CTO and Bifurcation Lesions: An Expert Consensus From the European Bifurcation Club and EuroCTO Club
Thierry Lefèvre1, Manuel Pan2, Goran Stankovic3
1Institut Cardiovasculaire Paris Sud, Hôpital Privé Jacques Cartier, Ramsay Santé, Massy, France.
Insights
Percutaneous treatment of chronic total occlusions (CTOs) often involves complex bifurcation lesions. This consensus provides practical strategies for managing side branches (SBs) to prevent occlusion and improve outcomes.
Area of Science:
- Interventional Cardiology
- Vascular Biology
- Medical Device Technology
Background:
- Significant advancements in treating bifurcation lesions and chronic total occlusions (CTOs) have occurred over two decades.
- Bifurcation lesions with side branches (SBs) are encountered in approximately one-third of CTO percutaneous treatments.
- SB occlusion during CTO procedures can lead to complications and adverse patient outcomes.
Purpose of the Study:
- To provide a joint consensus statement from the European Bifurcation Club and EuroCTO Club.
- To share knowledge and practical approaches for managing complex bifurcation lesions during CTO interventions.
- To offer guidance on preventing SB occlusion and improving procedural success rates.
Main Methods:
- Review and synthesis of current knowledge and techniques in bifurcation lesion management.
- Emphasis on simple rules for preventing SB occlusion, including early wiring and respecting fractal anatomy.
- Discussion of specific techniques such as provisional SB stenting, 2-stent approaches, retrograde techniques, and use of advanced imaging and devices.
Main Results:
- Provisional SB stenting is the recommended approach in most cases.
- Simple rules like the 3-diameter rule and avoiding certain dissection/re-entry techniques are crucial.
- Retrograde approaches and intravascular ultrasound are valuable for complex bifurcations, especially at distal caps or within CTOs.
- Specialized microcatheters aid in accessing difficult SBs or main branches.
Conclusions:
- Effective management of bifurcation lesions during CTO interventions requires adherence to established principles and utilization of advanced tools.
- Preventing SB occlusion is key to improving procedural success and patient outcomes in complex CTO cases.
- This consensus provides a practical framework for interventional cardiologists dealing with these challenging anatomies.
Abstract:
Knowledge in the field of bifurcation lesions and chronic total occlusions (CTOs) has progressively improved over the past 20 years. Therefore, the European Bifurcation Club and the EuroCTO Club have decided to write a joint consensus statement to share general knowledge and practical approaches in this complex field. When percutaneously treating CTOs, bifurcation lesions with relevant side branches (SBs) are found in approximately one-third of cases (35% at the proximal cap, 38% at the distal cap, and 27% within the CTO body). Occlusion of a relevant SB is not rare and has been shown to be associated with procedural complications and adverse outcomes. Simple bifurcation rules are very useful to prevent SB occlusion, and provisional SB stenting is the recommended approach in the majority of cases: protect the SB as soon as possible by wiring it, respect the fractal anatomy of the bifurcation by using the 3-diameter rule, and avoid using dissection and re-entry techniques. A systematic 2-stent approach can be used if needed or sometimes to connect both branches of the bifurcation. The retrograde approach can be very useful to save a relevant SB, especially in the case of a bifurcation at the distal cap or within the CTO body. Intravascular ultrasound is also a very important tool to address the difficulties with bifurcations at the proximal or distal cap and sometimes also within the CTO segment. Double-lumen microcatheters and angulated microcatheters are crucial tools to resolve access difficulties to the SB or the main branch.
