approch to bifurcation lesion

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1. DR SRIDHAR BABU 2. WHAT IS BIFURCATION LESION? APPROACH TO BIFURCATION LEISONS 3. APPROACH TO BIFURCATION LEISONS A ( approach) between proximal MB & SB. It defines difficulty in accessing side branch. If this angle more can be by guide wire insertion, which facilitates SB access after MB stenting. B ( between) between the two distal branches. If it small independently predicts SB occlusion after MB stenting 4. Possible locations LAD diagonal LCX obtuse marginal RCA PDA LMCA bifurcation APPROACH TO BIFURCATION LEISONS 5. INCIDENCE Account for 16% PCI Procedural complications 9% Restenosis as high as 36% Lower initial success rate APPROACH TO BIFURCATION LEISONS 6. Technical problems Difficulty in access to the side branch Plaque shift Lesion recoil Ineffective lumen expansion High periprocedural complication rate Sub optimal immediate and long term results Risk of side branch occlusion APPROACH TO BIFURCATION LEISONS 7. Anatomical Considerations Y-angulation precise stent placement with complete ostial coverage is often difficult or geometrically impossible. APPROACH TO BIFURCATION LEISONS 8. The outer walls of bifurcation points are subjected to diastolic flow reversal, which leads to oscillatory shear stress. Oscillatory (as versus laminar) shear stress is less efficient in stimulating eNOS. Monocytes bind more avidly to areas of oscillatory shear than to areas subjected to linear shear. oscillatory shear stress is proatherogenic The shear stress hypothesis Hsiai, T.K et al ATVB 2001; 21: 1770 APPROACH TO BIFURCATION LEISONS 9. APPROACH TO BIFURCATION LEISONS 10. APPROACH TO BIFURCATION LEISONS Classification of bifurcation lesions 11. APPROACH TO BIFURCATION LEISONS 12. APPROACH TO BIFURCATION LEISONS 13. Limitations of Medina classification Does not take into account 1. Length of disease in the ostium of the SB 2. Length of the LMCA before the bifurcation 3. Trifurcation 4. Vessel angulation 5. no differentiation is made between a normal segment (lesion free segment) and a