pci for bifurcation coronary lesion - summitmd.com lesion.pdf · cardiovascular research foundation...

40
Cardiovascular Research Foundation ANGIOPLASTY SUMMIT PCI for Bifurcation Coronary Lesion

Upload: vudieu

Post on 29-Sep-2018

222 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

PCI forBifurcation Coronary

Lesion

Page 2: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Bifurcation LesionsPCI is Challenging

Bifurcation LesionsPCI is Challenging

• Higher acute complication• Lower success rates• Higher restenosis & TLR

Restenosis Rate 21 ~ 57%TLR 8 ~ 43%

Page 3: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Event Free Survival after PCINHLBI Registry

Duration (months)0 1 2 3 4 5 6 7 8 9 10 11 12

60

70

80

90

100

% e

vent

free

Bifurcation (+), n=321Bifurcation (–), n=2115

* P < 0.0574.3%

67.9%

Suwaidi J, et al. AJC 2001;87:1139-44

Page 4: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Side Branch LossMain Mechanism of Adverse Outcomes

Side Branch LossMain Mechanism of Adverse Outcomes

Page 5: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Predictors ofSide Branch Occlusion

• Side branch DS > 50 %• Disease burden in parent vessel at

take-off of side branch• Dissection of parent vessel

Page 6: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

How to Stent ?

Stenting Technique

Page 7: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Single StentingSingle Stenting

Single stenting in the parent vessel with or without balloon dilatation in the side branch

Side branch

Main vessel

Page 8: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Two Stenting : T StentingTwo Stenting : T StentingSequential stenting in the main vessel and the side branch

Side branch

Main vessel

Page 9: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Two Stenting : Y (Culotte) Stenting

Two Stenting : Y (Culotte) Stenting

Stenting in the side branch followed by in the main vessel

Side branchMain vessel

Page 10: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Two Stenting : Kissing StentingTwo Stenting :

Kissing StentingSimultaneous stenting in the main vessel and the side branch

Side branch

Main vessel

Page 11: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Single Stent vs. Two StentSingle Stent vs. Two Stent

Procedural Results Double(n=53)

3.1 ± 0.692

127 ± 528713

Single(n=39)

3.0 ± 0.456

98 ± 45920

P

NS< 0.05< 0.05

NS< 0.05

Ref. vessel(mm)Kissing balloon (%)Procedural time (min)Success (%)In-hosp. MACE (%)

Yamashita T, et al. JACC 2000;35:1145-51

Page 12: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Single Stent vs. Two StentSingle Stent vs. Two Stent

6 Month Restenosis Rate

Main vessel Side branch Global

SingleDouble

13

25

38

28%

43

13

P=NS

Anzuini A, et al. Am J Cardiol 2001;88:1246-50

Page 13: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Single Stent vs. Two StentSingle Stent vs. Two Stent

Freedom fromdeath, MI, CABG, rePTCA & severe angina

Event Free Survival

Stent+Stent

Stent+PTCA

Months6

20

40

60

80

100%

*P=0.106

0 3 9 12 6Months

Suwaidi J, et al. JACC 2000;35:929-36

20

40

60

80

100

Y-stenting

T-stenting

*P=0.004

0 3 9 12

Page 14: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Tube Stent vs. Coil StentTube Stent vs. Coil StentSide Branch Occlusion (%) AMC Data

CrossFlex (Coil)NIR (Tube)GFX (Hybrid)

P = NS

Post-Balloon Post-Stent

01.8

7.78.8

10.5

1.3

Cho GY, et al. Cathet Cardiovasc intervent 2001;52:18-23

Page 15: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Two bare metal stents are not better than single stent.

Stent in main vessel andPOBA in side branch withOptional kissing balloon

Page 16: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Importance of StentingTechnique

Importance of StentingTechnique

Period Ⅰ(n=182)

59 %18 %

73 %29 %21 %

Period Ⅱ(n=191)

94 %75 %30 %93 %17 %14 %

P

< 0.01< 0.001

< 0.01< 0.01< 0.05

Tube stent (main vessel)Final Kissing balloonBoth branch stent6 Fr catheterMACETVR(7 months)

Lefevre T, et al. Cathet Cardiovasc Intervent 2000 ;49:274-83

Page 17: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Plaque Reduction in Main Vessel ?

Debulking Atherectomy

Page 18: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Role of DCA before StentingRole of DCA before StentingMinimal Lumen Diameter

DCA + S(n=58)

3.2 ± 0.52.2 ± 1.1

2.4 ± 0.51.6 ± 0.7

Stent alone(n=332)

3.0 ± 0.61.6 ± 0.9

2.0 ± 0.61.2 ± 0.7

P

0.010.01

0.010.03

Main VesselMLD post (mm)MLD F/U (mm)

Side BranchMLD post (mm)MLD F/U (mm

Chieffo A, et al. Am J Cardiol 2002;90:44H

Page 19: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Role of DCA before StentingRole of DCA before Stenting

Restenosis rate (%) MACE (%) Stent alone

Main vessel Side branch

DCA+Stent

16 16

3441

*P < 0.05

* *14

32P < 0.05

Chieffo A, et al. Am J Cardiol 2002;90:44H

Page 20: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Subgroup of AMIGO TrialSubgroup of AMIGO TrialRestenosis Rate

0

5

10

15

20

25

DCA+Stent Stent alone

9.8 %

4/45

20.9 %

9/43P < 0.05

Braden G, et al. TCT 2002

Page 21: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Debulking Followed By Stenting

Debulking Followed By Stenting

Might be beneficial in lesions with large plaque burden

Page 22: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

New Modality for Bifurcation Lesion ?

New Modality for Bifurcation Lesion ?

•True Bifurcated Stent

•Drug Eluting Stent

Page 23: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Bifurcated Stents Bifurcated Stents

NIRSIDE Stent

Guidant Frontier Stent

BARD Bifurcate XT

Page 24: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Bifurcated Stent Bifurcated Stent

Cordis DBS Stent Cordis DBS Stent

34 patients (mean 64 years)

•Technical Success 94%•MACE @ 30 days 0%•Restenosis @ 6 Mo 33%•TLR 19%

Dibie A, et al. Am J Cardiol 2002;90:13H

Page 25: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

AST SLK -View

Bifurcated Stents Bifurcated Stents AST SLK -View

Side holeStent length = 17mmCatheter length = 140 cmCrossing profile = 0.055 INAvailable in two sizes

- 3.0mm with 2.5mm side hole- 3.5mm with 3.0mm side hole

Page 26: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Main catheter system comprises of a main stent with a side hole and astabilizing catheter, which allows access to side branch after stenting

AST SLK -ViewAST SLK -ViewBifurcated Stents Bifurcated Stents

Page 27: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

AST SLK-View StentAMC Experience

AST SLK-View StentAMC Experience

48 pts (mean 58 years) 50 lesionsParentvessel

100 %

Sidebranch

100 %100 %100 %

Technical SuccessSide branch accessibilitySide branch preservation after stenting

Kim YH, et al. TCT 2002

Page 28: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Drug Eluting Stent

Page 29: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

SIRIUS Bifurcation Study SIRIUS Bifurcation Study Sirolimus Eluting Stent

Total 86 pts enrolledRandomization

Stent + Stent43 pts

Stent + PTCA43 pts

Stent + Stent63 pts(65les)

Stent + PTCA22 pts

1 withoutsuccess

Cross-over 2Cross-over 22

A Colombo, et al. AHA 2002

Page 30: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Procedural Technique Procedural Technique SIRIUS Bifurcation Study

Stent / PTCA(n=22)

19 (86%)8 (37%)

Stent / Stent(n=63)

604020 12

60 (95%)27 (43%)

Technique

T- stentingSide branch firstMain vessel first

V- stentingY- stentingKissing balloonGPⅡb/Ⅲa inhibitor

A Colombo, et al. AHA 2002

Page 31: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Main Vessel Minimal Lumen Diameter

Main Vessel Minimal Lumen Diameter

SIRIUS BifurcationSIRIUS Bifurcation

0

0.5

1

1.5

2

2.5

Baseline Follow-up

Stent+Stent Stent+PTCA

0.99(n=63) 0.92

(n=22)

2.4(n=46) 2.5

(n=19)

mm

Page 32: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Side Branch Minimal Lumen Diameter

Side Branch Minimal Lumen Diameter

SIRIUS BifurcationSIRIUS Bifurcation

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Baseline Follow-up

Stent+Stent Stent+PTCA

0.88(n=65)

1.14(n=22)

1.58(n=44) 1.56

(n=18)

mmP=0.02

Page 33: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

In-Segment RestenosisIn-Segment RestenosisSIRIUS BifurcationSIRIUS Bifurcation

0

5

10

15

20

25

30

Main Vessel Side Branch

Stent+Stent Stent+PTCA

2.35.0

25.0

10.0

P=0.20P=0.20

%

Page 34: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

6 Months Restenosis Rate6 Months Restenosis RateSIRIUS BifurcationSIRIUS Bifurcation

0011Proximal to the stent

0100Distal to the stent

21000Ostium of the side branch

Side, S+P(n=2)

Side, S+S

(n=11)

Main, S+P

(n=1)

Main, S+S (n=1)

Page 35: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

What We LearnedDES In Bifurcation LesionWhat We LearnedDES In Bifurcation LesionDES In Bifurcation Lesion

• EffectiveNearly eliminate restenosis in the main vessel

• IneffectivePersistent disturbingly high restenosis at the uncovered side branch ostium

Page 36: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Two Stenting Strategy in SIRIUS Bifurcation StudyTwo Stenting Strategy in SIRIUS Bifurcation Study

Potential gap susceptible toPotential gap susceptible to restenosisrestenosis

Page 37: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Proposed Stenting Strategy In the Era of DES

Proposed Stenting Strategy In the Era of DES

Complete coverage of side branch Complete coverage of side branch ostiumostiumY (Culotte) KissingModified T

Page 38: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Emerging New TechniqueEmerging New Technique

StentStent--CrushCrushCrushed first stentimplanted in side branch

Page 39: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

AMC ProposalAMC Proposal

Kissing Kissing Stenting Stenting with with Optional Optional StentStent--CrushCrush

Suboptimal result after kissing stenting

Page 40: PCI for Bifurcation Coronary Lesion - summitmd.com lesion.pdf · Cardiovascular Research Foundation ANGIOPLASTY SUMMIT Bifurcation Lesions PCI is ChallengingPCI is Challenging •

Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

Future Perspectives in the Era of DES

Future Perspectives in the Era of DES

• The role of debulking atherectomy • The fate of side branch after PCI with DES• Large randomized comparison of two DES and

single DES

Following consideration should be evaluated