Y. Louvard, ICPS, Massy, France. TCT Asia Pacific 2010

Transcription

1 Provisional Bifurcation Stenting: Main Branch First Y. Louvard, ICPS, Massy, France TCT Asia Pacific 2010

2 No conflict of interest to declare

3 M Main prox. first A Main Accross side first D Distal first S Side branch first 1 st stent PM stenting MB stenting across 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 Louvard et al. CCVI 2007

4 MB (Proximal) 0, 1 Medina Classification MB (Distal) 0, 1 SB 0, 1 1,1,1 1,1,0 1,0,1 0,1,1 1,0,0 0,1,0 0,0,1 Medina et al. Rev. Esp. Cardiol 2006; 59(2): 183-4

5 When to use 1 stent? 1,1,0 1,0,0 0,1,0 Medina et al. Rev. Esp. Cardiol 2006; 59(2): 183-4

6 When to use 1 stent? Adapted from Furukawa et al. Cir J 2005; 69:325-30

7 When to use 1 stent? No Need for SB Stenting! Adapted from Furukawa et al. Cir J 2005; 69:325-30

8 When to use 1 stent? 50% DS Koo et al JACC 2005; 46: Adapted from Furukawa et al. Cir J 2005; 69:325-30

9 When to use 1 stent? 1,1,1 1,1,0 1,0,1 0,1,1 1,0,0 0,1,0 Short SB stenosis (< 3 mm?, < 5 mm?) Medina et al. Rev. Esp. Cardiol 2006; 59(2): 183-4

10 Provisional SB stenting

11 POT* technique Balloon Carenal cell Post kissing 3.0 x 20mm 3.5 x 8mm entry The POT technique should be used in any case of difficulty recrossing into a side branch with either a wire or balloon *Proximal Optimisation Technique from O. Darremont

12 Provisional SB stenting

13 Provisional SB stenting

14 NORDIC III Lassen, EBC 2009

15 Provisional SB stenting

16 When to use 2 stents? Koo et al JACC 2005; 46: Adapted from Furukawa et al. Cir J 2005; 69:325-30

17 1 vs 2 stents or SB first / MB first

18 M Main prox. first A Main Accross side first D Distal first S Side branch first 1 st stent PM stenting MB stenting across SB DM stenting Provisional SKS SB ostial stenting After balloon 2 stents Skirt MB stenting + SB balloon MB stenting + kissing OR SB minicrush SB crush 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 Louvard et al. CCVI 2007

19 Systematic Two Stents Approach: 15%?

20 Why SB Stenting First? ü To simplify the procedure?

21 BBC1: Procedural Endpoints 2 stents Provisional P value Patients (n) Procedure time (min) <0.001 Fluoroscopy time (min) <0.001 Diamentor (cgy.cm 2 ) <0.001 No. guidewires used (n) <0.001 No. balloons used (n) <0.001 No. stents used (n) <0.001 Hildick-Smith, TCT 2008

22 Why SB Stenting First? ü To simplify the procedure? ü To improve acute result?

23 Why SB Stenting First?: improve acute result? Costa et al. JACC 2005; 46:

24 Why SB Stenting First? ü To simplify the procedure? ü To improve acute result? ü To improve immediate outcome?

25 BBC1: In-Hospital MACE Complex Simple P value Patients (n) MACE (%) RR 4.0 (1.5 to 10.5) Death (%) NS MI (%) CABG (%) NS David Hildick-Smith, TCT 2008

26 Why SB Stenting First?: to improve immediate outcome? Myocardial Infarction Katritsis et al. Circ interv 2009

27 Why SB Stenting First? ü To simplify the procedure? ü To improve acute result? ü To improve immediate outcome? ü To improve mid term outcome?

28 Why SB Stenting First?: to improve mid-term outcome? Target Vessel Revascularization Katritsis et al. Circ interv 2009

29 Why SB Stenting First?: to improve mid-term outcome? Stent Thrombosis Katritsis et al. Circ interv 2009

30 Main Branch Stenting First

31 Main Branch Stenting First Following the Rules of Provisional SB Stenting No SB predilatation Remo Albiero EBC IV, Prague 2008

32 Main Branch Stenting First Following the Rules of Provisional SB Stenting No SB predilatation Remo Albiero EBC IV, Prague 2008

33 Main Branch Stenting First Following the Rules of Provisional SB Stenting Respect the Murray s law: Stent diameter according to the Distal MB reference 1. No Carena shift 2. Jailed wire not realy jailed Remo Albiero EBC IV, Prague 2008

34 Main Branch Stenting First

35 Main Branch Stenting First

36 POT and kissing balloon

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38 SB Stenting after MB stenting: BBK study SB stenting failure 1.5% BBK Study, Ferenc et al. Eur Heart J 2008

39 Main Branch Stenting First

40 Main Branch Stenting First

41 Mandatory final kissing in complex techniques

42 Randomized trial on routine vs. Provisional T-stenting in the treatment of de novo coronary bifurcation lesions (BBK) M. Ferenc, EHJ Advance Access published October 9, 2008

43 Conclusion Provisional SB stenting is the gold standard fot bifurcation stenting A two stent approach is probably needed in < 15% of cases. In those cases the main reason for stenting the SB first is decrease the risk of SB failure. to By doing that we increase the complexity of the procedure and may compromise the result in the MB.

44 Conclusion (cont.) Why not stenting the MB first following the rules of provisional SB stenting approach? It may simplify the procedure, improve the MB result and decrease the need for SB stenting in relativaly short SB lesions (< 5 mm). This approach will be evaluated in the EBC 2 randomized study.

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