BIFURCATION STENTINGCoronary artery disease

Subha Ratha Yatra 2014

GUESS SOMETHING PEEING THROUGH STENT WINDOW?

BASIS

The approach to bifurcation lesions is based on the angiographic configuration of the lesion(s) in the main branch and the side branch

Significant disease (>50% stenosis) in the ostium of the side branch increases the likelihood of side-branch closure as well as the restenosis rate after PCI

ONE STENT VS TWO STENT STRATEGY

Default approach is one-stent technique ± provisional angioplasty/stent to side branch

Use two-stent technique if side branch is significant and has high-risk features for closure

RISK

The risk of side-branch closure with an ostial narrowing approaches 15%

PCI across an uninvolved side branch carries a less than 1% risk of occlusion

CLASSIFICATION

MEDINA CLASSIFICATION

GUIDE CATHETER

7 F or 8 F guiding catheter should be selected if the operator anticipates using two stents

A 6 F guiding catheter can accommodate only two monorail balloon

8 F guiding catheter can accommodate two stent systems as well as other large-diameter PCI devices such as the Rotablator or the Flextome Cutting Balloon

The maximum Rotablator burr that can be used with a 6 F guiding catheter is 1.5 mm

It may be prudent to “upsize” guiding catheters when approaching any bifurcation lesion so that all options remain available if trouble occurs during the procedure

GUIDEWIRE

To protect the side branch, two guidewires are placed, one in the side branch and one in the main vessel

The order of inflation is relatively unimportant

Wire markers or using two different wire types is helpful to reduce confusion during balloon inflations and wire repositioning

When using a two-guidewire system, the guidewires may become entangled after multiple wire manipulations

. Efforts should be made to avoid guidewire entanglement, which will prevent advancement of the balloon and may result in failure to recross the stenosis.

BALLOON

Standard balloon use

Different balloon sizes may be required for each branch

Sequential balloon inflations or simultaneous “kissing” balloon inflations can be performed with elimination of plaque shifting being the advantage of the latter

It is important to make sure that the main vessel can accommodate both balloon diameters when performing kissing balloon inflations (proximal vessel should be at least two thirds of the combined balloon diameters)

After stent placement in the main branch and the side branch, simultaneous kissing balloon inflations are critical to restore the circular and fully expanded stent to each lumen

Failure to perform final kissing balloon inflation will likely lead to restenosis

SEQUENTIAL BRANCH INFLATIONS

Dilate the main vessel first, the side branch second, and finish dilation in the main branch

A sequential main-side-main branch inflation strategy provides a safe and straightforward approach

Sequential inflations may result in suboptimal main vessel dilation and plaque shifting , requiring repeated dilatations

An unprotected major vessel dissection will require reinstrumentation and jeopardize further attempts to open the side branch

Serial inflations, first in one branch then in the other, as opposed to simultaneous balloon inflations in both branches, may limit the need for extra manoeuvres.

T STENTING-2 STENTS

The side branch off ostium ,therefore no crush

IAKOVOU I., GE L., AND COLOMBO A.: CONTEMPORARY STENT TREATMENT OF CORONARY BIFURCATIONS. J AM COLL CARDIOL 2005; 46: PP. 1446-1455

Although T stenting is less laborious than both culotte and crush, the T-technique invariably leads to inadequate coverage of the SB ostium and has consequently been discontinued in a number of institutions except for either isolated SB ostial lesions or when the result of a provisional single-stent strategy is suboptimal

V STENT-2 STENTS

Y STENTS-3 STENTS

DOUBLE BARREL(V STENT VARIANT)

CULLOTTE TECHNIQUE

Angle <70 degree

Bend branch stenting first

CHEVALIER B., GLATT B., ROYER T., AND GUYON P.: PLACEMENT OF CORONARY STENTS IN BIFURCATION LESIONS BY THE “CULOTTE” TECHNIQUE. AM J CARDIOL 1998; 82: PP. 943-949

First described by Chevalier et al.  using BMS, the culotte technique results in two layers of stent proximal to the bifurcation, full coverage of the SB ostium and of both branches distal to the bifurcation. The technique is suitable for all angles of bifurcation, but it does leave a double stent layer at both the carina and the proximal part of the bifurcation. Furthermore, rewiring both branches through stent struts may prove both difficult and time consuming.

CRUSH TECH

Side branch stenting protrudes into and get crushed after main stent expansion

COLOMBO A., STANKOVIC G., ORLIC D., CORVAJA N., LIISTRO F., AIROLDI F., CHIEFFO A., SPANOS V., MONTORFANO M., AND DI MARIO C.: MODIFIED T-STENTING TECHNIQUE WITH CRUSHING FOR BIFURCATION LESIONS: IMMEDIATE RESULTS AND 30-DAY OUTCOME. CATHETER CARDIOVASC INTERV 2003; 60: PP. 145-151

CRUSH was first introduced by Colombo et al. as a modified T-stenting technique using DES, ensures uninterrupted patency of both the MB and the SB as well as excellent coverage of the ostium of the SB. Final kissing balloon (FKB) dilatation is now considered mandatory to allow optimal strut contact and drug delivery to the ostium of the SB 15 16 .

MINICRUSH

The minicrush technique differs from classical crush in the amount of the SB stent protruding into the MB, with protrusion into the proximal end of the SB ostium in the latter, limiting multiple layering of stent struts and allowing for more complete stent endothelialization

REVERSE CRUSH

The reverse crush technique is employed when a provisional single-stent strategy becomes suboptimal. Following the placement of a stent in the SB, an appropriately sized balloon is positioned in the MB at the level of the bifurcation, before retracting the SB stent 2–3 mm into the MB and deploying it. If the result in the SB is satisfactory, the deploying balloon and SB wire are removed and the MB balloon is inflated, thus crushing the SB stent. Subsequent steps are similar to those of conventional crush technique.

1 VS 2 STENT STRATEGY IN DES ERA

ONLY FOR EXPERTS

Crush

Culottes

Angle is < 70 degree

Excellent coverage in excellent hand

CRUSH

Wire both vessels

Predilate both

Two stents are then advanced and positioned into each vessel of the bifurcation with the proximal end of the side-branch stent in the main vessel

The side-branch stent is deployed first

The main-branch stent is then deployed

The side branch then needs to be rewired and balloon dilated

Final kissing balloon inflation is then performed to complete the procedure

IAKOVOU I., GE L., AND COLOMBO A.: CONTEMPORARY STENT TREATMENT OF CORONARY BIFURCATIONS. J AM COLL CARDIOL 2005; 46: PP. 1446-1455

The simultaneous kissing stent (SKS) technique is considered most suitable for proximal bifurcation lesions, such as a distal left–main bifurcation lesion with an angle of <90° between the two branches . The technique has the advantage that control of the MB and the SB are not lost at any stage during the procedure and FKB dilatation can be undertaken without the need to recross either stent.

JAIL FOR ONLY UNPARDONABLE MISTAKE

Physiologic Guidance for Bifurcation or Jailed Side-Branch Stenting is decided by IVUS and FFR

IVUS

To overcome visual elusion of best result

FFR

By using FFR, the “jailed” side branches with an FFR >0.75 have a very low clinical event rate without further balloon or stent therapy to the side branch

Performing FFR of ostial side-branch lesions that appear to be <70% from angiography can prove that most of these lesions are not physiologically significant

KEEP IT SIMPLE STUPID: KISS

Wire both main branch and side branch if side-branch loss is important.

Consider treating side branch first (i.e., balloon dilatation, rotational atherectomy, or cutting balloon).

Dilate and stent main branch; reassess side branch (can use FFR to determine hemodynamic significance).

Provisional PTCA + stent side branch. If stenting side branch, stent with pullback technique.

Choice of two-stent technique depends on size of proximal vessel, an assessment of the importance and risk of side-branch closure, and operator expertise and preference.

Use two wires if side branch loss is important.

Dilate smaller branch first or use Rotablator or cutting balloon.

Dilate and stent main branch; reassess side branch.

Redilate side branch.

Stent side branch through main stent only when absolutely necessary; use FFR to assess physiologic significance of side branch.

If a two-stent technique is used, final kissing balloon inflation is necessary to optimize outcomes

SUBHA RATHA YATRA -2014