Medtronic Supplement November 2021

November 2021 | Educational Supplement

cardiovascularnews.com

This educational supplement has been sponsored by Medtronic

Introduction

Branch notes: Understanding bifurcation lesions Optimal treatment strategies for coronary bifurcation lesions—the narrowing of a coronary artery adjacent to or involving the origin of a significant side branch— remain a subject of major debate, even though it is more than 15 years on from the publication of the first large randomised trial to investigate the ideal stenting strategy in these lesions—the NORDIC Bifurcation study. Due to the complex nature of these cases, and the continued deliberation over the utilisation of the available techniques, there remains a great deal of urgency in understanding the fundamentals of approaches related to bifurcation lesions. This is particularly relevant given that these cases account for as many as 30% of all percutaneous coronary intervention (PCI) cases.

CENTRAL TO THE DEBATE IS THE choice to adopt a provisional (single-stent) or an up-front dual stent approach—which can comprise either the double kissing (DK crush), culotte or T and small protrusion (TAP) techniques. Various randomised studies have sought to shed light on the available strategies, chief among them the DEFINITION, BBC ONE and DKCRUSH trials, and most recently the EBC MAIN trial, which addresses the use of a provisional single stent approach, versus up-front double stenting in patients with true bifurcation distal left main disease.

According to Mirvat Alasnag (King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia), a major challenge in the treatment of bifurcation lesions is the acquisition of technical skills to be able to perform twostent techniques safely and correctly. “The default strategy is usually provisional with a single stent, lending fewer opportunities for operators to develop their skill,” she comments. Furthermore, the wide variation in the anatomy of bifurcation lesions, which can vary dramatically, even among those with a similar classification, also poses a significant challenge for operators. “Some may have a wide angle, and others may not; some may have a secondary branch, and others may not,” she comments to illustrate this point.

“Despite the fact that we are in the era of the drug-eluting stent, stenting of coronary bifurcation lesions is associated with suboptimal clinical results including more frequent stent thrombosis and unplanned repeat revascularisations compared with nonbifurcation lesions,” adds Beatriz Vaquerizo (Hospital del Mar, Barcelona, Spain). Many coronary bifurcation trials—particularly those focusing on non-left main lesions— have shown a lack of benefit associated with systematic two-stent strategies. However,

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explains Vaquerizo, as provisional stenting may require crossover to a second stent in more than one third of cases, this may also result in higher rates of clinical recurrence compared to a two-stent approach.

“In prior multicentre randomised trials, the DK crush, planned two-stent technique resulted in lower rates of target lesion revascularisation (TLR) compared with provisional stenting in non-left main bifurcation lesions,” she remarks, adding that the best PCI bifurcation technique still remains a matter of debate. “For the distal left main, it might be expected that these differences would be magnified, given the wide angle of separation between the two vessels, the heavy calcification often involved and the fact that neither vessel is a side branch,” Vaquerizo comments.

Stent strategies

Non-randomised data uniformly suggest that outcomes are worse with a two-stent strategy, but randomised data support the DK crush technique for true bifurcation left main disease, and support this technique over the culotte approach. Although some studies have reported that routine use of a twostent technique is not advantageous, the DK crush approach has demonstrated superiority to other approaches in bifurcations with increased complexity—for example those with a side branch lesion length >10mm— or in distal left main lesions, Vaquerizo details.

Classification of bifurcated lesions is a further area of challenge, and although a number of classification systems have been put

forward to characterise coronary bifurcation lesions, both Alasnag and Vaquerizo note that the most widely used of these is the Medina Classification. The Medina Classification assesses plaque burden based upon the presence (“1”), or absence (“0”), of stenosis in the proximal main branch, distal main branch, and side branch. Alasnag comments that, despite being the most widely used system, the Medina Classification does have limitations, which include the determination of the angle of the side branch, significance of the side branch, and length of the disease in the side branch and trifurcating lesions.

Medina is the means of categorising bifurcation lesions favoured by the European Bifurcation Club (EBC), a committee of

The most important consideration is the underlying anatomy and operator expertise. If the side branch disease is significant and the vessel is important such as a dominant left circumflex artery, it is important to secure the vessel with a stent.”

Mirvat Alasnag

experts in the interventional cardiology field who have shaped thinking on bifurcation lesions since 2004. EBC members seek to build consensus on the treatment strategies for bifurcation lesions, and an important recent development from the group is the publication of its 15th consensus statement, summarising the latest expert view on coronary bifurcation lesions and unprotected left main percutaneous interventions.

The consensus statement notes that, while bifurcation stenting techniques continue to be refined, a provisional approach with optional side November 2021

Bifurcation lesions: Exploring the latest science

branch treatment utilising T, TAP or culotte techniques continues to provide flexible options for the majority of coronary bifurcation lesion patients, whilst also acknowledging the ongoing debate regarding the optimal treatment of side branches, including assessment of clinical significance and thresholds for bail-out treatment.

In more complex coronary bifurcation lesions—particularly those involving the left main—the EBC consensus document notes that dedicated two-stent techniques should be considered.

Summarising other key components of the latest EBC consensus statement, Alasnag comments that the document provides

Despite the fact that we are in the era of the drug-eluting stent, stenting of coronary bifurcation lesions is associated with suboptimal clinical results including more frequent stent thrombosis and unplanned repeat revascularisations compared with nonbifurcation lesions.”

Beatriz Vaquerizo

important guidance on proximal optimisation, kissing inflations, use of fractional flow reserve (FFR) to assess side branch disease, the use of simulation, and the use of intracoronary imaging to optimise two-stent strategies and left main disease.

“Importantly,” she notes, “It emphasises the heart team in all decision making.”

“Operators using such techniques have to be fully familiar with their procedural steps and should acknowledge associated limitations and November 2021

challenges,” adds Vaquerizo, commenting on the important messaging from the latest EBC consensus statement, as well as noting that intracoronary imaging, drug-eluting balloon technology and tailored antiplatelet therapy have been identified as promising tools to enhance clinical outcomes.

Important considerations

Taking current thinking into account, both Alasnag and Vaquerizo also consider the important aspects to note when deciding to opt for a one-stent or two-stent approach.

“The most important aspect is the underlying anatomy and operator expertise,” says Alasnag. “If the side branch disease is significant and the vessel is important such as a dominant left circumflex artery, it is important to secure the vessel with a stent.”

As such, she continues, a two-stent strategy is likely to be required. “The choice of technique largely depends on the angle, but also operator comfort. Two stents are also used if flow is compromised in the side branch after treating the main vessel.” For Vaquerizo, the most significant parameters when dictating a one- or two-stent strategy are the bifurcation type, lesion location (whether it is in the left main or not) and lesion complexity.

Mirvat Alasnag is the director of the Catheterization Laboratory at King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia, and serves on a number of councils including the American College of Cardiology (ACC) Interventional Leadership, Society for Cardiovascular Angiography & Interventions (SCAI) Board of Trustees, and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Women’s Steering Committee.

Beatriz Vaquerizo is the chief of the Cardiology Department, Hospital del Mar, Barcelona, Spain.

Her main areas of research include intracoronary imaging techniques, ischaemic heart disease, and coronary arteriosclerosis. Vaquerizo is also a member of the Spanish Society of Cardiology (FEC), the Catalan Society of Cardiology (SCC), and an associate member of SCAI.

Left main bifurcations in focus The left main is the largest bifurcation of the coronary tree and is easier to access, and it is estimated that it supplies >75% of the left ventricular myocardium in cases of right dominant coronary circulation. Its reference diameter can make stent delivery more straightforward, but the proximal location of the vessel can prove challenging. Although the usual technical strategies implemented in coronary bifurcations can generally be applied to left main lesions, a number of important characteristics, including the ostial position of the main branch, the size of the side branch, the amount of calcification, the angle which is often in a T shape, the use of stents of variable suitability, the crucial role of proximal optimisation technique (POT) need to be taken into account in order to achieve optimal results.

Explore bifurcation techniques further The Bifurcation Exploration website details five step-by-step bifurcation techniques with endoscopic imaging that detail what is happening inside the vessel at each stage.

The website was developed in collaboration with the Visible Heart Lab at the University of Minnesota.

Scan here to visit the Bifurcation Exploration website.

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EBC Main

The left main agenda

“I think this has filled a very important void in our knowledge base,” Darren Mylotte (University Hospitals Galway, Galway, Ireland) tells Cardiovascular News, summing up some of the key take-away messages from EBC Main—the European Bifurcation Club Left Main trial. In this interview, he details the relevance and implications of the findings.

“ANY DATA ON LEFT MAIN bifurcations are very important, as we have ongoing controversy over whether these patients should be treated with surgical or percutaneous revascularisation,” says Darren Mylotte, commenting on the recent release of the EBC Main trial, first presented at EuroPCR 2021 (18–20 May, virtual) and published simultaneously in the European Heart Journal.

EBC Main sought to shed light on the merits of a provisional, single-stent approach versus up-front double stenting in 467 patients with true bifurcation distal left main disease. Only two other trials, to date, the DKCRUSH-V and DEFINITION II trials, have looked at the same question, and results of these studies favoured an up-front two-stent strategy with the DKCRUSH technique. EBC Main, Mylotte says, addressed a very important subset of patients with left main disease, those with involvement of both branches—distal left main bifurcations. “These account for nearly 80% of all patients with left main disease and certainly represent the more complex left main lesions,” Mylotte comments. “In these patients, it had become more common to use two stents up-front based on the only randomised evidence available.”

The study had a primary composite endpoint of one-year death, myocardial infarction and target lesion revascularisation, which occurred at the rate of 14.7% in the provisional vs. 17.7% in the up-front two-stent group (Hazard ratio 0.8, 95% confidence interval 0.5‒1.3, P=0.34 ).

Additionally, the trial did not detect any significant differences for any of the individual components of the primary endpoint. The rates of stent thrombosis were similar, 1.7% in the provisional arm and 1.3% in patients treated with up-front double stenting.

The core message from EBC Main comes through “loud and clear,” according to Mylotte. “If you have a patient with a distal left main stem, a provisional, single-stent approach is an appropriate initial strategy to follow,” he says. However, this does not rule out a dual-stent approach entirely. “You do not have to make a decision to implant two stents at the start of the procedure. Rather

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Darren Mylotte

You do not have to make a decision to implant two stents at the start of the procedure. Rather one can make a pragmatic decision as the procedure evolves, evaluating your progress as you move forward in the case, and decide whether you need a second stent later on in the procedure.” one can make a pragmatic decision as the procedure evolves, evaluating your progress as you move forward in the case, and decide whether you need a second stent later on in the procedure,” Mylotte adds.

Will the findings from EBC Main change the approach to the treatment strategies

adopted in left main bifurcation lesions?

Mylotte believes, and hopes, they will. He comments: “In general, I would hope that operators would now approach distal left main lesions in a more pragmatic, rather than dogmatic fashion. Both provisional and two-stent techniques can be appropriate, according to the anatomy and the operator’s experience. In the type of patients that were included in EBC Main, where the disease in the side branch is not extensive and relatively short, that an upfront provisional approach is appropriate with the option to transition to a two-stent approach in the 20% of patients that need it. The provisional approach is a more simple and straightforward technique compared to DK-Crush and the information detailing clinical equipoise between these strategies is important for the field.”

How do these findings compare to the existing literature on the topic? Comparing EBC Main to the DKCRUSH V study, Mylotte says that it is challenging to make a direct comparison, due to the difference in the nature of the patients studied in the trials.

Patients in the DK-Crush V trial tended to have longer more diffuse side-branch lesions compared to those in EBC Main, he explains, meaning that using a second stent in these patients may be more frequently required.

Nevertheless, he adds, the data from EBC Main suggest that both strategies have appropriate applications, and both work well in the right patients. Offering advice for colleagues about honing their technique, he summarises: “I think it is important that people get good at doing one of these strategies, but always have a second strategy when required. I think the data are very much complementary. Things work well when you are good at it. So get familiar with one strategy.”

Considering future areas of investigation in left main bifurcation treatment, Mylotte comments that the use of intravascular imaging was only around 40% in EBC Main, adding that further evidence demonstrating that the routine use could yield improvement in longer-term outcomes is required. He concludes: “We should continue to document the benefits of intravascular imaging in complex lesions.”

Darren Mylotte is a senior lecturer and consultant cardiologist at the University Hospital and National University of Ireland Galway (Galway, Ireland). He is a deputy editor of EuroIntervention and a course codirector for PCR London Valves.

November 2021

Stent choice

Bifurcation lesions: Exploring the latest science

Fundamentals in stent selection for optimal treatment of bifurcation lesions In treating bifurcation lesions not only does the number of stents matter, but the selection of the right tool from the armoury is also a fundamental consideration. From deliverability to expansion capabilities, there are a series of design attributes that influence the performance of a stent in these challenging lesions. This is the message underscored by David HildickSmith, a lead investigator in the EBC Main trial, who speaks to Cardiovascular News about the developments in stent design, and how these impact the treatment strategy in bifurcation lesions,

What are the most important attributes for a stent for treatment of bifurcation lesions?

For a drug-eluting stent (DES) to perform well in the treatment of bifurcation lesions, it needs to be flexible as well as deliverable.

Further to these points, it also needs to be able to resist longitudinal compression.

To what extent does overexpansion capacity influence a stent’s suitability for bifurcation lesions?

Overexpansion is a very important aspect for a stent platform used in the treatment of bifurcation lesions. This is particularly important when considering DESs that may run from the left main stem to either the circumflex artery or the left anterior descending (LAD) artery. It is ideal for a stent to be able to offer adequate expansion capacity. However, not all of the stents that are currently available on the market offer expansion capacity that is suitable for use in this setting.

Is stent selection influenced by the choice of stenting approach being used in the lesion?

If you are planning a culotte stent technique then the proximal part of the side vessel stent has to expand appropriately and therefore stent choice may depend on this capability.

EBC Main: One-year clinical outcomes of planned single-stent versus up-front two-stent strategy for true bifurcation distal left main disease

What have been the biggest developments in stent technology over time to help with the treatment of bifurcation lesions?

Reduction in stent strut thickness has had a big impact on deliverability. Some years ago it was not unusual to find that stent delivery was difficult, however these days, with developments in stent technology, particularly featuring thinner struts, that is rarely the case.

Are there any particular features of the Medtronic Resolute Onyx stent that make it particularly suitable in these cases?

The Resolute Onyx is highly deliverable which makes it excellent for left main lesions that may be particularly calcified or angulated. The 4.5mm and 5mm stent diameters can be useful in the left main and these will expand to 6mm with ease. In addition the radial strength of the stent is maintained with overexpansion and this is a valuable attribute.

David Hildick-Smith is a professor of Interventional Cardiology and consultant cardiologist at the Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton, UK. He is ex-Treasurer of the British Cardiovascular Interventions Society (BCIS).

The European Bifurcation Club Left Main (EBC MAIN) trial addressed the issue of provisional single stent versus up-front double stenting in 467 patients with true bifurcation distal left main disease.

The trial's primary message is that no difference was noted in terms of the studied clinical outcomes between the planned single stenting and the up-front use of two-stent

November 2021

David HildickSmith

Reduction in stent strut thickness has had a big impact on deliverability. Some years ago it was not unusual to find that stent delivery was difficult at times.

These days that is rarely the case.”

techniques. Importantly, 22% of patients randomised to a planned single-stent strategy were ultimately treated with two stents.

The primary composite endpoint of one-year death, myocardial infarction (MI) and target lesion revascularisation occurred at the rate of 14.7% in the provisional versus 17.7% in the up-front two-stent group (hazard ratio 0.8, 95%

confidence interval 0.5–1.3).

Furthermore, no significant difference was detected for any of the individual components of the primary endpoint. The rates of stent thrombosis were similar, 1.7% in the provisional arm and 1.3% in patients treated with up-front double stenting.

EBC Main used the Resolute Onyx (Medtronic) zotarolimuseluting coronary stent.

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Bifurcation techniques

Bifurcation lesions: Steps to success In the history of bifurcation stenting many different ways to implant drug-eluting stents (DESs) have been proposed, says Francesco Burzotta (Agostino Gemelli University Policlinic, Rome, Italy), noting that a number of trials have compared double- and single-stenting techniques.

“OVERALL, OUTSIDE OF LEFT main bifurcations, there were consistent signals in favour of single-stenting techniques,” he comments. “The novelty of the last prospective randomised trial in the field, EBC Main, is the fact that provisional stenting may also be as effective as double stenting in complex left main bifurcated lesions,” says Burzotta, himself a member of the team of investigators in the trial. “An important message is that one stent may be enough for many patients undergoing percutaneous coronary intervention (PCI) on left main bifurcation”, Burzotta adds.

In the past few years, it has been established that there are many ways to achieve good results in both the main vessel and the side branch, backed up by both the EBC group studies and consensus documents.

“It has emerged that there are not only different techniques to implant two stents, but also better steps allowing to start by implanting one stent and eventually proceed, if deserved, with the second stent,” he adds.

This was the situation prior to the presentation of the EBC Main trial results, which were released at EuroPCR 2021 (18– 20 May, virtual). After investigating the use of a (EBC-proposed) stepwise provisional or double-stenting approach in 467 patients with true left main stem bifurcation lesions, the study found that numerically fewer major adverse cardiac events occurred using this approach compared to dual stenting.

Although the differences were not statistically significant, the signal for safety of this approach was consistent and associated with less use of consumables during the PCI. “We are reminded that the double-stent techniques can be effective, but they are systematically complex techniques that deserve so many steps that may seldom create problems during the procedure flow,” says Burzotta. “An operator that starts a procedure with the aim of implanting two stents starting with the side branch aims to have a fantastic result in the entire bifurcation area. Yet, it is by far uncertain. Why? Because you have to do so many steps to adapt a tubular DES to two branches, that to fail in any of these steps may translate into stent mallapposition, stent

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Francesco Burzotta

under-expansion, uncovered segments of the vessel wall, or so on.”

According to Burzotta, the “stepwise” approach used in EBC Main should be described as a “series of manipulations that should warrant each patient being treated according to the required steps to have good results”. This approach involves preparing the lesion to have good stent expansion by predilating the main vessel (and, when really needed, the side branch). Imaging should be utilised in the presence of any minimal doubt regarding vessel anatomy and additional “preparation” techniques such as rotablation or intravascular lithotripsy (IVL) have to be considered in the presence of calcium.

Further steps include implanting the stent covering the left anterior descending artery (LAD) to the left main. To do this, the stent is selected according to specific regulations, meaning that it is sized 1:1 to the distal main vessel. This aims not to damage the circumflex ostium, but requires systematic post dilation of the stent inside the left main vessel. This step, known as the proximal optimisation technique (POT) allows perfect stent expansion in the left main.

“The POT looks like the most important improvement from the last two decades of stenting into bifurcations,” offers Burzotta.

“Why? Because it is a simple manoeuvre that allows treatment of two different-sized vessel segments with a single DES. “This is the efficacy of POT. Of note, it takes advantage of the technical improvement of DES platforms. First-generation DESs, with thicker struts and closed cell design,

were quite fixed and not able to be adapted to the anatomy with simple manoeuvres like large balloon inflation.” Burzotta says.

“Since there is a geometrical relation between the distal main vessel, the side branch and the proximal main vessel, as soon as the side branch size increases, you have an unparalleled increase in the mismatch between the distal main vessel and proximal main vessel. We should have a stent platform that is able to accommodate these two sizes.”

According to Burzotta, the latestgeneration DES platforms are very suitable to respond positively to POT without having measured distortion of the struts, warranting good coverage of the vessel into the proximal aspect. Yet the limits of stent expansion have to be respected since, in some cases, stent selection might be pivotal.

Considering tips to best apply the provisional technique, Burzotta recommends considering the patient anatomy and to carefully adapt the PCI plan. “Sometimes the left main’s side branch, the circumflex artery, is the main vessel in terms of amount of myocardium supplied,” he says, offering the example of a patient with anterior myocardial infarction (MI) into the LAD and having a dominant left circumflex that is stenosed.

“The operator should be aware of the potential risk of having transient ischaemia in the territory of the side branch during the procedure. Any time this risk is unacceptable, operators should remember that the first stent might also be implanted in the left circumflex covering up the left main according to the “inverted” provisional technique”, he says.

This technique was allowed in the EBC Main trial and could have added efficacy to provisional arm, he notes.

Summing up his views, Burzotta reflects on the main messages from EBC Main in terms of optimising clinical outcomes for patients. He offers the view that the number of stents is not—per se—what regulates the late prognosis of the patients.

“Honestly, I think that the final result achieved in the cath lab is the main modulator of the late outcome of the patient: it does not matter if you need one stent or two stents to have a fantastic result in the main vessel and the side branch—if the patient has disease on both branches they are both important—we should focus on having a good result in both branches without feeling obliged to cover-up all of them with metal.”

Francesco Burzotta is an interventional cardiologist at the Fondazione Policlinico Universitario A Gemelli IRCCS, and Università Cattolica del Sacro Cuore, Rome, Italy.

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Provisional technique

Bifurcation lesions: Exploring the latest science

Provisional stent technique: A step-by-step guide 1. Wire branches

Why wire both branches? Wiring the side branch should be considered the standard approach unless it is so small that, in the opinion of the operator, its loss would be irrelevant.

As this decision can be difficult to make when flow may be compromised by stenosis, an attempt to wire the side branch should always be actively considered. A narrow angle bifurcation, bifurcations with ostial side branch disease, and bifurcations with smaller side branch reference diameters are most likely to occlude after main branch stenting.

With difficulty wiring branches?

Microcatheters, especially those with dual lumen, can prove useful in wiring the side branch in difficult cases. Plaque modification may facilitate side branch wiring when access is difficult. The shape of the guidewire tip should be prepared manually in accordance with the angle, the main branch diameter and the anatomical take-off of the side branch.

It is recommended that the most difficult lesion should be wired first in order to avoid wire wrap.

3. Proximal optimisation technique (POT)

Why perform a POT? POT facilitates side branch access, reduces the risk of accidental abluminal rewiring, lowers the risk of stent distortion by catheter collision, and enhances scaffolding at the side branch ostium.

Size and type of balloon POT is carried out after main branch stenting by inflating a short balloon just proximal to the carina.

This parameter needs to be taken into account before choosing the main branch stent length, in order to leave at least 6–10mm of stent length proximal to the carina (the smallest length of commonly available balloons).

The diameter ratio between the balloon and the proximal main branch reference segment should be 1/1. Thus, compliant or non-compliant balloons can be used, depending on the diameter the operator wants to achieve.

Inflation is performed at nominal pressure or higher in order to reach the appropriate diameter.

5. Kissing balloon inflation (KBI)

When to perform a KBI Side branch treatment is indicated if the ostium is pinched or the flow is limited after POT. If side branch treatment is required, rewire and dilate the side branch and finalise with KBI and POT.

6. rePOT

Performing a final POT Distortion of the main vessel stent after kissing inflations is common and might result in a sub optimal outcome. An optimised sequence including a final POT (rePOT) has shown favourable results compared to finalising with kissing balloon only in bench testing and modelling.

4. Rewire branches

2. Main branch stent implantation Stent size selection Stent diameter should be selected according to the reference diameter of the main branch distal segment in accordance with the fractal law, the potential drawback being inadequate apposition of the stent on the proximal main branch segment. However, this can be easily corrected by proximal optimisation technique and/or kissing balloon inflation.

The choice of stent diameter for main branch stenting is crucial: when too large, it may significantly increase the risk of side branch occlusion caused by carina shifting or create a dissection in the distal segment.

Pullback technique Recrossing into the side branch in the distal portion of the stent promotes better ostial side branch stent coverage and apposition. This can be achieved by “pullback rewiring” by advancing the guidewire with a bent tip into the distal main vessel and carefully retracting the wire while turning and directing it towards the side branch.

With trouble crossing Difficult side branch rewiring may be facilitated by modifying the distal guidewire tip, using a CTO wire, or performing a new POT with higher pressure or a larger balloon if the first POT was inadequate.

Performing a wiring bail-out If side branch wiring is not possible, a bail-out technique is performed by leaving an uninflated balloon in the main vessel and advancing a low profile 1–1.5mm balloon catheter on the jailed wire.

A tunnel can then be created to allow passage of a side branch balloon. It is essential to ensure final re-expansion of the proximal main vessel stent.

7. Final result

When to treat the side branch? Stenting of the side branch is indicated during the provisional approach: (1) when side branch flow is compromised (TIMI Flow <3), (2) in the presence of a major side branch dissection (>Type B), or (3) when the side branch is significantly diseased and large enough to lead to significant residual ischaemia.

References 1. Lassen J, Burzotta F, Banning A, et al. Percutaneous coronary intervention for the left main stem and other bifurcation lesions: 12th consensus document from the European Bifurcation Club. EuroIntervention.

2018;13(13):1540-1553.

2. Lassen J, Holm N, Banning A et al. Percutaneous coronary intervention for coronary bifurcation disease: 11th consensus document from the European Bifurcation Club.

EuroIntervention. 2016;12(1):38-46.

3. Burzotta F, Lassen J, Lefèvre T, et al. (2021). Percutaneous coronary intervention for bifurcation coronary lesions: the 15th consensus document from the European Bifurcation Club. EuroIntervention. 2021;16(16): 1307–1317.

All rights reserved. Published by BIBA Publishing, London T:+44 (0)20 7736 8788, publishing@bibamedical.com. The opinions expressed in this supplement are solely those of the featured physicians and may not reflect the views of Cardiovascular News.

November 2021

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