DINO and Medina coronary bifurcation lesion classifications




I read with great interest the article written by Zlotnick et al. in the latest issue of Cardiovascular Revascularization Medicine . The article characterizes the interobserver variability of the Medina coronary bifurcation classification and examines its contribution to treatment selection strategy . The authors claim that the majority of other coronary bifurcation classification systems, which included the DINO classification (see Ref. ), are “cumbersome and impractical for every day clinical use” and a limitation of these systems is “their complexity”. These statements are regrettably inaccurate. The DINO classification is as simple as Medina and also covers all of the seven lesion categories at the bifurcation region. In addition, DINO has two advantages over the Medina classification. DINO is a descriptive, intelligible, and ordered classification system. It is an all-inclusive classification and considers both the lesion distribution at the bifurcation site and the bifurcation angle, which are absolutely necessary to consider in the selection of the angioplasty strategy. Regarding the lesion distribution, DINO divides the bifurcation region into three ostial regions: the proximal ostial region of the proximal segment of the main branch, the distal ostial region of the distal segment of the main branch, and the side branch ostial region of the side branch. Accordingly, depending on the segment localization (proximal, distal, or side branch) and the number of ostial regions involved (mono-ostial, bi-ostial, or tri-ostial), DINO classifies the bifurcation lesions into the following seven categories: proximal mono-ostial (Medina 1,0,0); distal mono-ostial (Medina 0,1,0), side branch mono-ostial (Medina 0,0,1); main branch bi-ostial (Medina 1,1,0), proximal bi-ostial (Medina 1,0,1), distal bi-ostial (Medina 0,1,1), and tri-ostial (Medina 1,1,1). The use of these verbally anchored and self-descriptive terms instead of abstract numbers, in my opinion, is an advantage of DINO over the Medina classification. The second advantage of DINO over the Medina classification is the consideration of the bifurcation angle in the former (Y-shaped, T-shaped, and reverse-angled). The side branch angulation has great impact on the complexity of the stenting technique and on the rate of success and complications. Of note, the Medina classification is included within parentheses for the sake of comparison.


The authors have also divided the bifurcation lesion into “complex versus non-complex lesions” using Medina score 1.1.1, 0.1.1, and 1.0.1 as complex lesions. This is not totally correct either. During coronary bifurcation angioplasty, the nightmare of the interventional cardiologist is the occlusion of a side branch subtending a substantial amount of myocardium. The maintenance of guide-wire accessibility to the side branch during the angioplasty procedure is central in preventing side branch occlusion. The plaque morphology and localization and the side branch angulation are the most decisive factors in having guide-wire access to the side branch. An example is that a proximal mono-ostial lesion (Medina 1,0,0) with a large plaque situated on the same side of the exit of a sharply angulated (T-shaped or reverse-angled) side branch is much more complex than a distal bi-ostial lesion (Medina 0,1,1) with a Y-shaped side branch angulation. The guide wire accessibility to the side branch may be very difficult in the first above-mentioned type of lesion. The bifurcation lesion may need rotablation in order to have guide-wire access to the side branch and may necessitate a specially tailored angioplasty technique . On the contrary, a distal bi-ostial lesion with a Y-shaped side branch angulation, where guide-wire accessibility to the side branch can be maintained during the whole angioplasty procedure when using the V-stenting technique, is a relatively simple lesion.


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Nov 16, 2017 | Posted by in CARDIOLOGY | Comments Off on DINO and Medina coronary bifurcation lesion classifications

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