Consensus so far and what we will be focusiong on this time

Transcription

1 Consensus so far and what we will be focusiong on this time The 6 th European Bifurcation Club Meeting Budapest October Jens Flensted Lassen, MD, PH.D., FESC. Department of Cardiology B Skejby Hospital, University of Aarhus, Denmark

2 Consensus so far... A bifurcation coronary lesion is a lesion occurring at, or adjacent to, a significant division of a major epicardial coronary artery. These lesions remain complex for the interventionist The EBC annual meetings remains compact and dedicated to a single topic. As such, the meetings are able to bring together clinicians, engineers and physicists for detailed discussions. The consensus statements from the meetings reflect that unique opportunity. Eurointervention 2010;6: 34-38

3 MEDINA classification Rev. Esp. Cardiol. 2006;59(2):183-4

4 Proposed by Yves Louvard and named MADS by Ran Kornowski Intention Final M Main prox. first A Main Accross side first D Distal first S Side branch first 1 st stent PM stenting MB stenting accross SB DM stenting Provisional SKS SB ostial stenting After balloon Skirt MB stenting + SB balloon MB stenting + kissing SB minicrush SB crush 2 stents Skirt + DM Skirt + SB Elective T stenting Internal crush Culotte TAP V stenting SKS Syst. T Stenting Minicrush Crush 3 stents Extended V Trouser legs and seat Catheter Cardiovasc Interv: 2008;71(7):981-2

5 Finet s adaption of Murray s law D mother On the design of the coronary arterial tree: a generalization of Murray s law D mother = 0.67 * (D daughter 1 + D daughter 2 )

6 Consensus so far Eurointervention 2009;5:39-49

7 Simpler is better Provisional stenting of side branch beginning by stenting the main vessel across the side branch, and then allowing techniques like provisional T, elective T stenting, classical Culotte...It is also the strategy for the most frequently used dedicated stents (Petal, Minvasys, Frontier, Invatec...) Y Louvard 2008 Supported by BBC 1 and Nordic 1 and advocated by EBC

8 How to do a Provisional Stenting Consensus 2008 Should we use a jailed wire? Yes 1. Modifies favorably the angle between both br. 2. Keeps the side branch open 3. Is a good marker of SB

9 We should avoid Side Branch pre-dilation and take advantage of the carena shift the guidewire (GW) will cross the stent strut exactly at the carena Side branch pre dilatation? By Remo Albiero No Pre-dilatation Carena shift Post MB stenting

10 The case of true bifurcation (1,1,1) Pre-dilatation->Dissection SB pre-dilation will dissect the plaque creating the subsequent possibility to: - enter a proximal strut Dissection Larger Dissection Carena shift SB stent Pre Post MB stenting

11 How to do a Provisional Stenting Consensus 2008 Should we predilate the SB? No Yes, if calcified lesion Yes, if long lesion (on SB)

12 Consensus 2008 Carina shift not plaque shift No need for routine SB predilatation unless lesion in the SB long and/or severely calcified

13 Consensus so far Volume 6;1;may 2010:34-38

14 Implications of Murrays law Consensus 2009: In single stent techniques, the primary stent should be sized according to the distal main vessel diameter Post dilatation, or kissing balloon inflations, are required to optimise the proximal main vessel stent diameter

15 POT, the proximal optimisation technique (devised by O. Darremont) Consensus 2009: The POT technique should be used in any case of difficulty recrossing into a side branch with either a wire or balloon.

16 Value of kissing inflations in simple stenting Consensus 2009: When using a single stent technique, in the absence of kissing balloon inflations, the proximal main vessel stent should be postdilated to an appropriate diameter. Kissing balloon inflation, or pressure wire interrogation, should be used when an angiographically significant (>75%) side branch lesion remains after main branch stenting Stent balloon inflation duration of 30 seconds minimum is encouraged.

17 Stent distortion after kissing balloon in single stent techniques Consensus 2009: When rewiring a side branch, efforts should be made to cross the main vessel stent distally, thereby ensuring stent coverage of the ostium of the side branch.

18 Stenting MV across the SB. Distal wire cross creates better SB scaffolding than prox crossing Proximal cross Distal cross Single balloon SB dilatation Kissing balloon postdilatation Ormiston

19 The dilemma in the provisional side branch stenting in Bifurcation lesions "Life can only be understood backwards; but it must be lived forwards. Søren Kirkegaard

20 Consensus 2009: When to use two stents Side branch diameter and length can both be used visually as surrogates for volume of muscle at risk. Large side branches with ostial disease extending >5mm from the carina are likely to require a two-stent. Side branches whose access is particularly challenging should be secured by stenting once accessed. Current evidence suggests that optimal two-stent technique does not predict a significant higher rate of stent thrombosis. Bifurcations with angulation of > 60 degrees between the daughter vessels should be approached with single stent strategies where possible

21 How to use two stents Consensus 2009: Provisional T stenting remains the gold standard technique for most bifurcations. Dedicated bifurcation stent systems remain limited but are likely ultimately to prevail. When two stents are required, the culotte technique, when appropriate, offers some advantages over crush stenting. Kissing balloon inflations for carina reconstruction is mandatory in two stent techniques. High pressure proximal inflation using a short noncompliant balloon should be considered for correction of proximal stent distortion after kissing balloon inflation.

22 ...And what we will be focusing on this year

23 ...And what we will be focusing on this year Will new evidence published since last year change the current EBC consensus? Will presentations within hot topics change the current EBC consensus. How to interpret and understand the different, new as well as, older imaging modalities in bifurcations. Controversies: Kissing in simple Strategy? How to treat bifurcation (in stent) restenosis? New insights from Bench to simulation New DES s in bifurcation stenting. Special focus on techniques, late outcome and new studies in LM stenting

24 ...And what we will be focusing on this year

25 Thank you for your attention and welcome to the 6 th European Bifurcation Club October BUDAPEST