6 th European Bifurcation Club October BUDAPEST. Kissing in simple strategy? Why and how I kiss. Y. Louvard, ICPS, Massy France

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1 6 th European Bifurcation Club October BUDAPEST Kissing in simple strategy? Why and how I kiss Y. Louvard, ICPS, Massy France

2 A long experience of kissing 1996 Patients 79 Final Kissing balloon (%) 13.9 Angiographic success (%) months TVR (%) PTCA (%) CABG (%) months Death (%) months Non Q MI (%) months Q MI (%) months MACE (%) P value < NS NS 2.4 NS 1.2 NS 0 NS 14.5 <0.001 Lefèvre et al. TCT Washington 1998

3 Kissing is part of a strategy One layer of DES when and where it is useful - no overlap, no protrusion - good expansion - SB only in case of poor result after balloon MB first: provisional SB stenting strategy Try to restore the original anatomy and function of the bifurcation

4 Excess of metal : endothelisation? Finn et al. Circulation; 112:270-8

5 Protrusion: flow perturbations 12 Application of fluid dynamics analysis: Macroscopic flow perturbations at stented bifurcation site A A B B B Physiological flow through a bifurcation model with palmaz stent A stagnation zone (A) appear if the stent does not conform to the artery. The stent implantation in a daughter branch induces recirculation zones in the healthy artery branch (B) due to the protruding part of the stent. Fabregues, 1998, J. of Biomech.31

6 Protrusion: flow perturbations Delplano et al, EBC 2007

7 Default of MB stent expansion when stenting SB first: crush IVUS data for non-lm bifurcation lesions (IVUS in both branches) R. Costa et al. JACC 2005; 46:

8 Balloon or stent for the SB? Postprocedural MLD of the side branch Athappan, J Cardiovasc Med 11: Q 2010

9 Balloon or stent for the SB? Follow-up MLD of the side branch Athappan, J Cardiovasc Med 11: Q 2010

10 Kissing is part of a strategy One layer of DES when and where it is useful - no overlap, no protrusion - good expansion - SB only in case of poor result after balloon MB first: provisional SB stenting strategy Try to restore the original anatomy and function of the bifurcation

11 Bifurcation branching laws Murray s law D 1 3* = D2 3* + D3 3* Finet s law D 1 = 0.67(D 2 + D3) D 1 D 2 D 1 D 2 D 3 D 3 Self replicating * 2.3 HK law From Koo, EBC, 2008

12 Structure-function scaling laws of vascular trees / Flow Myocardial mass / Length / Diameter Kassab, EBC 2009

13 Hemodynamic changes after MB stenting and subsequent SB balloon angioplasty Changes in time-averaged wall shear stress introduced by bifurcation stenting Williams J Appl Physiol (May 27, 2010)

14 Which technique?? From Gastaldi. Biomech Model Mechanobiol (2010) 9:

15 Successfull POT vs no POT Optimal Provisional SB Stenting * D1 D1= (D2 + D3) 2/3 POT* D2 D3 * *O. Darremont, publication very very soon *

16 Why kissing after simple stategy? To correct a poor result in SB (but QCA / FFR discrepancy): - TIMI flow < 3, EKG, Pain - carena / plaque shift - previous stenosis - to prepare a SB stenting When SB angiographic result / flow are good?: to remove the jail strut (possible SB stenting: > 2 mm) Always (?): to relocate the flow divider

17 Stable angina Male, 65 yo Stented on prox. LAD No image No diagonal protection, no kissing on the report Stable angina

18 Stress MRI (Dipyridamole, 1st pass myocardial perfusion)

19 Rotablator: 1.25 mm burr

20 Result

21 Kissing balloon clinical results

22 Nordic Baltic III (6 m) No kissing Kissing p-value n=239 n=238 Cardiac death (%) ns Non-cardiac death (%) ns Index lesion MI* (%) ns TLR (%) ns Stent thrombosis (%) ns * Non-procedure related Nordic III, EBC 2009

23 COBIS Registry Independent Risk Factors for MACE and TLR Gwon Circ J 2010 Sept 28

24 No! No! Too brutal!

25 Kissing With NC Balloons Don t kiss too big (non-compliant balloons) Bifurcation lesions (n) 100 FKS success (%) 100 FKS success without SB opening (%) 97 Metal projection in SB (%) 89 Need for SB stenting (%) 7 In-hospital MACE (%) 0 Hovasse et al. AHA 2009 Kinoshita, EBC 2009

26 Optimal FKB in the bench Kiss precisely (short balloons) Minimal overlaping Long overlaping Murasato et al. PCR 2010

27 20 seconds is not enough! Optimal FKB in the bench Cross-Sectional Area mm sec 1 20sec 2 20sec 3 Stent Recoil % s 1 20s 2 20s 3 Hikichi et al. EBC 2009

28 Optimal FKB in the bench Kiss subtle! (MV inflation first) Simultaneous MV balloon First SB balloon First CSA (mm 2 ) 10 Prox. Carina Dist. Prox. Carina Dist. Prox. Carina Dist. IVUS Main vessel stent * p<0.05 vs. Simultaneous, p<0.02 vs. Simultaneous Sung-Jin Oh et al. PCR 2010

29 After a good kiss you may have a good surprise!

30 Nordic-Baltic Bifurcation Study III (6 m) (Re)stenosis: Ostial Side Branch % 15.4% 7.9% p=0.039 Binary Restenosis: 50% diameter stenosis at follow-up

31 Nordic-Baltic Bifurcation Study III (6 m) Medina 1,0,1-0,1,1 1,1,1 True Bifurcation Subgroup FKBD (n=92) No-FKBD (n=80) p 8m SB 50% DS (%)

32 "Baiser de l'hôtel de Ville» Robert Doisneau