Ostial and Bifurcation Lesions

Question 1

What does the absence of a good backflush into the aorta during contrast injection suggest?

Answer 1

An ostial lesion

This suggests that there may be an obstruction at the ostium that prevents proper blood flow.

Question 2

What is a potential complication of aorto-ostial stenting?

Answer 2

Significant complications including:
* Stent deformation
* Accidental crushing of the stent
* Missing the ostium
* Retrograde dissection of the left main

These complications can arise from improper technique during the stenting procedure.

Question 3

What characteristics make ostial lesions more difficult to dilate?

Answer 3

More fibrous and elastic tissue in the aortic wall compared to coronary arteries

This structural difference increases the likelihood of recoil and makes dilation more challenging.

Question 4

What is the Medina classification used for?

Answer 4

It classifies bifurcation lesions

The Medina classification uses a three-number system to indicate the presence or absence of lesions in the proximal main branch, distal main branch, and side branch.

Question 5

True or False: The presence of backflow at the final angiogram is a sign of poor treatment outcome.

Answer 5

False

Backflow is an important sign indicating a good final result and satisfactory treatment of the aorto-ostial lesion.

Question 6

What technique is suggested for treating difficult to dilate ostial lesions?

Answer 6

High-speed rotational atherectomy and cutting balloons

These methods are particularly useful for dealing with calcified ostial lesions.

Question 7

What is the significance of FFR evaluation in side branches during provisional strategy?

Answer 7

Angiographic evaluation may overestimate severity

FFR helps to accurately assess whether significant stenosis is present in side branches after intervention.

Question 8

What does a geographic miss in stenting mean?

Answer 8

The stent does not adequately cover the ostium

This can lead to stent recoil and restenosis.

Question 9

What is the main difference between the classical crush technique and the step crush technique?

Answer 9

The stents are advanced and deployed separately in the step crush technique

This allows for better management in cases where a smaller guide catheter is used.

Question 10

What was the conclusion of the Nordic Bifurcation Study regarding stenting techniques?

Answer 10

No significant difference in restenosis rates between one-stent and two-stent groups

This indicates that provisional stenting is effective in many cases.

Question 11

Fill in the blank: The double kissing (DK) crush technique involves performing kissing balloon inflation ______.

Answer 11

twice

This method may enhance stent apposition and reduce stent distortion.

Question 12

What are the results of the CACTUS trial regarding angiographic restenosis?

Answer 12

Similar rates of angiographic restenosis between crush and provisional stenting groups

This suggests that both techniques can be effective for true bifurcation lesions.

Question 13

What is a critical consideration when performing ostial left main stenting?

Answer 13

Careful guide manipulation to avoid stent deformation

Specific maneuvers can inadvertently lead to complications such as stent deformation or geographic miss.

Question 14

True or False: The excimer laser is effective in treating severely calcified lesions.

Answer 14

False

Rotational atherectomy is recommended as the most appropriate treatment for calcific lesions.

Question 15

What are the recommended maneuvers to avoid stent deformation during ostial stenting?

Answer 15

Avoid:
* Advancing the guide catheter with jailed guidewires
* Pulling out jailed guidewires or partially deflated balloons
* Advancing the guide catheter without fully expanding the stent

These actions can lead to complications during the procedure.

Question 16

What technique is related to long-term outcomes in bifurcation stenting?

Answer 16

Bifurcation technique and optimization of the final result

This refers to refining standard crush techniques in double stenting.

Question 17

What angle between branches may independently predict MACE after crush stenting?

Answer 17

≥50 degrees

This was demonstrated by Dzavik et al. in their study.

Question 18

What is the preferred standard approach in treating bifurcation lesions?

Answer 18

Provisional side-branch stenting with a final kissing balloon

This preference is noted in the literature.

Question 19

What does the culote technique provide in bifurcation stenting?

Answer 19

Near-perfect coverage of the carina and side-branch ostium

This technique may lead to a more homogeneous distribution of drug and struts at the bifurcation site.

Question 20

What were the results of the Nordic Stent Technique Study comparing crush and culote stenting?

Answer 20

No significant differences in death, MI, or revascularization

Clinical follow-up at 6 months showed similar outcomes in both groups.

Question 21

In a nontrue bifurcation, what was the MACE rate for final kissing inflation versus no final kissing inflation?

Answer 21

2.1% vs. 2.5%

These rates were not statistically significant (p = 1.0).

Question 22

What is the recommended strategy for protecting side branches during bifurcation stenting?

Answer 22

Place a guidewire in both branches

This prevents side-branch closure and facilitates rewiring if necessary.

Question 23

What can cause acute hypotension during bifurcation PCI?

Answer 23

Wire perforation, cardiac tamponade, and procedural complications

All listed responses are conceivable complications.

Question 24

What is Finet’s formula used for in coronary bifurcation stenting?

Answer 24

Proximal main diameter = 0.678 × (distal main diameter + side-branch diameter)

This formula helps restore normal physiologic anatomy during stenting.

Question 25

What does the proximal optimization technique (POT) aim to correct?

Answer 25

Malapposition of the proximal stent

POT uses a larger diameter balloon to optimize the stent position.

Question 26

What should be considered for crossover to stenting the side branch?

Answer 26

> 75% residual stenosis, dissection, TIMI flow grade <3, or FFR < 0.75

These criteria indicate the need for side-branch stenting.

Question 27

What is the TAP technique in bifurcation stenting?

Answer 27

The easiest technique for side-branch stent implantation after a provisional approach

TAP minimizes strut protrusion into the main branch.

Question 28

True or False: The culote technique is limited by large mismatches in diameters between branches.

Answer 28

True

This risk is due to incomplete side-branch stent apposition.

Question 29

What is the TAP technique in side-branch stent implantation?

Answer 29

The TAP technique is the simplest and easiest to perform technique for side-branch stent implantation after a provisional approach.

TAP stands for ‘T and Provisional’ technique, used primarily in bifurcation lesions.

Question 30

What are the clinical outcomes associated with the TAP technique?

Answer 30

Registry data have shown excellent clinical outcomes with low TLR rates of 5.1%.

TLR stands for Target Lesion Revascularization.

Question 31

What were the binary restenosis rates for the TAP technique compared to culote stenting?

Answer 31

The binary restenosis rates were 17% with TAP and 6.5% with culote (p = 0.006).

Question 32

What is FKBI and why is it important after side-branch stent implantation?

Answer 32

FKBI is mandatory after implanting the side-branch stent to prevent protruding side-branch stents from obstructing the main branch.

Question 33

True or False: The side-branch balloon should be deflated first during FKBI.

Answer 33

False. The side-branch balloon should never be deflated first.

Question 34

What is the standard approach for treating left main coronary artery stenosis?

Answer 34

The standard approach for left main coronary artery stenosis is CABG (Coronary Artery Bypass Grafting).

Question 35

When might stenting be favored over CABG for left main coronary artery stenosis?

Answer 35

Stenting may be favored if there is a contraindication to CABG.

Question 36

What is the role of IVUS in complex lesions like bifurcations?

Answer 36

IVUS helps to confirm good stent apposition and optimize outcomes in complex lesions such as bifurcations.

Question 37

What challenges remain in optimizing outcomes at coronary bifurcations?

Answer 37

Challenges include variability in bifurcation anatomy, large anatomical permutations, dynamic changes during treatment, and flow dynamics.

Question 38

How does IVUS guidance compare to angiographic guidance in terms of clinical outcomes?

Answer 38

IVUS guidance likely results in improved freedom from target vessel revascularization and MACE compared to angiographic guidance alone.

Question 39

What did the MAIN-COMPARE study find regarding IVUS guidance?

Answer 39

The study found that the 3-year incidence of mortality was 61% lower with IVUS guidance compared to angiographic guidance, although it just missed statistical significance (p = 0.055).

Question 40

What did Kim et al. find regarding IVUS-guided PCI for bifurcation lesions?

Answer 40

IVUS-guided PCI was associated with a lower incidence of death and MI at 3-year follow-up compared to angiography-guided PCI.

Question 41

Fill in the blank: IVUS may help to better define bifurcation ________, geometry, and plaque distribution.

Answer 41

morphology

Question 42

What are the potential benefits of using IVUS at bifurcation lesions?

Answer 42

IVUS may ensure optimal stent expansion, adequate lesion coverage, and full stent apposition.

Question 43

What is the limitation of the studies that support the use of IVUS?

Answer 43

The studies have been derived exclusively from retrospective observational studies.

Question 44

What was the outcome of the AVIO trial regarding IVUS optimization?

Answer 44

The AVIO trial was underpowered to show reductions in clinical outcome.