When and how to treat the side branch in provisional stenting · Angela Hoye MB ChB, PhD Castle...
Transcript of When and how to treat the side branch in provisional stenting · Angela Hoye MB ChB, PhD Castle...
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When and how to treat the side branch in provisional
stenting
Angela Hoye MB Angela Hoye MB ChBChB, PhD, PhD
Castle Hill HospitalCastle Hill HospitalKingstonKingston--uponupon--Hull, UKHull, UK
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Disclosure Statement of Financial Disclosure Statement of Financial InterestInterest
Within the past 12 months, I have received consulting Within the past 12 months, I have received consulting fees / honoraria from the following:fees / honoraria from the following:
–– CCordisordis, Johnson & Johnson, Johnson & Johnson
––Abbott VascularAbbott Vascular
––The Medicines CompanyThe Medicines Company
––Boston ScientificBoston Scientific
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Provisional stenting: the concept1. Protect the side branch with a wire2. Dilate and stent the main vessel3. Evaluate the result in the SB particularly
the flow4. If necessary, re-wire the SB to optimise
with kissing balloon post-dilatation5. Perform stent implantation to the SB if poor
result particularly if TIMI 0 or I flow
When?
When?
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• Desiderius Erasmus of Rotterdam, Dutch Humanist and Theologian (1466-1536) coined the phrase “prevention is better than the cure”
• “it is better to stop something bad happening than it is to deal with it after it has happened”
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Wire the side branch• Compromise of SB occurs to some extent
unpredictably
Brunel et al CCI 68:67-73
Predictors of Side Branch FailureInsights from the TULIPE Study (n=186)
p valueFailureSuccess
0.03171.492.9Jailed wire (%)0.001976.598.1Final kissing balloon (%)0.04132.2 ± 0.32.5 ± 0.5SB ref diameter (mm)0.00852.8 ± 0.33.1 ± 0.4MB ref diameter (mm)0.000757 ± 866 ± 11Age (years)
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Y. Louvard and T. Lefèvre TCT 2003
87° 68°
• Favorable modification of the side branch angulationafter wiring• the lesion becomes Y shape
Why wire the side branch?
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Always use 2 wires!
62 year old man with NYHA II stable angina
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Always use 2 wires!
Final result
• Severe chest pain• ST elevation in lateral leads• CK rise of 800
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Bon-Kwon Koo et al JACC 2005; 46: 633-7
100908070605040
1.0
.9
.8
.7
.6
.5
r = - 0.464p < 0.001
Percent Stenosis (%)
Frac
tiona
l Flo
w R
eser
ve
Jailed side branch lesions (n=94)
38 % of lesions
When do we need to treat the SB?
• Ostium SB stenosis is overestimated by angio
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QCA versus FFR
FFR: 0.61
FFR: 0.58
FFR: 0.93
FFR: 0.84
Courtesy of Dr Remo Albeiro
• Visual estimate / QCA of the significance of stenosis of the SB ostium is unreliable
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When do we need to balloon the SB in provisional stenting?
• Is final kissing balloon dilatation mandatory?– Await the results of randomised studies (NORDIC
KISS and CROSS)• < TIMI 3 flow• “Significantly stenosed”……..?
• Must be performed optimally– After dilatation of SB, kissing
balloon dilatation is essential to correct the MV stent deformation
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• Crossover to a 2nd stent in the provisional stenting group of randomised studies
01020304050607080
Colombo Pan NORDIC CACTUS
% SB DS ≥50%
Severe stenosis
&/or major flow-
limiting dissection
TIMI 0 flow after
balloon dilatation
SB DS ≥50%
Type B of worse
dissection
TIMI flow ≤2
Colombo et al Circ 2004; Pan et al AHJ 2004; Colombo et al Circ 2004; Pan et al AHJ 2004; SteigenSteigen et et al Circ 2006; Colombo et al al Circ 2006; Colombo et al
When do we need to stent the SB?
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Provisional stenting: MACE rates
Colombo et al Circ 2004; Pan et al AHJ 2004; Jensen et al Eurointervention 2008; Colombo et al
0
5
10
15
20
25
Colombo Pan NORDIC 14 months
CACTUS
MA
CE
(%)
Single 2-stent
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When do we need to stent the SB?
• Long lesion (eg >10mm) in an important vessel
• Significant (≥type C) dissection
• TIMI 0 or 1 flow
• Significantly stenosed…………....?
Final result after Culottestenting
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Assess the angulation
Ostial restenosis was associated with incomplete coverage
>120˚
Y-shape
Y-shape incidence ~ 75%
Lemos et al Circulation 2003;108:257-60
CulotteCrush
T-stent
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Importance of lesion coverage• 178 consecutive patients undergoing provisional
stenting• 80 (45%) required a 2nd stent, and were treated with
either Culotte (n=45) or T-stenting (n=35)• FU angio at 6 months• Mean bifurcation angle was 57 ± 22˚
Kaplan et al Am Heart J 2007;154:336-43
P=0.14 P=0.051P=0.58 P=0.48 P=0.006
0
10
20
30
40
50
Prox.MV %DS
Distal MV%DS
SB %DS0
5
10
15
20
25
30
TLR MACE
Culotte
T-stent
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Crush stenting: influence of bifurcation angle
Dzavik et al AHJ 2006;152:762-9
Influence of bifurcation angle on outcome following use of the crush technique
MA
CE-
free
sur
viva
l (%
)
“Y”-shape
“T”-shape
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Culotte stenting
Adriaenssens et al EHJ 2008;29:2868-76
0.031.47 (1.03-2.09)Baseline main vessel DS (increase of 10%)
0.070.37 (0.13-1.10)Kissing balloon post-dilatation
0.0231.83 (1.71-592.77)SB ref. vessel diameter (decrease by 1mm)
0.031.53 (1.04-2.23)Bifurcation angle (increase of 10˚)
0.012.38 (1.21-4.96)Age (increase of 10 years)
p valueOdds ratio (95% CI)
Independent predictors of binary restenosis
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Stents don`t like large bends
Maximal inflation pressure
GW position was biased in the central core of the balloon and did not change
during inflation.
Dumbbell shape
Courtesy of Dr Murasato
T-stentingMini-crush
Gap
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Mini-crush
2 years9 month angio FU
2621*17170T-stent 1-stent
19**
9
SB binary restenosis (%)
88
199
No. pts
19
12
MV binary restenosis (%)
26T-stent 2-stents
21Mini crush
MACE (%)
Galassi et al JACC Interv 2009;2:185-94* p≤0.001, **p≤0.01
• Relatively straightforward technique, appears suitable irrespective of bifurcation angle
• Registry data of 457 patients
“These results may confirm the advantage of using prescheduled 2-stent technique to give a complete
coverage of the side branches` ostium”
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TAP: T-stenting & small protrusion
• 73 patients– Mortality rate 4%– AMI 0– TLR: 7%– 1 definite and 1 suspected stent
thrombosis• MACE-free survival at 9-
months 90%
Burzotti et al CCI 2007;70:75-82
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√XCulotte
√√TAP
X
√
TT--shape shape bifurcationbifurcation
YY--shape shape bifurcationbifurcation
T-stenting X
Internal crush √
Choice of stenting strategy for the SB: importance of the angle
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Final kissing balloon post-dilatation• Significant reduction in MV and SB restenosis• Must be performed optimally using
appropriately sized balloons:Sequential high pressure balloon dilatation of the SB stent then MV stentFinalise with lower pressure kissing balloon dilatation
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1. Try to avoid SB compromise in the first place• Pre-wire the SB especially if high angle and / or
significant SB disease at baseline
2. Avoid pre-dilatation of the SB 3. Significance of any “stenosis” in the ostuim
of the SB is overestimated on angiography4. Definite indications for use of a 2nd stent are
reduced flow +/- significant dissection5. When implanting a SB stent, choice of
technique depends on the angulation
Summary & Conclusions
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Thankyou!