ΣΥΜΠΛΟΚΕΣ ΑΓΓΕΙΟΠΛΑΣΤΙΚΕΣ ΑΓΓΕΙΟΠΛΑΣΤΙΚΗ ΔΙΧΑΣΜΩΝ

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Berniece Richards
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1 ΣΥΜΠΛΟΚΕΣ ΑΓΓΕΙΟΠΛΑΣΤΙΚΕΣ ΑΓΓΕΙΟΠΛΑΣΤΙΚΗ ΔΙΧΑΣΜΩΝ DR ΝΙΚΟΛΑΟΣ ΚΑΥΚΑΣ MD, FESC Διευθυντής, Υπεύθυνος Αιμοδ/κού Εργαστηρίου Καρδιολογική Κλινική Γεν. Νοσοκομείο ΚΑΤ-ΕΚΑ

3 PCI in Coronary Bifurcations Bifurcations occur in 20-25% of PCI cases True bifurcations represent ~60% Main technical concerns include: Plaque-shifting which may result in loss of the side-branch Dissection necessitating placement of second stent in sidebranch Inadequate stent expansion at ostium of side-branch (crush technique) Side-branch loss may occur in 15% of true bifurcations Stent thrombosis & restenosis is higher in bifurcations lesions Dedicated bifurcation stents not yet proven No two bifurcations are identical

4 The Bifurcation Issue Bifurcation is an heterogeneous lesion Variable vessels (branches) size Variable extent of side branch disease Variable morphology Variable angulation Variable plaque distribution Variable functional values (FFR) for same angiographic stenosis

5 The MEDINA Classification 1. Prox PV > 50%: 0 or 1 2. Distal PV > 50%: 0 or 1 3. SB > 50%: 0 or 1 1,1,1 1,1,0 1,0,1 0,1,1 1,0,0 0,1,0 0,0,1 Medina A.Rev Esp Cardiol Feb;59(2):183

6 When Two Stents Are Needed? 1,1,1 1,0,1 0,1, % of bifurcation lesions

7 The Many Faces of Medina Bifurcation 1,1,1

11 The proximal reference diameter is always larger than distal reference diamater D mother D daughter 1 D daughter 2 Murray s law D mother =0,678 ( D daughter 1 + D daughter 2 )

12 Why Protect SB s from Closure? Occlusion of SB s >1mm associated with 14% incidence of Myocardial Infarction Arora RR et al. Cathet Cardiovasc Diagn 1989;18: SB closure associated with large periprocedural MI Chaudhry EC et al. J Thromb Thrombolysis 2007.

13 Why Wire Both Branches? Protects SB from closure due to plaque shift and/or stent struts during MB stenting Jailed SB wire facilitates re-wiring of the SB: By acting as a marker for the SB ostium if SB occludes Changing the angle of SB take-off (often widening the angle between the MB and SB) In the Tulipe multicenter study, absence of this jailed wire was associated with a higher rate of reinterventions (OR:4.26; ) during follow-up CAUTION WHEN REMOVING JAILED WIRES!

22 The Approach to Bifurcation PCI The provisional approach of implanting one stent technique on the MB should be the default approach in most bifurcations lesions The approach is dictated by the SB: True vs. Non-true Size of SB Extent and distribution of disease in SB How important the side branch is for that patient and for that specific anatomy

25 The final angio should not look worse than the baseline: keep the side branch open

26 LM distal disease (1,0,0 Medina), LAD disease

27 LAD stent, LM stent

28 LM stent

29 LM stent

31 Final kissing balloon LAD/LCx

32 POT

33 Final result

34 rue Bifurcation lesion LAD/Diag,1,1 Medina

35 Stent LAD distal

36 Stent Diag, Balloon LAD

38 Crushing of stent Diag

39 Stent LAD

41 Rewiring Diag, Kissing balloon

42 Final result

50 Main Branch Stenting First T-stenting TAP Culotte Internal Crush

for gap-free T stenting Gaps can also be

54 T Stenting and Angle Shallow Distal (B) angle has potential for gaps in support and drug application T with protrusion overcomes gaps but has struts protruding into the main branch At angles close to 90 degrees there is greatest potential for gap-free T stenting Gaps can also be due to distal SB stent placement Ormiston

55 The T-stenting with Protrusion Technique (TAP) as a Cross-over from the Provisional Approach Step 3: Position stent in SB ensuring coverage of ostium with minimal protrusion into MB and place noncompliant balloon in MB stent Step 4: Inflate the delivery balloon in the SB and the MB balloon simultaneously Final Result:

56 Crush Stenting B 3: Deploy the SB stent 4: Check for optimal result in the SB and then remove balloon and wire from SB. Deploy the MB stent

57 Crush Stenting C 5: Rewire the SB and perform high pressure dilatation 6: Perform kissing balloon inflation

58 Reverse (internal) Crush Stenting B 3: Rewire side branch and advance a balloon and dilate toward SB EVALUATE RESULT: if the result is not acceptable then 4: Position a stent in the SB with minimal protrusion in the MB. Leave a balloon in the MB

59 Reverse Crush Stenting D 7: Rewire the SB and perform high pressure dilatation 8: Perform final kissing balloon inflation

60 V Stenting B 3: Deploy one stent 4: Deploy the second stent Some operators deploy the two stents simultaneously

66 MACE and TLR in Bifurcation Studies BBK CACTUS BBC ONE Nordic P=0.009 Steigen TK et al. Circulation. 2006;114: Ferenc M et al. Eur Heart J 2008; 29: Colombo A et al. Circulation. 2009;119:71 78 Hildick-Smith D et al. Circulation. 2010;121:

68 Nordic Bifurcation Study Nordic Bifurcation Study (NORDIC I): the randomized study on simple versus complex stenting of coronary artery bifurcation lesions /completed True bifurcations 71% (DS>50% in MV and SB) Steigen TK et al. Circulation. 2006;114:

69 Nordic Bifurcation Study (Nordic I) MACE: cardiac death, index lesion MI, TVR, stent thrombosis MACE* free survival 6 months Cardiac death, n(%) Total death, n(%) MI, n(%) TVR, n(%) Stent thrombosis, n(%) TLR, n(%) 36 months Total death (%) Cardiac death (%) MI (%) TLR (%) TVR (%) Stent thrombosis (%) Individual Endpoints MV MV + SB P value n=207 n=206 2 (1.0) 2 (1.0) 0 (0.0) 4 (1.9) 1 (0.5) 4 (1.9) (1.0) 3 (1.5) 1 (0.5) 4 (1.9) 0 (0.0) 2 (1.0) Steigen TK et al. Circulation. 2006;114: Iwar Sjögren EuroPCR 2009

70 British Bifurcation Study (BBC ONE) N=500, Simple vs. Complex strategy Simple: MV stented, optional kissing balloon dilatation/t-stent. Complex: Culotte or crush with mandatory kissing balloon dilatation 82% true bifurcations (50% narrowing in both vessels). MI 1º Outcome: Death, MI, TVF TVF Hildick-Smith D, et al. Circulation. 2010;121:

72 Nordic II Trial RCT of Crush vs. Culotte Stenting; 6-8 mo f/u 20 P=0.87 P=0.08 P= Crush Culotte 15,5 12, ,3 3,7 8,8 6,6 0 D/MI/TVR/ST Periproc. MI Lesion Restenosis n=424 n=296 n=324 Erglis A et al, Circ CV Interventions 2009

74 Limitations of the 2 Stents Techniques More Complex Wire management more difficult Final kiss difficult Overlap (delayed endothelialisation, stagnation) Stent not fully apposed Flow dynamics not optimal Higher risk of stent fractures

77 EuroIntervention 2014;10:

78 EuroIntervention 2014;10: Subgroup analysis: large side branch, true bifurcation

88 Σας ευχαριστώ

90 Σας ευχαριστώ

94 Bifurcation PCI Account for 15-20% of PCI Why an indivdualized approach? Variations in Anatomy Left main bifurcation disease Plaque burden & location of plaque Angle between MB and SB Dynamic changes in anatomy during treatment Plaque shift Dissection No two bifurcations are identical An appropriate strategy from the outset saves time and minimizes complication

98 Our Proposed Strategy to Bifurcation PCI Keep it Open Provisional Two stents

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118 The T-stenting with Protrusion Technique (TAP) as a Cross-over from the Provisional Approach Step 1: Wire both branches and predilate the main and the side branch as required. Stent the MB jailing the SB wire Step 2: If the result in SB unsatisfactory due to plaque shift or dissection and SB has to be stented, then re-cross into the SB through the MB stent struts

119 Crush Stenting A 1: Wire both branches and predilate if needed 2 : Advance the 2 stents. MB stent positioned proximally. The SB stent will protrude only minimally into MB

120 Reverse Crush Stenting C 5: Deploy the stent in the SB and remove the wire and the balloon 6: Crush the short protruding part of SB stent over the stent in MB by inflating the MB balloon

121 Bifurcations Bad Krozingen (BBK) N=202 Routine T-stenting in both branches vs. provisional T- stenting in MB followed by kissingballoon angioplasty and provisional SES placement in SB only for inadequate Results 68% true bifurcations 1 year outcome Ferenc M et al. Eur Heart J 2008; 29:

122 CACTUS study N=350, Elective "crush" vs only MB stenting, with provisional side-branch T-stenting. Mandatory final kissing-balloon inflation 100% true bifurcations (50% in both the MB and the ostium of the SB) Colombo A et al. Circulation. 2009;119:71 78

123 Double vs. Single Stenting Meta-Analysis N=1642 patients Death Myocardial infarction 2 stents 1 stent 2 stents 1 stent Katritsis DG et al. Circ Cardiovasc Intervent. 2009;2:

124 Double vs. Single Stenting Meta-Analysis N=1642 patients Stent thrombosis TLR 2 stents 1 stent 2 stents 1 stent Katritsis DG et al. Circ Cardiovasc Intervent. 2009;2:

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126 Nordic II: Rate of Restenosis ( 50% Diameter Stenosis by QCA) at 8M Restenosis (%) In-segment Crush Culotte P=0.10 P=0.10 P=0.19 MV+SB MV SB Erglis et al. Circ Cardiov Interv 2009

127 Ostial stenosis LCx

128 Stent LCx

129 Final result

I have nothing to disclose.

I have nothing to disclose. ESC congress of cardiology, 25-29th August 2012, Munich, Germany Minsk-Village 6, August 26 th, 2:22 PM Session: The grey zone of coronary interventions: The real bifurcation