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  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    PCI forBifurcation Coronary

    Lesion

  • 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%

  • 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

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    Side Branch LossMain Mechanism of Adverse Outcomes

    Side Branch LossMain Mechanism of Adverse Outcomes

  • 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

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    How to Stent ?

    Stenting Technique

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    Importance of StentingTechnique

    Importance of StentingTechnique

    Period (n=182)

    59 %18 %

    73 %29 %21 %

    Period (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

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    Plaque Reduction in Main Vessel ?

    Debulking Atherectomy

  • 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

  • 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

  • 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

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    Debulking Followed By Stenting

    Debulking Followed By Stenting

    Might be beneficial in lesions with large plaque burden

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    New Modality for Bifurcation Lesion ?

    New Modality for Bifurcation Lesion ?

    True Bifurcated StentDrug Eluting Stent

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    Bifurcated Stents Bifurcated Stents

    NIRSIDE Stent

    Guidant Frontier Stent

    BARD Bifurcate XT

  • 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

  • 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

  • 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

  • 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

  • Cardiovascular Research Foundation ANGIOPLASTY SUMMIT

    Drug Eluting Stent

  • 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

  • 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 balloonGPb/a inhibitor

    A Colombo, et al. AHA 2002

  • 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

  • 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

  • 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

    %

  • 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

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