PCI for Bifurcations: Which is the best strategy DK Crush,Culotte,SKS,T or TAP Subhash Chandra, MD,DM,FACC Chairman,Cardiac Sciences BLK Super Speciality Hospital, Pusa Road, New Delhi CSI 2018
Selection of Technique
DEFINITION Criteria of LM bifurcation Simple: SB <70% stenosis,length <10 mm Complex: If 2 of 6 minor criteria present 1. Calcification 2.Angle >70 3.MB diameter >2.5 mm 4.Multiple lesions 5.Thrombus 6.MB lesion length >25mm
Factors Influencing 2-Stent Approaches Size of SB @ to MB Important discrepancy: Avoid Culotte T-Stenting Crush/DK-Crush Bifurcation Angle >70 : T-stent, or T and Protrusion (TAP) <70 : Culotte, Crush, DK Crush (Secures the precious,most angulated SB as first stent)
T-Stent: Step-by-Step Wiring of MV and SB MV and/or SB dilatation (recommended but optional). Stenting MV with wire in place in SB (alternatively SB may be stented first). Good if angle is --- 90 degree Rewiring SB and removal of jailed wire. Dilatation of SB though MV stent. Stenting SB though MV stent with no stent protrusion in MV (or placement of the MV stent if the SB was stented first). Final kissing balloon inflation.
Simple T-Stent Technique Advantages and Limitations High rate of ostial restenosis of the SB due to suboptimal stent coverage in the bifurcation area, particularly the ostium Not true if TAP technique used (similar to a minimini crush)
Culotte Technique: Step-by-Step Typically, the first stent should be placed in the branch Wiring of with both the MV and most SB. angulated entry, whether Predilatation of MV and/or the MB SB (optional or SB but recommended). Should Stenting of not the be MV. used if a large difference ( 1.5 mm) in vessel diameter between the MV and SB Rewiring SB through MV stent and removal of jailed wire in SB. exists Dilatation of SB through MV stent. Stenting proximal MV and SB through MV stent. Rewiring MV through SB stent. Final kissing balloon inflation.
Culotte: Stent MB & POT before re-wiring
Culotte: Balloon SB after rewiring SB in most distal strut
Culotte: Stenting SB Remove wire from main branch
Culotte: Stenting SB & second POT
Culotte: Final Kissing After rewiring MB (Ideally also a final POT?)
Culotte Techique Advantages and limitations Full coverage of the bifurcation area (especially the carina and SB ostium), 2 layers of metal in the proximal MV Multiples steps with necessity of re-wiring SBs twice
NORDIC Bifurcation Study: Crush vs. Culotte
DKCRUSH-3
Crush Technique Wiring of both MV and SB. Predilatation of MV and/or SB (optional but recommended). Stenting of the SB first, with an un-inflated stent (or balloon) positioned in the MV. The proximal end of the SB stent should be several mm in the MV, but the proximal edge of the uninflated MV stent (or balloon) must be proximal to the proximal edge of the SB stent. SB wire and stent balloon are removed. Crushing the SB stent with MV stent or balloon inflation (followed by MV stent). Rewiring the SB through MV stent. High-pressure inflation of SB (optional). Final kissing balloon inflation (mandatory).
Crush: 2 stents in place; SB stent deployed first : Pre-dilation
Crush Technique: MB stent then inflated crushing SB stent previously deployed; SB wire removed
Crush Technique: Final kissing
Crush Technique Advantages and limitations Difficulty in SB rewiring for final kissing inflation (less with DK-Crush; hydrophilic wire can help) Presence of multiple layers of crumpled stent at the SB ostium, substantially increasing the rate of SB ostial ISR
DK-Crush Technique: Baseline
DK-Crush Technique: Stent LCx+ Deflated Balloon LAD
DK-Crush Technique: Crush of the LCx Stent with LM-LAD Balloon
DK-Crush Technique: Pre-dilatation ostium LCx (facilitate passage)
DK-Crush Technique: First Kissing
DK-Crush Technique: LM-LAD stent
DK-Crush Technique: POT
DK-Crush Technique: Second-Final kiss
DK-Crush Technique: Final
DK crush vs Classical crush
DKCRUSH-4 Trial(LM) Simple vs. Complex Strategy Chen et al,jacc 2017
DEFINITION-2 Trial Prospective,Multicentre,Randomized controlled, superiority clinical trial at 45 sites world wide 660 Pts Provisional Vs.Two stent approach in complex coronary bifurcation lesions
Why DK Crush advantageous Surprisingly DK crush has not gained desired acceptance. FKBI in classical crush technique is not always possible High adverse events in Crush tech. such as ST and ISR. Uniformly positive data from the DK crush trials. DK Crush is straightforward, reliable, safe and effective for complex LM bifurcation lesions and with all bifurcation angles. V stenting, SKS, Mini crush, Culotte may not be suitable in wide angled ( 70 ) bifurcations.
Simultaneous Kissing Stent (SKS)
Simultaneous Kissing Stent (SKS) Wiring of MV and SB Predilatation -Creation of MV of and a Neo SB Carina -Management of ISR extremely complex Placement of stents in both branches with -Really Challenging if proximal dissection minimal proximal protrusion in MV. occurred Placement of balloons in both branches and simultaneous (or sequential) deployment of stents. Final kissing balloon inflation.
Simultaneous Kissing Stent (SKS) Advantages and limitations Several limitations Double Barrel The most primitive, un-sophisticated, and anti-physiological technique! Used in cased of real life-threatening situation
Tips to remember Importance of balloon sizing for post dilation If too large distally, risk of carina shift Proximal MB: know the maximal stent expansion capacity Importance of Final Kissing Importance of POT and Final POT Importance of IVUS guided PCI Choose the technique you are the most comfortable with and avoid SKS as a first choice! DK Crush is going to supplant other stenting techniques and become sine-qua-non in LM bifurc.
Thanks for kind attention Subhash.Chandra@blkhospital.com