CAD: Bifurcation Blockage

Overview

What is a bifurcation blockage?

A bifurcation blockage is a type of coronary artery disease (CAD). It occurs when fatty deposits called plaque accumulate in the area where a main coronary artery branches into a smaller coronary artery. Healthcare providers use the term “side-branch vessels” to refer to these smaller branched arteries. They may also use the term “bifurcation lesion” to refer to the plaque that causes a bifurcation block.

What are the types of bifurcation blockages?

Healthcare providers assess the severity of the plaque buildup to determine the type of blockage or narrowing (also known as stenosis).

A bifurcation blockage may be:

  • Simple: There is less than 70% narrowing of the artery.
  • Complex: The blockage takes up more than 70% of the artery. There may also be more than one blockage, a blood clot or calcium buildup (calcification). Sometimes, the blockage is in a smaller artery branch that bends at a significant angle (more than 70 degrees). This angle makes it more difficult to reach and treat the blockage.

How common is a bifurcation blockage?

It’s estimated that bifurcation blockages account for up to 20% of all CAD cases that require medical treatment.

Symptoms and Causes

What causes a bifurcation blockage?

A buildup of plaque inside the walls of arteries causes CAD, including bifurcation blockages. The plaque makes the artery too narrow, which slows blood flow to your heart.

Who is at risk for a bifurcation blockage?

People who have completed menopause and people assigned male at birth who are over the age of 45 are more likely to have CAD and develop a bifurcation blockage. Other risk factors include:

What are the symptoms of a bifurcation blockage?

Because a bifurcation blockage is a type of CAD, the symptoms are the same. You may experience:

Diagnosis and Tests

How do healthcare providers diagnose a bifurcation blockage?

If you have symptoms of a bifurcation blockage, your healthcare provider may order

imaging tests, such as:

  • Cardiac catheterization to check for blockages in arteries.
  • Coronary computed tomography angiogram (CCTA) to obtain moving 3D images of blood flowing to your heart.
  • Intravascular optical coherence tomography (IVOCT) to capture high-definition images of plaque buildup inside an artery.
  • Intravascular ultrasound (IVUS) to produce detailed images of the artery walls.
  • Fractional flow reserve (FFR) to measure the pressure inside an artery.

Management and Treatment

How do providers treat a bifurcation blockage?

Treating a bifurcation blockage is challenging because the side-branch vessels are very small. This makes them more difficult to access than the main coronary arteries. Healthcare providers perform angioplasty to expand narrowed arteries. They place stents (tiny wire mesh tubes) to keep the artery open. Angioplasty and stenting are percutaneous coronary interventions (PCI).

During angioplasty and stenting, your provider:

  1. Inserts a catheter (thin, flexible tube) into a small incision in your skin.
  2. Threads the catheter through a blood vessel to reach the blockage.
  3. Inflates a balloon device on the tip of the catheter to push the plaque to sides of the artery wall.
  4. Places a stent inside the artery to keep it open.

After the procedure, your provider will prescribe medications called dual antiplatelet therapy to keep the stent open.

What are the types of procedures for treating bifurcation blockages?

Stents that treat CAD may be bare metal or coated with medication (a drug-eluting stent). Clinical trials are also underway to test specially designed side-branch stents for the smaller side-branch vessels.

Types of procedures for bifurcation blockages include:

  • Provisional stenting: Your provider places a stent in the main coronary artery. This leaves the option to stent the side-branch vessel at a later time if you continue to have symptoms.
  • Two-stent procedures: For complex blockages, your provider places a stent in both the blocked main coronary artery and the side-branch vessel.

What are the complications of bifurcation blockage treatments?

People who have angioplasty and stenting to treat a bifurcation blockage are at risk of developing:

  • In-stent restenosis: Scar tissue forms underneath the stent, causing the artery to become narrow again. Your artery may become narrow again. This is called in-stent restenosis, which typically occurs within six months of the initial stenting. You may need another angioplasty or a different procedure to open up the artery again.
  • Stent thrombosis: Blood clots form inside the stented area and blood vessels, causing thrombosis.

Prevention

Can you prevent bifurcation blockages?

You can take heart-protective measures to lower your risk of CAD and atherosclerosis. These steps include:

Outlook / Prognosis

What is the outlook for someone with a bifurcation blockage?

Angioplasty and stenting have about a 40% success rate in treating a bifurcation blockage. After treatment, some people still have coronary artery disease symptoms. It’s important to take measures like eating a healthy diet and losing weight, if needed, to protect your heart.

Living With

When should I call the doctor?

Call 911 if you think you’re having a heart attack. You should call your healthcare provider if you experience:

  • Chest pain (angina), arm pain or shoulder pain.
  • Cold sweats.
  • Shortness of breath
  • Unexplained fatigue or weakness.

What should I ask my provider?

You may want to ask your healthcare provider:

  • What caused the bifurcation blockage?
  • Am I at risk for blockages in other arteries?
  • Will angioplasty and stenting open the blockage?
  • What type of stent do you recommend?
  • How many stents do I need?
  • What steps should I take to protect my heart?
  • Should I look for signs of complications?

A note from Cleveland Clinic

A bifurcation blockage that occurs inside a branch of a coronary artery can be more difficult to access and treat. This blockage is a type of coronary artery disease that can cause chest pain. It increases your risk of life-threatening problems like heart attacks and strokes. Healthcare providers use angioplasty and stenting to open narrowed arteries. You may need one or two stents to improve blood flow. Your healthcare provider will discuss treatment options with you.

Last reviewed by a Cleveland Clinic medical professional on 06/29/2022.

References

  • American College of Cardiology (ACC). From the Starting Line | Left Main Bifurcation Stenting: Tips and Tricks. (https://www.acc.org/Latest-in-Cardiology/Articles/2021/12/01/01/42/Left-Main-Bifurcation-Stenting-Tips-and-Tricks) Accessed 6/29/2022.
  • De Luca L. Percutaneous Treatment of Coronary Bifurcation Lesions. (https://www.ahajournals.org/doi/10.1161/CIRCINTERVENTIONS.116.004328) Circulation: Cardiovascular Interventions. 2016 Sep;9(9): Accessed 6/29/2022.
  • Gwon HC. Understanding the Coronary Bifurcation Stenting. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5986747/) Korean Circ J. 2018 Jun;48(6):481-491. Accessed 6/29/2022.
  • Latib A, Colombo A. Bifurcation Disease: What Do We Know, What Should We Do? (https://www.sciencedirect.com/science/article/pii/S1936879808001684) JACC: Cardiovascular Interventions. 2008 Jun;1(3):218-226. Accessed 6/29/2022.

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