Bench Insights into Bifurcation Stenting in the DES Era: An Update
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1 Bench Insights into Bifurcation Stenting in the DES Era: An Update John Ormiston, Mark Webster, Peter Ruygrok, Jim Stewart, Douglas Scott, Duncan McNabb, Erin Currie, Monique Panther Mercy Hospital and Green Lane Cardiovascular Unit at Auckland City Hospital, Auckland, New Zealand Seoul, 2005
2 Some lessons learned from the bench
3 Methods: Stents were deployed in a phantom and photographed
4 Interiors were photographed through a paediatric endoscope Looking down the main branch Looking up the sidebranch
5 Provisional T Stenting
6 With provisional T stenting, the side-br stent should not be too distal leaving gaps * The Randomized Trial to Evaluate Sirolimus-eluting Stents in Coronary Bifurcations Showed marked reduction in restenosis with SES vs BMS historical controls Restenoses were at the side-br ostium?gaps after T * (Colombo, Circulation March 04)
7 With provisional T stenting, the side-br stent should not be too proximal potentially obstructing main br * *
8 The Crush Technique Aimed to reduce restenosis by fully covering the side-branch ostium without gaps in scaffolding or drug application Safe, quick, limited ischemic time Reliably treats the side-branch Always under control Kissing balloon post-dilatation is the most difficult and perhaps the most important part
9 Crush Technique with Zomaxx Main br Side br
10 Crush Technique with Zomaxx Stent Deploy side-br stent
11 Crush Technique with Zomaxx Deploy main br stent crushing side-br stent in main br
12 Crush Technique with Zomaxx
13 Crush Technique with Zomaxx Kissing balloon post-dilatation
14 Crush Technique with Zomaxx 2 layers 3 layers Kissing balloon post-dilatation
15 After Crush, kissing balloon post-dilatation releases the side-br from jail Improves subsequent access May reduce thrombosis risk Before kiss Side-br jail After kiss No Side br jail Ormiston
16 Kissing balloon post-dilatation fully expands the side branch ostium improving scaffolding and drug application (Cypher stents) Ormiston
17 If you get a crush you should kiss and if you kiss, you should do it well Antonio Colombo, Editorial CCVI, 2004
18 It may be wise to limit the length of the 3 layers of overlap 3layers Long overlap 3 layers Short overlap
19 Study in NZ rabbits comparing endothialization after overlapping of bare metal Bx Velocity stents with Overlapping Cypher sirolimuseluting stents (Finn, ACC 05)
20 Study in NZ rabbits comparing endothialization after overlapping of bare metal Express stents with Overlapping Taxus express stents In rabbits (Finn, ACC 05)
21 Endothelialization with BMS was better than with DES Endothelialization with a single layer of DES was better than with overlap Finn ACC 05
22 Scanning Electron Microscopy of DES polymers
23 Expanded Cypher stent normal polymer appearance
24 Normal appearance of the polymer on the expanded Taxus stent
25 Scanning Electron Microscopy after crush technique with kissing balloon postdilatation 3.5 and 3.0 mm DES Kissing balloon post-dilatation with 4.0 mm main br and 3 mm side-br 20 atmos five times (oversized, v high pressure and repeated) Stents were separated, sputter coated, and imaged with SEM
26 Side-branch ostium after crush + kiss with large balloons and multiple inflations at 20 atmos
27 Does polymer damage predispose to thrombosis and/or restenosis?
28 Side-branch ostium after crush and after single 10 atm kissing balloon post-dilatation- minimal polymer damage
29 With repeated high pressure postdilatation with oversized balloons, it is possible to damage polymers after crush technique
30 The Culotte Technique- Provisional side-br stenting in the DES era
31 Culotte Stenting with Liberte (new Boston DES delivery platform) Ormiston, 05
32 When the side-branch stent is passed partially through the side of the main branch stent and deployed, distortion appears Ormiston, 05
33 Culotte technique. The balloon is removed Ormiston, 05
34 Culotte. Main branch post-dilatation distorts the side-br ostium
35 The main branch post-dilating balloon is removed Ormiston, 05
36 Culotte. Kissing balloon post-dilatation.
37 Kissing balloon post-dilatation corrects distortion, and fully expands the stent improving scaffolding and drug application to the ostium
38 Kissing balloon post-dilatation releases the side-branch from jail after Culotte with Liberte Side-branch is jailed Kissing balloon postdilatation releases the side br from jail Ormiston, 05
39 After culotte, kissing balloon postdilatation relieves main branch obstruction (Taxus Express stents) SB MB SB Before kiss After kiss
40 Stent Distortion in Bifurcation Stenting -its prevention and repair
41 stent distortion may predispose to SAT predispose to restenosis limit subsequent access
42 Distortion caused by dilatation through the side of a single stent Distortion is repaired by kissing balloon dilatation Ormiston et al Cathet Cardiovasc Interv 1999;47:
43 An undersized kissing balloon post-dilatation.. Ormiston CCVI
44 causes distortion after conventional crush Ormiston CCVI (2004)
45 An appropriately sized main branch kissing balloon. Ormiston CCVI (2004)
46 .repairs (or prevents) distortion Ormiston CCVI (2004)
47 Kissing Balloon Post-dilatation After External Crush corrects distortion
48 A kiss is not just a kiss Antonio Colombo, Editorial CCVI, 2004
49 Summary- Bifurcations with DES Drug-eluting stents are a major advance in treatment of bifurcation lesions There is no perfect solution for bifurcation stenting with DES T stenting has potential for gaps in scaffolding and drug application The external crush technique ensures coverage of the sidebranch ostium without gaps but jails the side-br and has 3 layers of stent Kissing balloon post-dilatation corrects any main-br distortion, releases the side-br from jail and fully expands the stent at the side-br ostium after crush, culotte and T stenting
50 Summary Kissing balloon post-dilatation corrects any main-br distortion, releases the side-br from jail and fully expands the stent at the side-br ostium after crush, culotte and T stenting Undersized main branch kissing balloon post-dilatation after external crush, culotte and T stenting causes stent distortion Very high pressure, repeated oversized postdilatation after crush causes polymer disruption Length of overlap (3layers) with crush should be limited
51 Maximum cell size after side-br dilatation Bx Velocity (Cypher) Express (Taxus Express) Liberte (Taxus Liberte) Ormiston CCVI in press 05
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