Bifurkasyon Lezyonlarında Güncel Kılavuz Önerileri ve Tedavi Algoritması
Özet
Koroner bifurkasyon darlıklarının perkütan girişimsel tedavisi; anatomi, darlık şiddetini değerlendirme yöntemleri ve teknik çeşitlilik nedeniyle tartışmalıdır. Tedavide provizyonel stentleme (PS) veya iki stent (2-stent) stratejileri arasında karar verilirken yan damarın prognostik önemi ve lezyonun kompleksliği belirleyicidir. Genellikle daha basit olan PS yaklaşımı önerilse de, geniş miyokard alanını besleyen lezyonlarda veya DEFINITION II çalışmasında belirtildiği gibi yan damar lezyon uzunluğu 10 mm ve üzerinde olan gerçek kompleks bifurkasyonlarda 2-stent tekniği tercih edilebilmektedir. İki stent stratejisinde DK culotte, T/TAP veya özellikle tecrübeli merkezlerde PS'ye üstünlüğü gösterilen DK crush teknikleri bifurkasyon açısına göre seçilir; ancak her durumda final kissing balon ve proksimal optimizasyon (POT) uygulanmalıdır. Tedavi adımlarını standardize etmek amacıyla Avrupa Bifurkasyon Kulübü tarafından, stentleme ve balon işlemlerinin sırasını belirleyen MADS ve güncel MADS-2 sınıflamaları geliştirilmiştir. Sonuç olarak, seçilen teknikler işlem sonundaki stent görünümünü ve hastanın klinik sonuçlarını doğrudan etkilemektedir.
The percutaneous interventional treatment of coronary bifurcation stenosis remains controversial due to variations in anatomy, lesion severity assessment, and available techniques. The choice between provisional stenting (PS) and a two-stent (2-stent) strategy depends on the prognostic significance of the side branch and lesion complexity. Although the simpler PS approach is widely recommended, a 2-stent technique is preferred for lesions supplying large myocardial areas or true complex bifurcations with a side branch lesion length of 10 mm or more, as supported by the DEFINITION II trial. Depending on the bifurcation angle, 2-stent strategies include DK culotte, T/TAP, or DK crush—the latter showing superiority over PS in high-volume centers; however, final kissing balloon and proximal optimization technique (POT) are mandatory for all. To standardize procedural steps, the European Bifurcation Club introduced the MADS and updated MADS-2 classifications, which categorize stenting and balloon sequences. Ultimately, the selected technique directly determines the final stent configuration and significantly impacts long-term clinical outcomes for the patient.
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