleasure to be on the Skydive Vacation Club and being part of this session.

bifurcation strategies

provisional approach

EBC Main Study

distal left main lesions

Definition 2 study