axxess bifurcation dedicated self-expandable drug eluting stent. step by step tutorial. part 1...
TRANSCRIPT
Male BD 29/7/1932
Hypertension, smoking
1999 STEMI anterior > DES LAD
2003 PM VVI
2014 Effort angina
Positive exercise test – V3-V6
29/8/2014 DES on PD (RCA)
Residual stenosis LAD/D1
Femoral
LAD/D1 stenosis
Medina 1.0.1
Femoral
LAD/D1 stenosis
Medina 1.0.1
Femoral
LAD/D1 stenosis
Medina 1.0.1
Femoral
LAD/D1 stenosis
Medina 1.0.1
Femoral
LAD/D1 stenosis
Medina 1.0.1
Femoral
LAD/D1 stenosis
Medina 1.0.1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira 2,5x12
POBA LAD
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira 2,5x12
POBA LAD
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• PostNC Empira 2,5x12
Result LAD
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• PostNC Empira 2,5x12
Result LAD
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Sprinter 2,0 x 102
POBA D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira2,5 x 15
POBA D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira2,5 x 15
POBA D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• IVA satisfying
• D1
• Not satissfying
Result post POBA
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• IVA satisfying
• D1
• Not satissfying
Result post POBA
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• IVA satisfying
• D1
• Not satissfying
Result post POBA
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• IVA satisfying
• D1
• Not satissfying
Result post POBA
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira2,5 x 15
2nd POBA D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira2,5 x 15
2nd POBA D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira2,5 x 15
3rd POBA LAD
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• NC Empira2,5 x 15
3rd POBA LAD
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Satisfying
Result post POBA
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Satisfying
Result post POBA
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Inside the GC
Axxess 3,0x11
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Inside the GC
Axxess 3,0x11
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• After the bifurcation
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• After the bifurcation
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Correct position
• Start opening
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Correct position
• Start opening
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Two markers in D1
• One marker in LAD
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Two markers in D1
• One marker in LAD
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Two markers in D1
• One marker in LAD
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Two markers in D1
• One marker in LAD
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Point of no return
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Point of no return
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Complete opening
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Removing the whole system
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Result
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Result
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Rewiring LAD
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Rewiring LAD
Axxess
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Biomatrix 2,25 x 14
DES D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Biomatrix 2,25 x 14
DES D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Biomatrix 2,25 x 14
DES D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Biomatrix 2,25 x 14
DES D1
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Kissing LAD/D1
Finalizing
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
• Kissing LAD/D1
Finalizing
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
Final result
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
Final result
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
Final result
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
Final result
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
Final result
Sheathless 7,5F PB
Sion Blu LAD
Luge D1
Final result
•Two orthogonal, projection. Enough contrast. Higher frame rate
Good visualization of the bifurcation
•At least 7F GC. Sheathless 7,5F is good for radial. Choose GC permitting sufficient support.
Guiding catheter
•Use sufficiently supportive wires
Wires
•Prepare both branches gradually incrementing the balloon diameter. Use non compliant balloon if needed. Prepare the lesion – stent like result. Control the preparation in two projection
Lesion preparation
•Use the wire of the branch less angulated respect the parent vessel
Wire to chose for Axxess placement
•When the distal stent markers are exactly at the carina start slowly, very slowly to open the stent
Initial opening Axxess
•Once the three distal markers start to separate at the carina site, push gently the system to see their further separation and to feel resistance
Engaging the carina
•When seeing one distal stent marker in one branch and rest distal markers in the other branch.
•Confirm with another projection the same separation of the markers
Confirming the correct position
•Once confirmed the correct position in two projection
Final opening of Axxess
•While opening the stent push the whole system to see how the distal part of the stent engages the branches
•Use contrast to control the position
Technique of opening Axxess
•Once delivered the stent control it in two orthogonal projection
•Evaluate well, even with zoom the proximal and the distal part of the stent
Finalising the procedure
•Use two appropriate to the branches balloons in kissing technique
• If need place further stents to the side, main or parent vessel
Post-dilatation
