Bifurcation lesions
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Transcript of Bifurcation lesions
BIFURCATION STENTING
PROVISIONAL (OR) ELECTIVE
BY DR D MANJUNATH
Coronary bifurcations are prone to develop atherosclerotic plaque due to turbulent blood flow and high shear stress.
Bifurcation lesions account for approximately 15% of all percutaneous coronary interventions (PCI).
In comparison to other PCIs, bifurcation interventions have lower rates of procedural success, higher cost, higher resource utilization, longer hospitalization, and higher rates of clinical and angiographic restenosis
Introduction
Coronary bifurcations have been classified according to the angulation between the MV and the SB, and according to the location of the plaque burden
A Y-angulation is less than 70 degrees and allows easy wire access to the SB, but plaque shifting is potentially more pronounced and precise stent placement with complete ostial coverage is often difficult or geometrically impossible.
Anatomical Considerations
Any > 50 % stenosis adjacent (< 5 mm) to and/ or
at the ostium of a side branch (> 2 mm of diameter)
Definition:
15-20 % of all PCIs involve bifurcations of importance
Lower initial success rate Higher restenosis rate Higher thrombosis rate
Epidemiology:
Duke Classification of Bifurcation Lesions
A) If the side branch is significantly diseased at its ostium or nearby, it is sufficiently large to be stented, safety and duration of PCI are an issue: 2 stents
B) In all other conditions 1 stents and then evaluate
Provisional or elective
1)ProvisionalMainvessel stenting ± sidebranch angioplasty(Provisional) T-stenting, TAP, REVERSE INTERNAL CRUSH, REVERSE CULOTTE.
2) elective Culotte-stenting Crush technique (reverse crush) T TECHNIQUE AND TAP V STENTING Y STENTING(SKS technique)
Stenting of Bifurcation Lesions
Provisional stenting of Bifurcations:technique
FINAL KISSING BALOON INFLATION:
Avoid Pre - dilation of SB
Dilate the main vessel stent at high pressure The original Universal Balance wire Prowater/ Rinato (Asahi Intech wire) Intermediate wire Pilot 50 or 150 wire Always perform high pressure inflation in the
side branch before doing kissing
About the side branch: wires for recrossingand Kissing Balloon dilatation
DIFFICULT ACCESS TO SIDE BRANCH: OPTIONS
ELECTIVE DOUBLE VESSEL STENTING
Pt selection◦ D.E.S. is considered default strategy for
E.D.S.technique.◦ Should undergo at least 12 mnth antiplatelet
treatment.◦ So avoided in pts non compliant with medications
and at high risk for bleeding.
E.D.S.
Step crush
The V-stenting Technique
The “Simultaneous Kissing Stents” Technique
1. Inability to wire the SB. Make Sure That The Wire Is Directed Towards The
Distal Part But Not The Proximal Part. If The Primery Guide Wire Failes Try Hydrophilic
Wires. If They Also Fail Consider Tapered Tip Wires(MIRACLE).
2. INABILITY TO PASS BALOON IN TO SB. USE COMPLIANT MONORAIL 1.5 MM BALOON. IF FAILS REWIRE SB THROUGH A DIFFERENT SITE
AND RE ATTEMT BALOON CROSSING. IF FAILS THEN USE FIXED WIRE BALOON SYSTEMS.
Potential failure modes of crush and suggested solutions
L.M.C.A. BIFURCATION STENTING
L.M.C.A. BIFURCATION STENTING
Interventional Algorithm for Bifurcation Lesions
Provisional Bifurcation Crush Stenting
Rotablation prox/mid LAD burr 1.5mm
After Rotablation
Provisional Bifurcation Crush Stenting IVUS controlled (Main Branch)
Post bifurcation stentingAfter Rotabltor at MB, before SB balloon dilatation
Provisional Bifurcation Crush Stenting Final IVUS: from MB to SB
diagonal
Provisional Bifurcation Crush Stenting Final IVUS: from MB and from SB
diaLAD
diaLAD
1.Nordic I: provisional T stenting as good as systematic side branch stenting
2.Nordic II: Culotte better than Crush
3. Cactus: provisional T stenting not worse than crush
4 . BBC ONE: step wise approach with provisional T stenting better than initial complex procedures
5.Bad Krozingen: no difference provisional vs systematic T
6.Double Kiss Crush Study: DK Crush better than conv. crush
Randomized Trials in Bifurcation Stenting supportthe concept of initial simple procedures with only
provisional side branch stenting
Steigen Circulation 2006; 114:1955; Erglis TCT 2008; Hildick-Smith TCT 2008Ferenc EHJ 2009; Chen J Interv Cardiol 2009; 22:121-27
Randomized Trial of Simple Versus Complex Drug-ElutingStenting for Bifurcation Lesions
The British Bifurcation Coronary Study: Old, New, andEvolving Strategies
David Hildick-Smith, MD, FRCP; Adam J. de Belder, MD, FRCP; Nina Cooter, MSc;Nicholas P. Curzen, PhD, FRCP; Tim C. Clayton, MSc; Keith G. Oldroyd, MD,
FRCP;Lorraine Bennett, MSc; Steve Holmberg, MD, FRCP; James M. Cotton, MD, FRCP;Peter E. Glennon, PhD, FRCP; Martyn R. Thomas, MD, FRCP; Philip A. MacCarthy,
PhD, FRCP;Andreas Baumbach, MD, FRCP; Niall T. Mulvihill, MD; Robert A. Henderson, DM,
FRCP;Simon R. Redwood, MD; Ian R. Starkey, BSc, FRCP; Rodney H. Stables, DM, FRCP
Circulation. 2010;121:1235-1243
BRITISH BIFURCATION CORONARY STUDY
ConclusionsFor treatment of coronary bifurcation lesions, a
systematic 2-stent technique results in longer procedures, higher x-ray doses, more procedural complications, and a higher rate of in-hospital and 9-month MACE.
The provisional T-stent strategy should be the default treatment for most bifurcation lesions; however, there may be subtypes of coronary bifurcation that nonetheless merit a systematic 2-stent strategy.
Randomized Study of the Crush Technique VersusProvisional Side-Branch Stenting in True
Coronary BifurcationsThe CACTUS (Coronary Bifurcations: Application of the
CrushingTechnique Using Sirolimus-Eluting Stents) Study
Antonio Colombo, MD; Ezio Bramucci, MD; Salvatore Saccà, MD; Roberto Violini, MD;
Corrado Lettieri, MD; Roberto Zanini, MD; Imad Sheiban, MD; Leonardo Paloscia, MD;
Eberhard Grube, MD; Joachim Schofer, MD; Leonardo Bolognese, MD; Mario Orlandi, MD;
Giampaolo Niccoli, MD; Azeem Latib, MD; Flavio Airoldi, MD
(Circulation. 2009;119:71-78.)
CACTUS STUDY
ConclusionsIn most bifurcation lesions with a significant stenosis inboth branches, a strategy to stent the MB is effective, with the need to implant a second stent in the SB occurring approximately one third of the time.
The implantation of 2stents does not appear to be associated with a higher incidence of adverse events, taking into account that the follow-up was limited to 6 months and that most patients were still ondual-antiplatelet therapy.
Randomized Comparison of Coronary Bifurcation StentingWith the Crush Versus the Culotte Technique Using
Sirolimus Eluting StentsThe Nordic Stent Technique Study
Andrejs Erglis, MD; Indulis Kumsars, MD; Matti Niemela¨, MD; Kari Kervinen, MD;Michael Maeng, MD; Jens F. Lassen, MD; Pål Gunnes, MD; Sindre Stavnes, MD; Jan S.
Jensen, MD;Anders Galløe, MD; Inga Narbute, MD; Dace Sondore, MD; Timo Ma¨kikallio, MD; Kari
Ylitalo, MD;Evald H. Christiansen, MD; Jan Ravkilde, MD; Terje K. Steigen, MD; Jan Mannsverk,
MD;Per Thayssen, MD; Knud Nørregaard Hansen, MD; Mikko Syvänne, MD; Steffen
Helqvist, MD;Nikus Kjell, MD; Rune Wiseth, MD; Jens Aarøe, MD; Mikko Puhakka, MD;
Leif Thuesen, MD; for the Nordic PCI Study Group
Circ Cardiovasc Intervent. 2009;2:27-34.
NORDIC TRIAL
ConclusionsIn conclusion, excellent 6 months clinical and 8 months angiographic results can be obtained with the crush and culotte stenting of de novo coronary artery bifurcation lesions using SES.
Culotte-stented lesions tended to have lowerangiographic restenosis rates making this technique an attractive bifurcation stenting technique in feasible bifurcation lesion anatomies.
Stent thrombosis incidence in clinical trials comparing 1-stent (1S) with 2-stent (2S) strategies in treatingcoronary bifurcations
Major adverse cardiac event (MACE) and TLR incidence in randomized trials comparing 1-stent (1S) with2-stent (2S) strategies.
Randomized Comparison of Provisional Side Branch Stenting versus a Two-stent Strategy
for treatment of True Coronary Bifurcation Lesions Involving
a Large Side Branch.
The Nordic-Baltic Bifurcation Study IVIndulis Kumsars, Matti Niemelä, Andrejs Erglis, Kari
Kervinen, Evald H. Christiansen, Michael Maeng, Andis Dombrovskis, Vytautas Abraitis, Aleksandras Kibarskis, Terje K. Steigen, Thor Trovik, Gustavs Latkovskis, Dace
Sondore, Inga Narbute, Christian Juhl Terkelsen, Markku Eskola, Hannu Romppanen, Per Thayssen, Anne
Kaltoft,Tuija Vasankari, Pål Gunnes, Ole Frobert, Fredrik Calais, Juha Hartikainen, Svend Eggert Jensen, Thomas
Engstrøm, Niels R. Holm, Jens F. Lassen and Leif Thuesen
For the Nordic-Baltic PCI Study Group
• Provisional (simple) stenting is the preferred strategy in treatment of most bifurcation lesions
• It is unknown if this also applies to true bifurcation lesions involving a large side branch
Background
Nordic-Baltic Bifurcation Study IVThe Nordic-Baltic PCI Study Group
Nordic-Baltic Bifurcation Study IVParticipating Centers
DenmarkAarhus University Hospital
(112 pts)Aalborg University Hospital
(13 pts)Odense University Hospital
(10 pts)Rigshospitalet Copenhagen
(3 pts)
LatviaP.Stradins University Hospital, Riga
(159 pts)
SwedenÖrebro Hospital
(11 pts)Linköping
(3 pts)Karolinska University Hospital
(1 pts)
FinlandOulu University Hospital (75 pts)Tampere University Hospital (8 pts) Turku University Hospital (6 pts)Kuopio University Hospital (2 pt)
NorwayTromsø University Hospital (18pts)Arendal Hospital (3 pts)Feiring Heart Clinic (2 pts)
LithuaniaVilnius University Hospital (21 pts)
The Nordic-Baltic PCI Study Group
To compare provisional stenting and two-stent techniques for the treatment of true coronary bifurcation lesions involving a large side branch
Aim
Nordic-Baltic Bifurcation Study IVThe Nordic-Baltic PCI Study Group
• Open label, randomized, multicenter trial• 1:1 randomization• Clinical FU at 0, 1 and 6 months• Angiographic substudy with 8 months FU• Study stents:– Sirolimus eluting Cordis Cypher Select+ (first 225
patients)– Everolimus eluting Abbott Xience V (last 225
patients)
Methods
Nordic-Baltic Bifurcation Study IVThe Nordic-Baltic PCI Study Group
Combined endpoint after 6 months:
• cardiac death
• non-index procedure related myocardial infarction
• TLR
• definite stent thrombosis
Primary endpoint
Nordic-Baltic Bifurcation Study IV
• Individual endpoints of:
• Total death
• Cardiac death
• Non-index procedure related MI
• Target lesion revascularization (TLR)
• Target vessel revascularization (TVR)
• Definite stent thrombosis
• Procedure related myocardial infarction
• 8-month angiographic follow-up results
Secondary endpoints
Nordic-Baltic Bifurcation Study IV
Inclusion criteria• Age≥18• Stable Angina, UAP,
NSTEMI• MV≥3.0mm• SB ≥2.75mm• Bifurcation stenosis
involving both MV and SB
(≥50%DS by eyeballing)
Methods
Exclusion criteria• STEMI
• Cardiogenic shock
• Other critical illness
• Relevant allergies
• Cr ≥ 200 µmol/L
• SB lesion length >15mm
Nordic-Baltic Bifurcation Study IV
Provisional SB stenting–Two wires –Predilatation–MV stenting– If TIMI flow<III or >75%DS in ostial SB:
kissing balloon dilatation– If SB TIMI flow <III after kissing balloon
dilatation, SB stenting using a T- or Culotte technique
Implantation techniques
Nordic-Baltic Bifurcation Study IV
Two-stent techniques
– Two wires
– Predilatation of segments to be stented
– Culotte stenting recommended
• T-stenting and mini-crush allowed
– Final kissing balloon dilatation
Implantation techniques
Nordic-Baltic Bifurcation Study IVThe Nordic-Baltic PCI Study Group
Patient flowchart
Nordic Baltic Bifurcation study IV
n=450
Provisional SB stening n=221*
Two stentn=229*
1 lost to FU1 excluded due to protocol violation
ProvisionalCompleted 6M
FUn=220
Two stentCompleted 6M
FUn=227
1 withdrawal
*numbers not balanced due to block randomization and sites with less than 4 inclusions
Nordic-Baltic Bifurcation Study IVThe Nordic-Baltic PCI Study Group
Eventfree survival curve at 6 months
4.6%
1.8%
p=0.09
Nordic-Baltic Bifurcation Study IVThe Nordic-Baltic PCI Study Group
• After 6 months, two-stent techniques for treatment of true bifurcation lesions with a large side branch showed no significant difference in MACE rate compared to provisional side branch stenting
• • Longer and more complex procedures in the two-
stent group did not translate into more procedural myocardial infarctions
• Recommendations on optimal strategy for this lesion subset should await longer term follow-up
Conclusion
Nordic-Baltic Bifurcation Study IVThe Nordic-Baltic PCI Study Group
WHY WE NEED DEDICATED STENT. PROVISIONAL ASSOCIATED WITH S.B CLOSURE E.D.S . Is complex, time consuming, need one more
stent What are desired features
Low profile Less cost Easy trouble
If the side branch is significantly diseased at its ostium or nearby, it is sufficiently large to be stented, safety and duration of PCI are an issue: 2 stents
In all other conditions 1 stents and then evaluate
Conclusion: provisional or elective
THANK U ALL