There are numerous complex grading for bifurcation lesions available.
The one proposed by Medina is simple and most useful.
In this grading three segments
- Proximal main vessel
- Distal main vessel
- Branch vessel
Are given a code 0, and 1 if lesion is present or absent .
This grading gives simple and fast method to label a bifurcatiuon lesion and to asssess the response to PCI. The only issue here is the individual lesions are not graded , for example branch vessel ostium just involved about 20 % is not addressed . Further TIMI flow in these vessels may also be incorporated
How medina grading can be used to assess effectiveness of
A patient with 1.1.1 after the treatment should revert back to 0.0.0. if converted into 0.0.(.5) may indicate a residual side branch lesion .5 shall indicate 50% residual lesion, .3 , 30% etc
What is the best management strategy for bifurcation lesions?
The topic has been discussed extensively for over a decade in various forums.
Though the lesions and intervention techniques appear complex the basic concept is simple.
Following is the 8 point algorithm
1. Assess the bifurcation lesion accurately.
2. Apply the general rule and ask the first question whether PCI is neccessary at all ? if decided for PCI
3. Stent the main vessel.Protect the side branch.
4. Dilate the side branch with a balloon.(KIss or through the struts)
5. Very rarely, if the side vessel is more significant and large stent it and balloon the main vessel.
6. Use drug eluting stents with caution .
7. Resist the temptation of using two stents unless the situation demands and is absolutely required.
8. Never attempt to do bifurcation angioplasty during ACS as apart of primary angioplasty.( Unless you’re extremely competent, even then aim of primary PCI is to salvage myocarium quickly , not to provide TIMI 3 flow in non IRA vessel.)
Dr.S.Venkatesan.Madras medical college.Chennai.
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