Technical considerations in the Treatment of Left Main Lesions Ioannis Iakovou, MD, PhD

Transcription

1 Technical considerations in the Treatment of Left Main Lesions Ioannis Iakovou, MD, PhD Onassis Cardiac Surgery Center, Athens, Greece

2 Critical issues in LM PCI Anatomic variability Techniques

3 Variability of LM bifurcation Angle of bifurcation Burden of atherosclerotic lesion Relative involvement of the ostia of LAD or CX Relative relation between diameter of LM and diameters of stemming arteries

4 Left Main Measurements Author Year Method Ramus Diameter (mm) Angles (degrees) Russell 2009 CAST 27% Kawasaki 2009 CT Girasis Zenia 2007 CT 4.11 Rodriguez- Granillo 2007 CT 87.8 Reig 2004 anatomy 38%

5 Bifurcation Stent Techniques More Complex Technique Crush Culotte V, Kissing Less Ostial Coverage Most Ostial Coverage T-Stent Provisional Less Complex Technique

6 Contemporary Stent Treatment of Coronary Bifurcations The T Stenting Technique Applications: - Angulation > 75 - SB with severe stenosis at the ostium location Advantages: - Simpler than Crush - Covers proximal lesion in the MV Considerations: - Accurate C position of SB stent is critical for SB ostium coverage Drawbacks: - Does not grant full coverage of the SB ostium Iakovou I. et al, JACC 2006;46: FKB: final kissing-balloon SB: side branch PV: parent vessel

7 Contemporary Stent Treatment of Coronary Bifurcations The Culottes Stenting Technique Applications: - Left Main - Large SB - Angulation > 75 Restenosis in-stent Advantages: - Optimized stent expansion in both branches -Suitable for lesions with wide angles Considerations: - C - Both advancement of 2º stent through metal struts - Re-wiring for FKB Drawbacks: - High metal concentration at the bifurcation carina Iakovou I. et al, JACC 2006;46: FKB: final kissing-balloon SB: side branch

8 Contemporary Stent Treatment of Coronary Bifurcations The V/Simultaneous Kissing Stents Technique Applications: - Left Main - Large branches - Angulation < 90 - Significant disease in the proximal vessel Advantages: - Both branches are never lost - No need for re-wiring for FKB - Covers proximal lesions Considerations: - C - Combined stent size should match vessel size proximal to the bifurcation Drawbacks: - Implantation of stents proximal or distal to kissing-stents Iakovou I. et al, JACC 2006;46: FKB: final kissing-balloon

9 Simultaneous kissing stent (SKS) and V-stent a b Long kissing stenting in LMCA c Twisting of the two stents Multilink Penta 3.0/28 Cross sectional view a b c d e d Multilink Zeta 4.0/33 Circle e Murasato Y. ACC i2 summit 2007

10 Contemporary Stent Treatment of Coronary Bifurcations The Crush Technique Applications: - All true bifurcation, especially non- Left Main - Angulation < 75 Advantages: - Immediate patency of both branches - Full coverage of the SB ostium Considerations: - C - Single high pressure balloon inflation in the SB before FKB may be hepful to optimize stent expansion Drawbacks: - High metal concentration at the bifurcation carina, less with Mini Crush - Re-wiring into SB Iakovou I. et al, JACC 2006;46: FKB: final kissing-balloon SB: side branch

11 MACE-free survival Influence of Bifurcation Angle on Outcome of Crush Technique Kaplan-Meier plot comparing MACE-free Survival up to 648 days between the low-angle group (BA<50 o and high-angle group BA>50 o Dzavik et al AHJ 2006;152:762-9

12 Combined Crush experience: Milan and Rotterdam 231 pts, 241 de novo bifurcations ST=4.3% Hoye A, Iakovou I, et al. JACC 2006

13 CACTUS trial Coronary Bifurcation Application of the Crush Technique Using Sirolimus-Eluting stents Final kissing balloon inflation YES NO P value Myocardial 7.5% 29.0% < infarctions (24/319) (9/31) Stent thrombosis 0.9% (3/319) 6.5% (2/31) 0.06 Colombo et al Circ 2009

14 J-Reverse: OCT substudy-kobe

15 J-Reverse: Thrombus attachment

16 J-Reverse: Thrombus attachment

17 Two-step kissing is more effective than one-step kissing for improving metallic side-branch ostial area No kissing One-step kissing postdilatation Two-step kissing postdilatation SB ostial stenosis (%) with one step vs. two step kissing 58 crush deployments Two steps: Inflate at high pressure only the SB balloon Perform kissing inflation Ormiston Courtesy J.Ormiston

18 Clinical outcomes at 12 month FU

19 Impact of asymmetric expansion induced by KBT on mid and long term results Murasato, EBC 2009 KB deformation Position of the balloons: long overlapping vs minimal overlapping

20 Intimal growth Symmetrical vs. Asymmetrical expansion

21 Impact of struts malapposition on flow DiMario EBC 2012

22 Vascular tissue reaction to acute malapposition in human coronary arteries: 43 pts, 66 stents & 6-13 m0s) Incomplete stent apposition (ISA) - Acute ISA size (estimated as ISA volume or maximum ISA distance per strut) was an independent predictor of ISA persistence and of delayed healing at follow-up. - The larger the acute ISA, the greater the likelihood of persistent malapposition at follow-up and delayed healing

23

24 OCT guidance of distal cell recrossing in bifurcation crossing: choosing the right cell matters N= 52 pts EuroIntervention.2012;8(2):205-13

25 n Stenting Technique (n = 139) 80 % single stent for distal lesions Courtesy O Darremont

26 MACCE at 1 year n = 172/173 patients % Any Revascul. Total MACCE ULM Stent Thrombosis with a provisional T stenting approach is a relatively rare event, with a rate of 1.1% at 12-month-FU O Darremont

27 French left main Taxus Registry: 5-y outcomes: 1 vs. 2 stents Mylotte et al Eurointervention 2012

28 Several techniques 3 y outcomes after SES implantation for ULM coronary artery disease: impact of technique Kaplan-Meier curves for cumulative incidences of cardiac death (A) and TLR (B) among patients treated for ULMCA according to distal bifurcation stenting strategy (j-cypher) Toyofuku, M. et al. Circulation 2009;120:

29 Cumulative Event Rate (%) MACCE to 12 Months LM Distal PCI: T-stenting vs Non T-stenting T-stenting (n=135) Non T-stenting (n=49) 40 P=0.03 * % 10.4% Months Since Allocation Event Rate ± 1.5 SE, * Fisher exact test ITT population Patients with LM, LM+1,2,3VD included

30 ISAR-LEFT MAIN Intracoronary Stenting and Angiographic Results: Drug-Eluting Stents for Unprotected Coronary Left Main Lesions 607 patients with unprotected left main lesions Clopidogrel 600 mg at least 2h before procedure Aspirin 500mg i.v. Paclitaxel-eluting stent (Taxus) n=302 Sirolimus-eluting stent (Cypher) n=305 Clopidogrel 2x75 mg/day until discharge, then 75 mg indefinitely Aspirin 200 mg/day Mehilli J. et al. JACC ;

31 Several techniques ISAR LM late outcome / technique Mehilli et al JACC 2009

32 Sequential SB-MV 2 Step dilatation can be used instead of Kissing Balloon after Provisional Stenting of Bifurcations N.Foin EBC 2012

33 Results KB vs SB-MV sequence N.Foin EBC 2012

34 Pooled data from several LM registries Jérôme Van Rothem EBC 2012

35 Should we stent toward the tightest lesion? Jérôme Van Rothem EBC 2012

36 What about the bifurcation angle? Jérôme Van Rothem EBC 2012

37 POT or not POT? Jérôme Van Rothem EBC 2012

38 Frequency of stent underexpansion Kang et al CCI 2011

39 Long-Term Events after IVUS v Angio Guided DES Stenting 758 Consecutive Bifurcation Pts/7731Pts treated 420 DES (82% Cypher) v 338 BMS 473 IVUS Guided v 284 Angio Guided 82 v 92% 1 Stent Technique All- Cause Mortality Stent Thrombosis SH Kim, HW Kim,.., SW Park et, CCI 2009

40 Average MLA in pts incurring events after deferred revascularization Okabe et al. J Invas Cardiol 2008;20:635-9 Abizaid et al. J Am Coll Cardiol 1999;34: De la Torre, et al. J Am Coll Cardiol 2011; 58:351-8

41 Recommendations Pertaining to Unprotected Left Main Intervention in the ACC/AHA/SCAI 2011 Guidelines for PCI

42 Open issues with LM bifurcations Technically demanding Time consuming Too much operator dependent Off the-shelf standard stents don t fit bifurcations Long term outcome? Is dedicated bifurcation stent the answer? Iakovou et al Interventional Cardiology 2011

43 The promise of bifurcation stents Conformance to vessel contour without disruption of the stent coating Preservation of the side branch Enhanced long term outcomes Safety Iakovou et al Interventional Cardiology 2011

44 Approach to LM Bifurcational Lesions Is the lesion True Bifurcation? (significant stenosis on the MB and SB) No Yes provisional SB stenting No Is the SB suitable for stenting? Yes Stent on MB PTCA on the SB Does the disease on the SB extends> 3 mm from the ostium? No Yes provisional SB stenting elective implantation of 2 stents (MB and SB)

45 An approach for bifurcational lesions when using 2 stents as intention to treat no disease proximal to the bifurcation or very short LM MB disease extending proximal to the bifurcation and SB which has origin with about 90 angle MB disease extending proximal to the bifurcation and SB which has origin with about 60 angle V-Stent/SKS T-Stent/Culotte Culotte/Crush Pre Post Pre Post Pre Post Iakovou I. et al, JACC 2006;46:

46 Conclusions Stenting LM lesions remain one of the most demanding field in PCI Most bifurcation lesions are relatively simple and can be treated with 1 stent. Results are critically dependent on technique and appear to be improved by the use of IVUS

47 Conclusionstechnical considerations Distal cell recrossing is associated with lower mallapposed struts. It seems that with the provisional approach, the outcome is not influenced by the angle. Stenting towards the tightest lesion is associated with a lower rate of double stenting. The use of POT and systematic (better short) FKBI may be associated with better outcome.

48 Thank you!