PCI for Bifurcation Coronary Lesion
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- Miles Brice Harvey
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1 PCI for Bifurcation Coronary Lesion
2 Bifurcation Lesions PCI is Challenging Higher acute complication Lower success rates Higher restenosis & TLR Restenosis Rate 21 ~ 57% TLR 8 ~ 43%
3 Event Free Survival after PCI NHLBI Registry % event free Bifurcation ( ), n=2115 Bifurcation (+), n= % 67.9% Duration (months) * P < 0.05 Suwaidi J, et al. AJC 2001;87:
4 Side Branch Loss Main Mechanism of Adverse Outcomes
5 Predictors of Side Branch Occlusion Side branch DS > 50 % Disease burden in parent vessel at take-off of side branch Dissection of parent vessel
6 How to Stent? Stenting Technique
7 Single Stenting Single stenting in the parent vessel with or without balloon dilatation in the side branch Main vessel Side branch
8 Two Stenting : T Stenting Sequential stenting in the main vessel and the side branch Main vessel Side branch
9 Two Stenting : Y (Culotte) Stenting Stenting in the side branch followed by in the main vessel Main vessel Side branch
10 Two Stenting : Kissing Stenting Simultaneous stenting in the main vessel and the side branch Main vessel Side branch
11 Single Stent vs. Two Stent Procedural Results Single (n=39) Double (n=53) P Ref. vessel(mm) 3.0 ± ± 0.6 NS Kissing balloon (%) < 0.05 Procedural time (min) 98 ± ± 52 < 0.05 Success (%) NS In-hosp. MACE (%) 0 13 < 0.05 Yamashita T, et al. JACC 2000;35:
12 Single Stent vs. Two Stent 6 Month Restenosis Rate P=NS Single Double % Main vessel Side branch Global Anzuini A, et al. Am J Cardiol 2001;88:
13 Single Stent vs. Two Stent Event Free Survival Freedom from death, MI, CABG, reptca & severe angina % Stent+PTCA T-stenting Stent+Stent Y-stenting 20 *P= *P= Months Months Suwaidi J, et al. JACC 2000;35:929-36
14 Tube Stent vs. Coil Stent Side Branch Occlusion (%) AMC Data P = NS CrossFlex (Coil) NIR (Tube) GFX (Hybrid) Post-Balloon Post-Stent Cho GY, et al. Cathet Cardiovasc intervent 2001;52:18-23
15 Two bare metal stents are not better than single stent. Stent in main vessel and POBA in side branch with Optional kissing balloon
16 Importance of Stenting Technique Period Period (n=182) (n=191) P Tube stent (main vessel) Final Kissing balloon Both branch stent 6 Fr catheter MACE TVR(7 months) 59 % 18 % 73 % 29 % 21 % 94 % 75 % 30 % 93 % 17 % 14 % < 0.01 < < 0.01 < 0.01 < 0.05 Lefevre T, et al. Cathet Cardiovasc Intervent 2000 ;49:274-83
17 Plaque Reduction in Main Vessel? Debulking Atherectomy
18 Role of DCA before Stenting Minimal Lumen Diameter DCA + S (n=58) Stent alone (n=332) P Main Vessel MLD post (mm) MLD F/U (mm) Side Branch MLD post (mm) MLD F/U (mm Chieffo A, et al. Am J Cardiol 2002;90:44H
19 Role of DCA before Stenting Restenosis rate (%) MACE (%) DCA+Stent Stent alone *P < * * P < Main vessel Side branch Chieffo A, et al. Am J Cardiol 2002;90:44H
20 Subgroup of AMIGO Trial Restenosis Rate P < % 4/45 DCA+Stent 20.9 % 9/43 Stent alone Braden G, et al. TCT 2002
21 Debulking Followed By Stenting Might be beneficial in lesions with large plaque burden
22 New Modality for Bifurcation Lesion? True Bifurcated Stent Drug Eluting Stent
23 Bifurcated Stents NIRSIDE Stent Guidant Frontier Stent BARD Bifurcate XT
24 Bifurcated Stent Cordis DBS Stent 34 patients (mean 64 years) Technical Success 94% 30 days 0% 6 Mo 33% TLR 19% Dibie A, et al. Am J Cardiol 2002;90:13H
25 Bifurcated Stents AST SLK -View Side hole Stent length = 17mm Catheter length = 140 cm Crossing profile = IN Available in two sizes - 3.0mm with 2.5mm side hole - 3.5mm with 3.0mm side hole
26 Bifurcated Stents AST SLK -View Main catheter system comprises of a main stent with a side hole and a stabilizing catheter, which allows access to side branch after stenting
27 AST SLK-View Stent AMC Experience 48 pts (mean 58 years) 50 lesions Technical Success Side branch accessibility Side branch preservation after stenting Parent vessel 100 % Side branch 100 % 100 % 100 % Kim YH, et al. TCT 2002
28 Drug Eluting Stent
29 SIRIUS Bifurcation Study Sirolimus Eluting Stent Total 86 pts enrolled Randomization Stent + Stent 43 pts Cross-over 2 Cross-over 22 Stent + PTCA 43 pts 1 without success Stent + Stent 63 pts(65les) Stent + PTCA 22 pts A Colombo, et al. AHA 2002
30 Procedural Technique SIRIUS Bifurcation Study Technique T- stenting Side branch first Main vessel first V- stenting Y- stenting Kissing balloon GP b/ a inhibitor Stent / Stent (n=63) (95%) 27 (43%) Stent / PTCA (n=22) 19 (86%) 8 (37%) A Colombo, et al. AHA 2002
31 Main Vessel Minimal Lumen Diameter SIRIUS Bifurcation mm (n=63) 0.92 (n=22) Baseline Stent+Stent 2.4 (n=46) 2.5 (n=19) Follow-up Stent+PTCA
32 Side Branch Minimal Lumen Diameter SIRIUS Bifurcation mm P= (n=44) 1.56 (n=18) (n=22) (n=65) 0 Baseline Follow-up Stent+Stent Stent+PTCA
33 In-Segment Restenosis SIRIUS Bifurcation % P= Main Vessel Stent+Stent Side Branch Stent+PTCA
34 6 Months Restenosis Rate SIRIUS Bifurcation Ostium of the side branch Distal to the stent Proximal to the stent Main, S+S (n=1) Main, S+P (n=1) Side, S+S (n=11) Side, S+P (n=2) 2 0 0
35 What We Learned DES In Bifurcation Lesion Effective Nearly eliminate restenosis in the main vessel Ineffective Persistent disturbingly high restenosis at the uncovered side branch ostium
36 Two Stenting Strategy in SIRIUS Bifurcation Study Potential gap susceptible to restenosis
37 Proposed Stenting Strategy In the Era of DES Complete coverage of side branch ostium Modified T Y (Culotte) Kissing
38 Emerging New Technique Stent-Crush Crushed first stent implanted in side branch
39 AMC Proposal Kissing Stenting with Optional Stent-Crush Suboptimal result after kissing stenting
40 Future Perspectives in the Era of DES Following consideration should be evaluated The role of debulking atherectomy The fate of side branch after PCI with DES Large randomized comparison of two DES and single DES
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