solaci 2012

SOLACI 2012

IVUS in coronary bifurcations: is it underused?

A. MedinaServicio de Cardiología

Hospital Universitario de Gran Canaria Dr. Negrín Canary Islands (Spain)

No conflict of interest

Lesion in a non bifurcated segment Bifurcation lesions

{1,1,1}

LAD

Dg

Medina et al. Rev Esp Cardiol 2006;59(2):183

… BEYOND MEDINA´S CLASSIFICATION

SB: focal vs long (>10 mm) lesion

{0,1,0,0}

{1,1,1} {1,1,1}

Trifurcation (LM 10%)

balanced vs small SB

{1,1,1}

Angle: Y and T shape

{0,1,0}

LAD

DgDg

{1,1,1}

Proximal MB SB

Distal MB

Medis QAngio XA 7.1 dedicated bifurcation QCA system

Paieon CardiOp-B 3D

Long axis reconstruction

{0,1,1}

Proximal LAD Distal LAD

Dg

{0,1,1}

Dg

LAD

plaque

Virmani

plaque

plaque

{0,1,1}

Proximal LAD Distal LAD

Dg

p

p

DgLAD LADLAD

LAD LAD

After kissing

Carina displacement – Ostial damage Carina repositioning

stent

LAD

Dg

LAD

Dg

LAD

Dg

After MB stenting

{0,1,1}

Baseline

Ca

rin

a r

eg

ion A B C

…IVUS allows to monitor the treatment

Strategies for bifurcation lesion stenting:Impact of IVUS guided

Park SJ et al. Circ Cardiovasc Intervent 2009;2:167-77

Strategies for bifurcation lesion stenting:Impact of IVUS guided

Oval shape

LADLM

LCx

LADLM

LCx

LADLM

LCx

LADLM

LCx

“Vulnerable anatomy of the carina in ostial left anterior descendinglesions treated with floating stent”. Medina et al . Rev Esp Cardiol.2009;62(11):1240-9

“Ultrasound study of the prevalence of plaque at the carina in lesionsthat affect the coronary bifurcation. Implications for treatment withprovisional stent” Medina et al. Rev Esp Cardiol. 2011;64(1):43-50

“Predictors of ostial side branch damage during provisional stenting ofcoronary bifurcation lesions not involving the side branch origin: anultrasonographic study ”. Suárez de Lezo et al. Eurointervention (Suárezde Lezo et al. Eurointerv 2012;7:1147-54)

Ultrasound anatomy of bifurcation lesions and techniques

“Ultrasounds findings during percutaneous treatment of bifurcatedcoronary lesions”. Suárez de Lezo et al . Rev Esp Cardiol.2008;61(9):930-5

“Sequential side-main-side vessels balloon dilation (SMS technique) forbifurcation lesions treated with provisional stenting” Medina et al . ESCCongress 2011

Ult

raso

un

d a

na

tom

y o

f b

ifu

rca

tio

n

Eyebrow sign

CARINA MORPHOLOGY IN BIFURCATION CORONARY LESIONS

“spiky carina”

Medina et al. Rev Esp Cardiol 2009;62:1240-9Suárez de Lezo et al. Eurointerv 2012;7:1147-54

Carina shifting

2009

2011

Medina et al. Rev Esp Cardiol 2009;62:1240-9

Osuma et al. Eurointervention 2011;62:1240-9

Baseline After MB stenting Final kissing balloon

LM LAD

LCx

LM LAD

LCx (jailed)

LM LAD

LCx

Carina displacement Carina repositioning

{1,1,?}

{1,1,0}

{1,1,?}

Spiky carina

Spatial and phasic oscillation of non-Newtonian wall shear

stress in human left coronary artery bifurcation: an insight

to atherogenesis.

Soulis JV et al. Coron Artery Dis. 2006 May;17 (4):351-8.

Wall shear stress & carina

early systole

Virmani

*

*

*

*

LM LAD

LCx

LM LAD

LCx

LADp LADd

Dg

LCx MB

LCx

*

**

LM LAD

LCx Dg

LAD LAD

Dg

Plaque at the carina 63/195 (32%)

Carina free of plaque 132/195 (68%)

LM LAD

LCx

LADp LADd

Dg

LCx LCx

MB

Medina et al. Rev Esp Cardiol 2011;64(1):43-50

The carina is not always free of disease! Is it important or not?


LCx LCx

MB MB

LCx {1,1,0}

*

SBMB

SBMB

Plaque at the carina might prevent carina shifting!!

LAD

Dg

Septal

LAD

Dg

Septal

LAD

LAD-DG {1,1,0}

Fro

m p

rox

ima

l to

dis

tal

Snow plow effect & provisional stenting

?

A B

C D


Floating stent in distal left main {0,1,0} and {0,0,1}

Ostial LAD (n=96): LM stenting or not

LM stenting (n=25)

Floating (n =71)

21

6 65

4

2002 2005 2008

“Precise” stent deployment “Floating” stent (IVUS guided)

LAD

LCx

LCx

LCx

FLOATING STENT TECHNIQUE & IVUS

LAD

LAD

LM

carina

Floating struts

Stent positioning at the level of the carina

(fluoroscopy & IVUS)

transducer

LCX

LADLM

LCX

LADLM

LADLCX

Floating

Outcome of floating struts n=37/49 (75%)

I know so

very little

about you…

7 months later

Outcome of floating struts

It is all right

LAD

0

200

400

600

800

1000

1200

LM 2002-2011 Technique

One stent Two stent

1138

905 (79%)

233 (21%)

350 (30%)

{1,1,1}

0

200

400

600

800

1000

1200

LM 2002-2011 Technique

{1,1,1} Others

DISTAL LEFT MAIN

Medina classification

One stent 238/350 (68%)

Two stent 112/350 (32%)

IVUS guided 815 / 1138 p (72%)

LM LAD

LCx

LM

LAD

LCx

LCxLCx

LM LM

LADLAD

{1,1,1}

##1

LCx

T and small protusion (LCx across)

LAD

LM

LM

LAD

LCxLM LAD

LCx

LM

LAD

LCxLM LAD

LCx

LM LAD

LCxLM

LCx pull-back

LAD pull-back

2010 March

4 x 18 mm LCx floating stent

Two stages modified V-stenting##2

{0,0,1}

Baseline

After stenting

15 months

later

LM LCx

LAD LAD

LCx

{0,1,0}

A B

C

MB

LM

LCx

LAD

LAD

LCxLM

LAD

LCx

LCx

LAD

##3

FFR 0,83

LAD

LAD

Dg

Dg

FFR 0,71

{0,1,1/2}

LAD

LAD

LAD

Dg

Dg

LADLAD

LADDg LAD Dg

IVUS Guided Intervention in Provisional Stenting

Precise lesion characterization (one or two pull-backs)

Predicts success of direct stenting (IVUS catheter crosses the lesion and there is not heavy calcification)

Anatomy of the carina region:

Carina (spiky vs non spiky / plaque at the carina)

Need of a jailed wire

Distribution of plaque in MB and SB

Measurement of distal MB reference diameter (selection of the stent Ø)

LE

SIO

N

AS

SE

SS

ME

NT

ST

EN

T

D

EP

LO

YM

EN

T

Ostium of the SB

No compromise

Carina displacement

Downstream axial plaque shift

MB proximal apposition of the stent.

SB

INT

ER

VE

NT

ION

Position of the guide wire (MB SB)

Evaluation of the SB after angioplasty

Evaluation after SMS or final kissing

Evaluation of a two-stent technique

Precise lesion characterization to select the strategy of intervention

IVUS Guided Intervention in Two-Stent Techniques

solaci 2012

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