approach to bifurcation pci: a step by step refresher...for left main bifurcation lesions scripps...

Approach to Bifurcation PCI:A Step By Step Refresher

Curtiss T. Stinis, M.D., F.A.C.C., F.S.C.A.I.Director, Peripheral Interventions

Director, Interventional Cardiology Fellowship Program

Division of Cardiology

Scripps Clinic

La Jolla, CA

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PCI Bifurcation Techniques:

How to Decide?

• Provisional Stent Technique

• Crush Techniques

• Simultaneous Stent Techniques

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• T Stent Techniques

• Culotte Technique

STEP 1:Which Ostia are Involved?

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RULE OF THUMB:If the ostium is ½ the size (orsmaller) than the proximalvessel, then it is involved

STEP 2:What are the vessel sizes?




Requires a large enoughproximal vessel(2/3 of the sum of the 2 branchstent diameters)

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Requires similar sized vessels

NOTE:Any vessel less and 2mmshould be ignored forpurposes of PCI planning




Side branch ostium is notsignificantly diseased

Side branch ostium isseverely diseased and youare concerned it will close

STEP 3:Is There a Specific Need for a Particular Technique?

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Need to minimize ischemictime (ie: LM bifurcationdisease in crashing patient)




Traditional Crush requires7Fr or larger guide catheter

“Step Crush” can beperformed with a 6Fr guide

STEP 4:What Equipment is Needed?

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Requires minimum of 7Frguide catheter

STEP 5:Which Vessels Should I Wire?

So…. Why wire a side branch in the first place?

“To Protect the Side Branch”

But… what does that really mean?

If the side branch gets pinched after the main branch is stented,

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If the side branch gets pinched after the main branch is stented,then the side branch wire will need to be removed and the vesselrewired before any PCI can be performed

If the vessel completely occludes, then the wire serves as amarker of where the vessel is so you can rewire it, or the wire canbe used to convert to a reverse crush

SO… the only reason to really wire a side branch is if youthink you are going to completely close it when the mainbranch is stented

Bifurcation Techniques

•Provisional Stent Technique

•Crush Techniques

•Simultaneous Stent Techniques

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•T Stent Techniques

•Culotte Technique

Provisional Stent Technique:Use when the side branch ostium is not significantly diseased

MainBranch

Wire main vessel

Pre-dilate as needed

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SideBranch

Stent main branch

Rewire and balloonside branch if needed

Provisional Stent Technique:Plan B

• If a second stent is needed after provisionalstenting is performed (ie: dissection orcompromise of the side branch) thefollowing techniques can be used:

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following techniques can be used:


•Reverse Crush Technique

•TAP Technique

Provisional Stent Technique

• Simple

• Less Metal

• Potentially easier to

• Residual stenosisat side branch

• If side branch stent

ADVANTAGES: DISADVANTAGES:

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• Potentially easier totreat restenosis

• Less thrombosis?

needed, it can bemore difficult toinsert it throughfirst stent

If I Use a One Stent Strategy and the Side Branchisn’t Compromised, Do I Need to do a FinalKissing Inflation?

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Meta-analysis of all published studies that included kissingballoon inflation vs. no kissing balloon inflation when using asingle stent strategy

Kissing balloon inflation was associated with a higherrestenosis rate of the main branch and no difference in overallclinical outcome

PLoS One. 2018; 13(6)

Commonly Used BifurcationTechniques


•Crush Techniques


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The Classic Crush Technique

MainBranch

Wire both vessels


Position stents

Deploy side branch stent,remove balloon/wire

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SideBranch

remove balloon/wire

Deploy main branch stent-‘crushes’ side branch stent

Rewire side branch andperform kissing ballooninflation

The Crush Technique

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The Evolution of the ‘Crush’ Technique:Post-Crush Kissing Balloon Inflation

After KissingBalloon Inflation

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Before KissingBalloon Inflation

Crush Technique:Variations

• Classic Crush

• Mini Crush

• Double Kissing Crush (DK Crush)

• Reverse Crush

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• Reverse Crush

• Step Crush

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Classic Crush Technique Mini Crush Technique

DK Crush Technique

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• Position side branch stent as if performing a Mini Crush, in conjunction with aballoon in the main branch

• Deploy side branch stent, withdraw side branch stent balloon slightly, thenreinflate to high pressures to “flare” the proximal side branch stent

• Remove side branch balloon and wire• Crush side branch stent with main branch balloon• Rewire side branch and perform a kissing balloon inflation

DK Crush Technique

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• Remove side branch wire and balloon• Position stent in the main branch and deploy it• Rewire side branch and perform final kissing balloon inflation

Reverse Crush Technique

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Performed as a bailout strategy if provisional stenting of the main branch issuboptimal

Crush Stent Technique

• Assures coverage ofside branch ostium

• Prevents loss of side

• More complex

• Time consuming

• More costly (additional


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branch

• Can be used if sidebranch and main branchare of significantlydifferent sizes

• More costly (additionalwires/balloons)

• Sometimes unable toperform the final kiss-destined for a worseoutcome

• More difficult to treatrestenosis



•Crush Techniques


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The Simultaneous Kissing Stent(SKS) Technique

MainBranch

Wire both vessels


Position stents

Deploy stentssimultaneously

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SideBranch

simultaneously

Perform kissing balloonpost-dilatation

Simultaneous Kissing StentTechnique (SKS)

• Simple

• Maintain wireaccess to both

• Can be difficult totreat later due toneocarina


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branches at alltimes

• Minimal ischemictime

• Requires largervessels of similar size

• Treating proximaldissection or residualdisease highlyproblematic

Simultaneous V StentingTechnique

• Identical to theSKS technique,but without the

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but without thecreation of anew carina

Simultaneous V StentingTechnique

• Simple

• Maintain wireaccess to both

• Only works ifproximal mainbranch is free ofdisease


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branches at alltimes

• Minimal ischemictime

disease

• Plaque shift moreproximally can bedifficult to treat:

Add a stent proximally andpotentially leave a gap vs.convert to SKS



•Crush Techniques


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Traditional TStent Technique

PROBLEM:

Almost NEVER is therea perfect 90 degreeangle between main

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angle between mainbranch and sidebranch!

Use of the traditional Tstent technique isassociated with highrisk of missing the sidebranch ostium

The TAP Technique

T stent And Protrusion

MainBranch

Wire both vessels


Position and deploy mainbranch stent

Rewire side branch andballoon dilate

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SideBranch

balloon dilate

Position side branch stent soproximal edge protrudesslightly into main branch,‘backstop’ balloon inmain branch

Deploy side branch stentfirst, then inflate mainbranch balloon to kiss

TAP Technique

• Relatively simple

• Assures coverage ofside branch ostium

• Less metal at side

• Excessive stentprotrusion can leadto troubleaccessing distal


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• Less metal at sidebranch ostiumcompared to Crushtechnique

• Works when vesselsare different sizes

accessing distalmain branch in thefuture



•Crush Techniques


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The Culotte Technique

MainBranch

Wire both vessels


Position and deploy stent inmost angulated branch

Remove first wire, wiresecond branch and

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SideBranch

second branch andballoon dilate

Position second branch stentso proximal portion equalwith previous stent edgeand deploy

Rewire initially stentedbranch and performkissing post-dilitation

Culotte Technique

• Assures sidebranch ostiumcoverage

• Complex

• Vessels must be ofsimilar size


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• Excellent radialstrength in mainbranch

• Somewhat timeconsuming

What is POT?

Proximal Optimization Technique

Dilatation of the stent within theproximal vessel to an appropriate

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proximal vessel to an appropriatesize to achieve proper appositionto avoid rewiring behind the stentand causing inadvertent crush ordistortion of the stent

Does it Really Matter WhatTechnique I Use?

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A registry of unprotected left main bifurcation lesions treatedwith T-stenting, mini-crush, and Culotte techniques

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DK Crush vs. Provisional Stentingfor Left Main Bifurcation Lesions

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Chen et al. JACC Volume 70, Issue 21, 28 November 2017, Pages 2605-2617

482 patients from 26 centers in 5 countries with true distal LMbifurcation lesions (Medina 1,1,1 or 0,1,1) randomized to provisionalstenting (n = 242) or DK crush stenting (n = 240)

DK Crush vs. Provisional Stentingfor Left Main Bifurcation Lesions

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Conclusions

• Multiple techniques have been developed toeffectively treat bifurcation lesions

• Each has unique advantages anddisadvantages and details of why you would

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disadvantages and details of why you wouldwant to use one over the other

• Being proficient with multiple techniqueswill assure that you are able to perform PCIregardless of varying patient anatomy withexcellent technical success

Thank You

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approach to bifurcation pci: a step by step refresher...for left main bifurcation lesions scripps...

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