Aims: To evaluate the distribution of atherosclerosis at bifurcations with computed tomography coronary angiography (CTCA) and propose a novel CT-Medina classification for bifurcation lesions. Methods: In 26 patients (age 55 +/- 10 years, 81% male) imaged with CTCA, 39 bifurcations were studied. The bifurcations analysis included the proximal main vessel, the distal main vessel and the side branch (SB). Plaque contours were manually traced on CTCA; the lumen, vessel and plaque area were measured, as well as plaque burden (%). The carina cross-sections were divided into four equal parts according to the expected wall shear stress (WSS) to assess circumferential plaque distribution. All the bifurcation lesions were classified using the Medina classification and a novel CT-Medina classification combining lumen narrowing and plaque burden >= 70%. Results: Presence of severe plaque (plaque burden >= 70%) by CTCA was demonstrated in 12.8% (5/39) of the proximal segments, 15.4% (6/39) of the distal segments and 7.7% (3/39) of the SB segments. The thickest plaque was located more often in low WSS parts of the carina cross-sections, whereas the flow divider was rarely affected. Although in the majority of bifurcations plaque was present, based on the Medina classification 92% of the assessed bifurcations were identified as 0,0,0. Characterization of bifurcation lesions using the new CT-Medina classification provided additional information in seven cases (18%) compared to the Medina classification Conclusion: Atherosclerotic plaque is widely present in all bifurcation segments, even in the absence of coronary lumen stenosis. A CT-Medina classification combining lumen and plaque parameters is more informative than angiographic classification of bifurcation lesions and could potentially facilitate the decision-making on the treatment of these lesions. (C) 2014 Wiley Periodicals, Inc.