Medina Classification Research Articles

The shortcomings of the Medina compared to the Movahed coronary bifurcation classification.

The Medina classification separates true bifurcation lesions into three unnecessary groups: 1.1.1, 1.0.1, and 0.1.1. Non-true bifurcation lesions are divided into three unnecessary subgroups called 0.0.1, 0.1.0, and 1.0.0. Furthermore, the Medina classification does not describe any other important features of a given bifurcation lesion, making it useless when comparing complex bifurcation lesions. This has led to confusion in clinical settings and stagnation of bifurcation research. The Movahed bifurcation classification has overcome those problems by summarizing all true bifurcation lesions into one simple relevant category called B2 (B for bifurcation, 2 meaning both main and side branches at bifurcation site have significant lesions) and non-true bifurcation lesions into two simple categories called B1m (B for bifurcation, 1 m meaning only the main branch has significant lesion) and B1S lesions (B for bifurcation and 1 s meaning only the side branch has significant lesion). Moreover, at the same time, additional unlimited suffixes can be added if needed to describe a given bifurcation lesion, making this bifurcation also very comprehensive. In this perspective, the shortcomings of the Medina classification compared to the Movahed classification are discussed in detail.

Long-Term Outcomes of True versus Non-True Coronary Bifurcation Lesions Treated with Bioresorbable Polymer Sirolimus-Eluting Ultimaster Stent under Intravascular Imaging Guidance.

Limited evidence exists regarding the long-term outcomes of true vs. non-true coronary bifurcation lesions (CBLs) treated with current-generation drug-eluting stents and intravascular imaging guidance. The SCVC (Sapporo Cardiovascular Clinic) registry was a prospective, single-center, all-comers registry enrolling 1,727 consecutive patients treated with bioresorbable polymer sirolimus-eluting stent (BP-SES) under complete imaging guidance. From this registry, 440 patients with CBLs (25.5%) were analyzed. Patients were categorized into the true and non-true CBL groups according to the Medina classification (n=234 and 206, respectively). The primary endpoint was the cumulative incidence of target vessel failure (TVF; a composite of cardiac death, target vessel-related myocardial infarction, and clinically driven target vessel revascularization. One-stent strategy was predominantly chosen for both the true and non-true CBL groups (93.9% and 96.2%, respectively). During the median follow-up of 5.4 years, the cumulative incidence of TVF did not differ between true and non-true CBL groups after adjustment for baseline differences (five-year incidence; 22.0% vs. 17.7%, adjusted hazard ratio, 1.27 [95% confidence interval: 0.79-2.05]; P=0.32). Although the Medina 0.0.1 lesions were very rare (1.1%), they had the highest rate of TVF among the Medina subtypes. Final kissing balloon inflation technique was associated with a lower incidence of TVF (P=0.036). In conclusion, imaging-guided PCI with BP-SES resulted in comparable long-term clinical outcomes between true and non-true CBLs, primarily using the one-stent technique.

Impact of the distribution of calcification around the left main coronary artery bifurcation on prognosis after percutaneous coronary intervention

Abstract Backgrounds The presence of true bifurcation lesions (TBL) by Medina classification at the left main coronary artery (LMCA) bifurcation is known to be associated with cardiovascular events after percutaneous coronary intervention (PCI). However, the prognostic impact of the distribution of calcification at LMCA bifurcation has not been adequately investigated. Methods This retrospective study consisted of consecutive patients who were implanted with a second or subsequent generation drug-eluting stent for LMCA bifurcation at a single center from 2014 to 2018. We excluded patients with a protected LMCA and those in whom calcification or stenosis of the LMCA bifurcation could not be assessed. With reference to the Medina classification, the region was divided into three segments (LM, LAD, and LCX). Each segment was assigned a value of 0 (for less than moderate calcification) or 1 (for more than moderate calcification) and expressed as calc (X.X.X). Calc (1.1.1), calc (1.0.1), and calc (0.1.1) were defined as true bifurcation calcification (TBC). The primary endpoint was 3-year target lesion failure (TLF), a composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularization. Results Of 498 patients in this analysis, the mean age was 73 years, males accounted for 78% overall, acute coronary syndrome 31% overall, and TBL 42% overall. Moderate or severe calcification at any site around the LMCA bifurcation was observed in 184 (37%). In order of frequency, calc (1.1.0) in 70 (14%), calc (1.1.1) in 58 (12%), calc (0.1.0) in 43 (9%), calc (0.1.1) in 11 (2%), and calc (1.0.1) in 2 (0.4%), while calc (1.0.1) and calc (1. 0.0) were not present. TBC accounted for 14% overall. Patients with TBC at LMCA bifurcation had a higher incidence of 3-year TLF (Log-rank P <0.001; Figure1). Multivariable logistic regression, including age, acute coronary syndrome, maintenance hemodialysis, SYNTAX score ≥33, TBL, and TBC in the model as covariates, TBC was significantly associated with the primary endpoint (adjusted odds ratio 3.4, 95% confidence interval 1.6-7.2, P=0.013). In contrast, a significant association between TBL and the primary endpoint was not observed (adjusted odds ratio 1.5, 95% confidence interval 0.8-2.8, p=0.206). Conclusion Even after adjusting the presence of TBL at LMCA bifurcation, the presence of TBC at LMCA bifurcation was significantly associated with the 3-year TLF.

Early effect of different bifurcation techniques on left ventricular mechanics in elective percutaneous coronary intervention

BackgroundBifurcation lesions are prevalent amongst patients with symptomatic coronary artery disease subjected to percutaneous coronary intervention (PCI). Recent consensus commends a conservative (provisional) approach when managing the side branch. Here, the aim was to explore the immediate impact of different bifurcation techniques (one stent and two stent strategies) on left ventricular LV) myocardial functions using speckle tracking echocardiography in patients subjected to elective PCI. Sixty two consecutive patients diagnosed with coronary bifurcation lesion (CBL) were enrolled. Patients were categorized into: one-stent strategy (Provisional group, n = 44) and a two-stent strategy (TAP, DK crush, or Culotte technique, n = 18), based on the coronary bifurcation site, angle, side branch diameter and Medina classification. LVEF%, regional and global longitudinal strain (GLS), and E/E' were measured before and within 24 h post PCI.ResultsIn both provisional and 2- stent technique, the mitral inflow velocities and mitral annular velocities showed improvement with significant reduction in E/e' (P < 0.03 and P < 0.001) respectively while LVEF% did not change. There were no significant changes in any other echo parameters post PCI. In provisional group, there were significant improvements in LAD (P < 0.001), RCA (P < 0.01) territories and GLS (P < 0.01). Δ LAD was expressively higher (34.5%) compared with Δ LCX (9.6%) and ΔRCA (25.4%), P < 0.001, P < 0.01 respectively. In the 2-stent technique group, there were significant improvements in peak longitudinal strain of LAD territory (P < 0.01), RCA territory (P < 0.01) and GLS (P < 0.01) respectively. Δ LAD territory was significantly higher in provisional group in comparison with the 2- stent technique group. Δ GLS was correlated inversely to Gensini score in provisional group and to the number of vessel diseased in 2-stent technique group.ConclusionPCI of the bifurcation lesion positively impact myocardial function. Both bifurcation techniques improve LV mechanical properties using 2D strain imaging while LV EF% remains unchanged.

A Perspective on a Two-stent Approach in Bifurcation Cases

Abstract Bifurcation lesions are the cause of 20% of all percutaneous coronary interventions, representing a complex category associated with lower procedure success rates and higher restenosis rates. However, the optimal approach to bifurcation needs further research. This paper aims to determine the optimal method for implementing a two-stent strategy in bifurcation cases. It desires to identify the characteristics that can guide our approach and the outcomes that can be expected. This paper also highlights relevant trials that support the findings. In nontrue bifurcation cases (Medina 1-1-0, 1-0-0, 0-1-0, 0-0-1), a one stent strategy, eventually with the provisional approach, is preferable. When treating a left main or non-left main bifurcation in a Medina classification of 1-1-1, 1-0-1, or 0-1-1 without meeting at least one major and two minor criteria and of DEFINITION II Classification (simple true bifurcation), the layered provisional approach is the appropriate strategy. In cases of left main or non-left main complex true bifurcation (Medina 1-1-1, 1-0-1, 0-1-1) meeting the Definition II Classification criteria, a two-stent strategy could be a suitable option in cases where the SB is more than 2.5 mm and has a lesion length of more than 16 mm.

Kissing Balloon-Stent Technique for Simple Bifurcation Lesions.

Background: Coronary bifurcation lesions are commonly encountered during coronary angiography. The management of bifurcation lesions remains challenging, with various bifurcation techniques being available and outcomes varying depending on the Medina classification and operator experience. Methods: We present a short case series and the outcomes of a new bifurcation technique for the management of simple Medina '0,0,1' and '0,0,1' bifurcation lesions using the kissing balloon-stent technique (kissing BS). Results: We retrospectively identified 8 patients who underwent bifurcation stenting using the kissing Balloon-Stent technique, along with their clinical and angiographic follow-up outcomes. We also describe the benefits and limitations of the technique, delineate the potential mechanisms of target lesion failure, and outline appropriate patient selection. Conclusions: Kissing Balloon-Stent technique is a simple single stent technique that is safe and feasible in select patients with Medina '0,0,1' and '0,0,1' bifurcation lesions.

The impact of the bifurcation angle for the Nano-Crush two-stent coronary bifurcation technique on long-term outcomes in a real-world clinical population

AimThis study aims to assess the direct impact of bifurcation angle (BA) on immediate procedural outcomes and patient prognosis post-Nano-Crush stenting for coronary bifurcation lesions. MethodsA retrospective analysis was conducted for all consecutive patients treated with the Nano-Crush technique across two high-volume interventional centers from January 2020 to October 2022. Primary endpoint: comparison of target lesion failure rate in two cohorts based on bifurcation angle (<70° vs. ≥70°), with secondary endpoints including side branch ostium coverage, rate of successful final kissing balloon inflation (FKBI), need for conversion to another technique, and procedure length. ResultsBaseline demographics included 71 patients in the BA<70° group and 49 in the BA≥70° group, with well-balanced characteristics. Angiographic characteristics revealed similar trends, including anatomic and morphological lesion characteristics (referencing Syntax score, Medina classification, and presence of calcifications). Both groups predominantly had complex coronary disease, with a baseline mean Syntax score of 24.18 ± 8.19 in the BA<70° group and 23.91 ± 7.29 in the BA≥70° group, respectively. A dedicated debulking device for lesion preparation was used in 25.35 % of patients in the first group and in 28.57 % of patients in the second group.The primary endpoint occurred in 5.63 % of patients in the BA<70° group and in 4.08 % of patients in the BA≥70° group (P = 0.7014) after ≥ 2 years of clinical follow-up. Angiographic success was achieved in 100 % of both groups, with procedural time averaging 74.99 ± 25.55 min in the BA≥70° and 76.94 ± 27.81 min in the BA<70° (P = 0.6922). The rate of successful final kissing balloon inflation was 98.59 % in the BA<70° group and 95.91 % in the BA≥70° group (P = 0.3566). The mean contrast volume was 189.54 ± 73.74 ml in BA<70° and 168.9 ± 62.77 ml in BA≥70° (P = 0.1126). Clinical follow-ups at 30 days and 2 years revealed similar outcomes and complications for each group, as summarized in Table 3. ConclusionsOur results demonstrate that the bifurcation angle does not significantly impact long-term clinical outcomes or procedural parameters, such as side branch ostium coverage, conversion to a modified DK Crush technique, FKBI success rate, and procedure length. These findings suggest that the Nano-Crush technique can be a viable option for bifurcation lesions, irrespective of the bifurcation angle, achieving optimal side branch ostium coverage while preventing excessive protrusion into the main vessel.

Acute and long-term results of percutaneous coronary intervention of bifurcation lesions with the dedicated Bioss Lim C stent: the Italian BIfurcation Observational Spontaneous Study (IBIOSS).

Percutaneous coronary intervention (PCI) for bifurcation lesions still represents a clinical challenge. The Bioss Lim C is a dedicated device for bifurcation lesions, features a tapered shape and large cells, and thus appears as a promising adjunct to the current interventional cardiologists' armamentarium. We aimed at conducting a prospective multicenter study focusing on early and long-term results after Bioss Lim C implantation for true coronary bifurcation lesions. Patients with true bifurcation lesions in whom Bioss Lim C implantation was attempted were enrolled in four Italian centers. An explicit bifurcation management approach was recommended, leaving however the choice between one- vs. two-stent strategies at operator's discretion. Acute and long-term results were systematically appraised, focusing on an acute composite of complex side branch (SB) rewiring, SB pinching, or SB occlusion (primary efficacy endpoint), as well as major adverse events (MACE, i.e. death, myocardial infarction [MI], or target vessel revascularization [TVR]), individual components of MACE, and stent thrombosis. A total of 207 patients were included, with age of 67.3±10.8 years, and 40 (19.3%) women. The target lesion was located in the left main in 48 (23.2%) patients, whereas proximal reference vessel diameter was 3.69±0.48 mm, and lesion length 20.3±3.4 mm. According to the Medina classification, most patients (60 [30.9%]) had 1-1-1 lesions. Drug-eluting stent implantation in the SB was carried out in 19 (9.3%) subjects, and kissing balloon inflation was used in 67 (32.5%). The primary efficacy endpoint occurred in 27 (13.0%), with side branch (SB) occlusion in two (1.0%), SB pinching in 23 (11.1%), and complex SB rewiring in six (2.9%), and was most frequent in patients with lower body mass index or dyslipidemia. After 24.1±19.5 months, MACE were adjudicated in 23 (11.1%) subjects, with death in 10 (4.8%), MI in six (2.9%), and TVR in seven (3.4%), as well as stent thrombosis in one (0.5%). This study supports a wider adoption of the Bioss Lim C dedicated bifurcation device, thanks to the favorable acute results as well as long-term clinical outcomes, as well as its versatility for the stenting strategy provisionally or eventually adopted by operators.

A Modified Medina and Movahed (3M) Classification of Coronary Bifurcation Lesions.

A Modified Medina and Movahed (3M) Classification of Coronary Bifurcation Lesions.

Coronary Bifurcation Stenting Influenced by the Medina Classification in Image-Guided Procedures

Coronary Bifurcation Stenting Influenced by the Medina Classification in Image-Guided Procedures

Left Main Rotablation: Case Series From a Tertiary Care Centre in North India

Background: Calcified left main (LM) disease is an important subset of coronary artery disease, associated with a high risk and procedural complexity. Advances in percutaneous coronary intervention (PCI) are making it a viable alternative to coronary artery bypass grafting. Methods: This was a retrospective study of patients aged ≥18 years who underwent rotational atherectomy (RA)-assisted PCI of LM disease at a tertiary-care centre in North India from August 2018 to May 2023. PCIs also involved use of intravascular ultrasound and adjuvant plaque-modifying therapies, such as cutting balloons, and intravascular lithotripsy, as indicated. Procedural details and clinical outcomes were analysed. Results: The study included 55 consecutive patients. A total of 52 patients (94.5%) were men, and the mean age was 64.7 ± 9.0 years. The mean follow-up was 16.3 ± 11.2 months. The mean ejection fraction was 52.7 ± 8.2%. On angiography, the mean SYNTAX score was 34.9 ± 7.7, and true bifurcation lesions (Medina class 1,1,1 or 1,1,0) were present in 22 patients (40%). Adjuvant plaque modification therapy included a cutting balloon in 25 patients (45.5%), and intravascular lithotripsy in nine (16.4%). Intravascular ultrasound guidance was used in 46 patients (83.6%). Supported PCI was performed in six cases (10.9%). Angiographic success was achieved in 100% of the patients. One patient (1.8%) died in hospital due to an upper gastrointestinal bleed. On follow-up, one patient died (1.8%), and target vessel revascularisation was needed for three patients (5.5%). Conclusion: Rotational atherectomy-assisted PCI for calcific LM disease can be performed safely, with judicious use of intravascular ultrasound and adjunct plaque modification therapies, providing satisfying short- to medium-term outcomes.

Impact of Medina classification on clinical outcomes of imaging-guided coronary bifurcation stenting

BackgroundIntracoronary imaging improves clinical outcomes after stenting of complex coronary bifurcation lesions (CBLs), but the impact of Medina classification-based CBL distribution on outcomes of imaging-guided bifurcation stenting is unclear. MethodsIn this integrated analysis of four previous studies, in which all CBLs were treated with drug-eluting stents under intravascular ultrasound or optical coherence tomography guidance, the distribution of 763 CBLs was assessed using angiographic Medina classification. Major adverse cardiac events (MACE), including target lesion revascularization (TLR), myocardial infarction, stent thrombosis, and cardiac death, were investigated at 1-year follow-up. ResultsThe most and least prevalent Medina subtypes were 0-1-0 (27.9 %) and 0-0-1 lesions (2.8 %). The most and least frequent MACE/TLR rates were 18.2 %/18.2 % for 0-0-1 lesions and 4.1 %/2.8 % for 0-1-0 lesions. Risks were higher for 0-0-1 lesions than for 0-1-0 lesions for both MACE (hazard ratio [HR]: 4.04, 95 % confidence interval [CI]: 1.21–13.45, p = 0.02) and TLR (HR: 6.19, 95 % CI: 1.69–22.74, p = 0.006). MACE rates were similar for true and non-true CBLs excluding 0-0-1 lesions (8.2 % and 5.9 %, HR 1.54, 95 % CI: 0.86–2.77, p = 0.15), while MACE (HR: 3.25, 95 % CI: 1.10–9.63, p = 0.03) and TLR (HR: 4.24, 95 % CI: 1.38–12.96, p = 0.01) risks were higher for 0-0-1 lesions. ConclusionsThis integrated analysis of imaging-guided bifurcation stenting demonstrated similar clinical outcomes in true and non-true CBLs, except for 0-0-1 lesions, which had a significantly higher risk of MACE/TLR.

B-16 | The RESOLUTE ONYX Bifurcation Study: 3-Year Outcomes in Patients With Coronary Bifurcation Lesions

Coronary bifurcation lesions are challenging to treat, with higher risk of procedural complications and adverse events than non-bifurcation lesions. In this study, we evaluated the 3-year clinical outcomes in patients with bifurcation lesions treated with the Resolute Onyx zotarolimus-eluting stent (ZES). Patients with a single bifurcation target lesion undergoing planned treatment using the provisional stenting technique were enrolled at 25 centers in the United States and Europe. Inclusion criteria included main branch reference vessel diameter (RVD) 2.25-5.0 mm, lesion length ≤35 mm, stenosis ≥50%, side branch ≥2.0 mm, and TIMI flow ≥2. The primary endpoint was target vessel failure (TVF) at 1-year. Follow-up was for 3 years. Between Apr 2017 to Dec 2019, 205 patients with 209 bifurcation lesions (of 267 total) were enrolled. Patients were 66.6 ± 10.7yrs, 21.5% female, 26.3% type II diabetic, 35.1% had previous PCI. Core lab analysis showed that 32.5% of lesions were true bifurcation lesions per Medina classification (1.1.1, 1.0.1, 0.1.1). Target vessel RVD was 2.65 ± 0.47 mm and lesion length was 17.03 ± 9.64 mm. 12.1% of patients had TVF through 3 years. There were no instances of stent thrombosis (Figure). Patients with coronary bifurcation lesions treated with the Resolute Onyx ZES had favorable long-term clinical outcomes at 3 years, with only 6% of target lesion revascularization and no cases of stent thrombosis. These results support the use of Resolute Onyx ZES to treat complex coronary bifurcation lesions using a planned provisional stenting technique, safely and effectively.

Anatomical classification of chronic total occlusions in coronary bifurcations.

Percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) in coronary bifurcation lesions (CBL) is undergoing substantial technical progress and standardization, paralleling the evolution of dedicated devices, tools, and techniques. A standard consensus to classify CTO-CBL might be instrumental to homogenize data collection and description of procedures for scientific and educational purposes. The Medina-CTO classification replicates the classical three digits in Medina classification for bifurcations, representing the proximal main vessel, distal main vessel, and side branch, respectively. Each digit can take a value of 1 if it concerns atherosclerosis and is anatomically stenosed, or 0 if it is not. In addition, the occluded segment(s) of the bifurcation are noted by a subscript, which describes key interventional features of the cap: t (tapered), b (blunt), or a (ambiguous). This approach results in 56 basic categories that can be grouped by means of different elements, depending on the specific needs of each study. Medina-CTO classification, consisting of adding a subscript describing the basic cap characteristics to the totally occluded segment(s) of the standard Medina triplet, might be a useful methodological tool to standardize percutaneous intervention of bifurcational CTO lesions, with interesting scientific and educational applications.

Prediction of side branch occlusion in bifurcational lesions during percutaneous coronary interventions by preprocedural coronary computed tomography using the CT bifurcation score.

Coronary computed tomographic angiography (CCTA) is a highly diagnostically accurate non-invasive imaging method for a thorough evaluation of atherosclerotic plaques. Many CCTA-based imaging investigations concentrate on bifurcation lesions. To determine whether intraprocedural side branch (SB) obstruction during the percutaneous coronary intervention (PCI) of lesions involving bifurcations might be predicted by preprocedural CCTA. This retrospective observational study was conducted on 200 stentable bifurcation lesions of 200 coronary artery disease patients with the SB ≥ 2 mm in diameter. All patients were planned for elective bifurcation PCI after undergoing CCTA for quantitative plaque characterization of both the main vessel and SB to obtain the CT bifurcation score. Then, angiography-based bifurcations were classified using both the Medina classification and the RESOLVE score before PCI of the bifurcation lesions. Most of the cases were managed by the provisional technique. The CT bifurcation score was substantially higher in patients with SB occlusion (p < 0.001) with 80% sensitivity and 60% specificity at a cut-off point of 3. There was a borderline significant relation between the Medina score and SB occlusion in the studied cases (p = 0.05) with 60% sensitivity and 40% specificity. The RESOLVE score was unexpectedly an insignificant predictor of SB occlusion (p = 0.25) in our study, with 40% sensitivity and 50% specificity. Intraprocedural SB occlusion can be predicted by a comprehensive CCTA evaluation. The CT bifurcation score, a novel and simple points scoring system based on six CCTA parameters, outperformed current angiographic classification or scoring systems for predicting SB occlusion.

Effect of Clinical and Lesional Characteristics On Side Branch Compromise During Provisional Bifurcation Stenting

Background :One of the most serious side effects of percutaneous coronary intervention (PCI) for bifurcationlesions is major side branch (SB) blockage. PCI is used to treat coronary bifurcations lesions inabout 15-20% of cases. Because of the risk of SB compromise, PCI of coronary bifurcationlesions is frequently thought to be a difficult procedure.OBJECTIVE: The goal of this study was to investigate the clinical and lesional predictability ofsevere SB blockage during coronary bifurcation intervention.MATERIAL &amp; METHODS: It was a retrospective study performed at Cardiac CatheterizationLab, Punjab Institute of Cardiology, Lahore. It was a six months study from 15th April 2022 to14th Oct, 2022. 93 patients enrolled using non-probability sampling technique. Patients betweenthe ages of 30 and 70 of either gender, with coronary bifurcation lesions undergoing PCI and atleast one significant SB were included. Data was entered in the predesigned proforma. SPSSversion 24 was used to analyze our data.RESULTS: In our study a total of 93 patients were enrolled, the mean age of the cases was53.30 ± 1.12. There were 68 (73%) male and 25 (27%) females in our study. There were 52(56%) diabetic, 50 (54%) hypertensive, 63 (68%) smokers and 42 (45%) hypercholestrolemicpatients were present in our study. In our study 36 (39%) patients were found with family historyof CAD and 6 (7%) patients found with recent MI. LAD was most frequently utilized bifurcationlesion in our study. The mean of lesion length was 28.82 ± 10.91 in this study. SB angle was 41º-50º in most of the cases 20 (22%), side branch diameter stenosis post MV stenting was 70-75%in 40 (43%) cases. Medina classification 1,1,1 was found in 43 (46%) cases. In 62 (67%) casesno side branch jailing was observed. Side branch predilatation before MV stenting was found in72 (77%) cases. Need of stenting in SB was found in 60 (65%) cases. Most frequently usedtechnique for SB provisional stenting was DK crush and mini crush in this study.Keywords: Bifurcation Lesions, SB, PCI

Abstract 11910: Contemporary In-Hospital Outcomes of Bifurcation Percutaneous Coronary Interventions: Update From the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION)

Introduction: Bifurcation percutaneous coronary intervention (PCI) techniques are rapidly evolving and can be challenging to perform. Methods: We examined the angiographic, procedural characteristics, and outcomes of 472 bifurcation PCIs in Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION, NCT05100992). Results: A total of 472 bifurcation PCIs were included. Mean age was 67±12 years, 74% were men with a high prevalence of comorbidities: hypertension (81%), diabetes mellitus (36%), dyslipidemia (90%). Overall technical success was 95%. The incidence of in-hospital major adverse cardiovascular events (MACE) was 5.1%. The most common stenting strategy was provisional (71%), double-kissing (DK) crush (12%), mini-crush wish 2 stents (3%), culotte (3%), T-and protrusion (4%), and T-stenting (1.5%). Patients treated with the DK-crush had more severe stenosis of the left main (35%±38 vs. 19%±30, p&lt;0.001), proximal left anterior descending (68%±29, vs. 52%±35, p=0.001), and side branch lesion (82%±15, 51%±36, p&lt;0.001). Medina classification was more often 1,1,1 (79% vs. 39%, p&lt;0.001), with higher use of intravascular ultrasound/optical coherence tomography (57% vs. 31%, p&lt;0.001) compared to non-DK crush. The DK-crush required use of more contrast and took longer to perform (Table). Conclusions: Despite high patient comorbidity, bifurcation PCI can be performed with high technical success and low in-hospital MACE rates. DK-crush technique was more commonly preferred in bifurcation lesions with more severe/proximal vessel involvement.

Medina classification since its description in 2005

Medina classification since its description in 2005

Clinical Outcomes of Percutaneous Coronary Intervention for Bifurcation Lesions According to Medina Classification.

BackgroundCoronary bifurcation lesions (CBLs) are frequently encountered in clinical practice and are associated with worse outcomes after percutaneous coronary intervention. However, there are limited data around the prognostic impact of different CBL distributions.Methods and ResultsAll CBL percutaneous coronary intervention procedures from the prospective e‐Ultimaster (Prospective, Single‐Arm, Multi Centre Observations Ultimaster Des Registry) multicenter international registry were analyzed according to CBL distribution as defined by the Medina classification. Cox proportional hazards models were used to compare the hazard ratio (HR) of the primary outcome, 1‐year target lesion failure (composite of cardiac death, target vessel–related myocardial infarction, and clinically driven target lesion revascularization), and its individual components between Medina subtypes using Medina 1.0.0 as the reference category. A total of 4003 CBL procedures were included. The most prevalent Medina subtypes were 1.1.1 (35.5%) and 1.1.0 (26.8%), whereas the least prevalent was 0.0.1 (3.5%). Overall, there were no significant differences in patient and procedural characteristics among Medina subtypes. Only Medina 1.1.1 and 0.0.1 subtypes were associated with increased target lesion failure (HR, 2.6 [95% CI, 1.3–5.5] and HR, 4.0 [95% CI, 1.6–9.0], respectively) at 1 year, compared with Medina 1.0.0, prompted by clinically driven target lesion revascularization (HR, 3.1 [95% CI, 1.1–8.6] and HR, 4.6 [95% CI, 1.3–16.0], respectively) as well as cardiac death in Medina 0.0.1 (HR, 4.7 [95% CI, 1.0–21.6]). No differences in secondary outcomes were observed between Medina subtypes.ConclusionsIn a large multicenter registry analysis of coronary bifurcation percutaneous coronary intervention procedures, we demonstrate prognostic differences in 1‐year outcomes between different CBL distributions, with Medina 1.1.1 and 0.0.1 subtypes associated with an increased risk of target lesion failure.

Comparison of the Incidence of Periprocedural Myocardial Infarction in Bifurcation Lesions Between Medina (1,1,1) and (0,1,1) in Elective Percutaneous Coronary Intervention.

Periprocedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) is more frequently observed in true bifurcation lesions such as Medina (1,1,1) and (0,1,1). The aim of this study is to compare the incidence of PMI in elective PCI between Medina (1,1,1) and (0,1,1) bifurcation lesions. This was a retrospective, single-center study. We included 162 true bifurcation lesions, which were divided into the (1,1,1) group (n = 85) and the (0,1,1) group (n = 77). We compared the incidence of PMI between the two groups and performed multivariate logistic regression analysis using PMI as a dependent variable. The incidence of PMI was similar in the (1,1,1) group and the (0,1,1) group (12.9% versus 15.6%, P = 0.658). The final TIMI flow grade of the side branches and that of the main branches were also similar in the two groups. In multivariate logistic regression analysis, Medina classification (1,1,1) was not associated with PMI (odds ratio (OR), 0.996; 95% confidence interval (CI), 0.379-2.621; P = 0.994), but the angle of the side branch < 45° (OR, 3.569; 95% CI, 1.320-9.654; P = 0.012), lesion length in a main vessel (per 10-mm increase) (OR, 1.508; 95% CI, 1.104-2.060; P = 0.010), and absence of side branch protection (OR, 3.034; 95% CI, 1.095-8.409; P = 0.033) were significantly associated with PMI. In conclusion, the Medina (1,1,1) bifurcation lesions did not increase the incidence of PMI as compared to Medina (0,1,1). However, the narrow side branch angle, diffuse long lesion, and absence of side branch protection were significantly associated with PMI. We should pay attention to these high-risk features in the treatment of true bifurcation lesions.