What We Should Know About Bifurcation Disease
Mohammad Reza Movahed, MD, PhD, FSCAI, FACC, FACP*
I read with great interest the paper by Latib and Colombo (1). This review discussed 6 major classifications of coronary bifurcation lesions. However, it failed to include a recently published comprehensive classification of bifurcation lesions that is simple, practical, and inclusive of other important features of coronary bifurcation lesions that are not mentioned in other classifications (2). This classification is based on a system composed of a single prefix (B, for bifurcation lesion) to which up to 3 main suffixes are added, describing important anatomical features of a given bifurcation lesion. This classification addresses 3 important technical features of bifurcation lesions: the proximal segment size, atherosclerotic disease burden, and the bifurcation angle. It is known that if the proximal segment is too small (small is defined as less than two-thirds of the sum of the diameters of both branch vessels [suffix S, for small]), the kissing stenting technique cannot be utilized (3). The Medina classification does not include this important anatomical feature, and this review did not mention this important feature.
The second suffix describes the involvement of the disease area of the bifurcation branches, namely, if both ostia at the bifurcation site are involved, the number "2" is used; if the main branch only is involved, "1m" is used; and if the side branch only is involved, "1s" is used. A B2 lesion in this classification is a true bifurcation lesion based on the Latib and Colombo (1) algorithmic approach to bifurcation intervention in their review. The labeling of B2 lesions would include 1.1.1, 1.0.1, and 0.1.1 in the Medina classification. As one can see, the Medina classification is more complicated in regard to true bifurcation lesions.
It is interesting to note that Latib and Colombo (1) did not include the Medina classification in their algorithmic approach to interventional techniques, although they referred to it as the preferred classification. Some other publications that used the Medina classification for simplicity also did not use it in their technical decision making, calling into question the clinical applicability of the Medina classification.
The bifurcation angle is another important feature of bifurcation lesions that is not mentioned in the Medina classification or in this review (1). Steep angulations have been found to be associated with higher risk for abrupt vessel closure (4), side branch occlusion (5), and major adverse cardiac events (6). In the Movahed classification, a third suffix describes the angulation of bifurcation branches. The suffix V is for angles of less than 70°, and the suffix T is for angles of more than 70°. A comparison of known classifications, including the Movahed classification with a detailed algorithmic approach to coronary bifurcation interventions based on the Movahed classification was recently published (7) as a guide to interventional cardiologists for technical decision making based on the lesion characteristics.
* University of Arizona School of Medicine, Southern Arizona VA Health Care System, University of Arizona Sarver Heart Center, Department of Medicine, Division of Cardiology, 1501 North Campbell Avenue, Tucson, Arizona 85724 (Email: rmovahed{at}email.arizona.edu; rmova{at}aol.com).
 |
REFERENCES
|
|---|
- Latib A, Colombo A. Bifurcation disease: what do we know, what should we do? J Am Coll Cardiol Intv 2008;1:218-226.[Abstract/Free Full Text]
- Movahed MR, Stinis CT. A new proposed simplified classification of coronary artery bifurcation lesions and bifurcation interventional techniques J Invas Cardiol 2006;18:199-204.[Medline]
- Sharma SK, Choudhury A, Lee J, et al. Simultaneous kissing stents (SKS) technique for treating bifurcation lesions in medium-to-large size coronary arteries Am J Cardiol 2004;94:913-917.[CrossRef][Web of Science][Medline]
- Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morphologic determinants of coronary angioplasty success and complications: current experience J Am Coll Cardiol 1995;25:855-865.[Abstract]
- Aliabadi D, Tilli FV, Bowers TR, et al. Incidence and angiographic predictors of side branch occlusion following high-pressure intracoronary stenting Am J Cardiol 1997;80:994-997.[CrossRef][Web of Science][Medline]
- Dzavik V, Kharbanda R, Ivanov J, et al. Predictors of long-term outcome after crush stenting of coronary bifurcation lesions: importance of the bifurcation angle Am Heart J 2006;152:762-769.[CrossRef][Web of Science][Medline]
- Movahed MR. Coronary artery bifurcation lesion classifications, interventional techniques and clinical outcome Expert Rev Cardiovasc Ther 2008;6:261-274.[CrossRef][Medline]
Related Article
-
Reply
- Azeem Latib and Antonio Colombo
J. Am. Coll. Cardiol. Intv. 2008 1: 596-597.
[Full Text]
[PDF]
|
Top
REFERENCES