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

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


• 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


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


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


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


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


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


Eventfree survival curve at 6 months

4.6%

1.8%

p=0.09


• 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


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

bifurcation lesions

Education

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