We know, atherosclerosis preferentially develops at arterial bifurcations because of shear stress, and other hemorheological forces.It is therefore no surprise that left main bifurcations and bifurcations at major branch points (diagonal, obtuse marginal, posterior descending artery) and form significant lesion subsets.(Estimated 20-30%)
Coronary lesions are treated according to their obstructive potential or, occasionally, their vulnerability to cause acute coronary syndrome (ACS). The former is the stronger indication, because the latter can often be addressed medically. PCI for plaque passivation of a non-flow-limiting thin-cap fibroatheroma (TCFA) remains a controversial indication, even after the PREVENT trial.
Returning to bifurcation lesions, interventional cardiologists have tied themselves into a debate over single vs two-stent strategies, as if no other means of treating bifurcations existed. Thanks to Drug-eluting balloons (DEB). They have added some fresh new thinking into the debate.
Scientifically and pragmatically, there are three non-stent alternatives for bifurcation lesions .
- Standalone Optimal medical therapy (OMT): Appropriate in a significant subset, often as part of the management of multivessel CAD.( Non flow limiting, Stress test/FFR negative)
- CABG: For critical bifurcation or trifurcation disease.(Trifurcation lesions is seen in about 5 %)
- Balloon-only strategy (POBA or DEB): simple kissing inflation with two plain balloons at adequate pressure (atmospheres) can achieve an acceptable result. The fear of dissection at the carina and ostium is real but manageable, with bailout stenting if needed. Delayed dissection or delayed closure is uncommon when the acute result is satisfactory. Restenosis is the main limitation, so a final DEB touch-up over a POBA-kissed lesion is advisable.
*Note : Even Bifurcation lesions under medina1,1,1 need not frighten us as long as plaques a re stable and non flow limiting.
Evidence?
Surprisingly, major trials such as ISCHEMIA, COURAGE and ORBITA do not report the bifurcation subset of their populations. Nevertheless, it is reasonable to believe that a significant subset of stable, non-left-main bifurcation lesions can be managed with medical therapy alone, by extrapolation physiology-guided studies. The true proportion is unknown and needs bifurcation-specific research , especially in methods to assess the true FFR in bifurcation lesions are required. (Note :Even a minimal ostial LCX or LAD can cross influence the FFR of either vessels diverting medical lesions to cath lab or vice versa)
Final message
If we are unable to think beyond , catheter based strategies in bifurcation lesion , there is something seriously wrong in they we are producing cardiologists.Bifurcation clubs across world to please take a note of this.
