Bifurcation PCI which lesion should be treated how to treat for optimal outcomes

Bifurcation PCI: Which lesion should be treated & how to treat for optimal outcomes Koh Tian Hai Senior Consultant, Dept of Cardiology Senior Advisor National Heart Centre, Singapore 1

Bifurcation PCI: Which lesion should be treated & how to treat for optimal outcomes

Koh Tian Hai Senior Consultant, Dept of Cardiology

Senior Advisor National Heart Centre, Singapore

14 th VNCC Danang 10-14 Oct 2014

SCAI Fellow Course 12 Oct 2014

NEW NATIONAL HEART CENTRE BUILDING, S’PORE

Conflicts of Interest

None related to this presentation

Many Bifurcation Stent Strategies

Default Choice in Bifurcation Stenting:

Provisional Side Branch Stenting

• Progression to next step occurs only when there is severe sidebranch residual stenosis

STEPWISE APPROACH

Why Single Stent Strategy?

KISSS Principle

• KISSS: Keep it Simple, Swift & Safe

• Potentially Reduced Stent Thrombosis

• Side branch usually not as important / large

• Reduce risk of Stent Complications / Dissections

• Save Cost

Why Two Stent Techique?

T stent, Crush or Culotte

• Risk of acute closure of involved large side branch

• Reduce MACE events

• Visually appealing

• Technically satisfying

When to do T Stenting?

• 90 degree angle branch take off

– Eg LCX take off from LM/LAD

• Advantages:

– Provisional technique

– Single drug layer

• Risk of:

– missing sidebranch ostium

– stent strut protrusion into main stented vessel

Colombo’s 2 Stent Crush Technique

J Ormiston CCVI 2004

When to do Crush / Minicrush Stenting?

• Shallow take off of sidebranch <70 degree angle

• Smaller sized sidebranch

• Advantages:

– Easier initial 2 stent technique

– Complete ostial coverage assured

Culotte Stent Technique

Final- AP cranial

2

LAD Bifurcation lesion

-LAO cranial view

1

When to do Culotte Stenting

• Relatively equal sized branches

• Shallow take off of branches < 70

Some Technical Considerations during Bifurcation Stenting

JF Lassen et al EuroIntv 2014; 10: 545-60

Maximal Stent Size Achievable

Balloon Sizing for Kissing Inflations

GA Segueglia & B Chevalier JACCIntv 2012; 5: 803-11

Proximal ~2/3

of combined Balloon diameters

JF Lassen et al EuroIntv 2014; 10: 545-60

Vessel Size (MB & Daughter Br) Estimation

POT Technique

to enlarge Stent Cell Size

N Foin et al EuroIntv 2013: 9:885-7

Reduce risk of wiring outside of stent

Increase success of crossing into sidebranch

Main Stent Distortion with

Sidebranch balloon dilatation

N Foin at AsiaPCR-SLIVE Jan 2012

Tips

• POT technique

• Wire the most distal sidebranch stent cell

– Better sidebranch scaffolding

• Always Kiss whenever sidebranch is inflated through the MB (main branch) stent

– Prevents MB stent distortion

Why don’t we do two stent techniques

as a routine?

Long term (5yr) followup Nordic I trial:

single vs two stent technique

M Maung et al JACC 2013; 62: 30-4

206 pts 207 pts

What about true (1,1,1) bifurcations with large sidebranch > 2.5mm ?

Nordic-Baltic IV Trial

Simple vs Complex in Large Bifurcations

I Kumsars at TCT 2013

N=221 simple N= 229 complex

Which two stent technique is best?

Nordic II: Crush vs Culotte

Kari Kervinen - Presented at EBC London, Oct 2013

NORDIC II: Crush vs Culotte Study

36 mth follow-up MACE free Survival

Kari Kervinen et al JACCIntv 2013; 6: 160-5

209 Crush vs

Other Bifurcation Stenting Issues

Stent Thrombosis & MI: Meta-analysis of

Bifurcation Stent Trials/Registries

M Zimarino et al JACCIntv 2013: 6: 687-95

Nordic-Baltic Bifurcation III Trial Final Kissing vs No Kissing balloon

M Niemela et al Circ 2011; 123; 79-86

239 pts 238 pts

ACCF/AHA/SCAI Guidelines

on PCI: Bifurcation Lesions

GN Levine et al CCVI 2011

ESC Guidelines on Revascularisation

2014 lesion subsets

S Windecker , P Kolh et al EHJ 2014; 35: 2541-2619

EBC Consensus Statement

JF Lassen et al EuroIntv 2014; 10: 545-60

• For Large branches with true bifurcations: Two stent

technique not inferior to provisional single stenting

• Increased risk of Stent Thrombosis /MI with two stent techniques

21st to 24th January 2015

Thank You

7 - 8 November 2014 (Friday - Saturday)

National Heart Centre Singapore

5 Hospital Drive, Singapore 169609

Masahiko OCHIAI

Showa University Northern Yokohama Hospital

Etsuo TSUCHIKANE

Toyohashi Heart Center

Key Speakers and Guest Operators

Who Should Attend

Programme Highlights

• Live demonstrations

• Moderated case presentation sessions

• Didatic lectures focusing on antegrade techniques and retrograde approach

• Tips and tricks for clinical use

• Managing complications of CTO interventions

• Case studies

7 - 8 November 2014 (Friday - Saturday)

National Heart Centre Singapore

5 Hospital Drive, Singapore 169609

Key Speakers and Guest Operators

Who Should Attend

Programme Highlights

• Live demonstrations

• Moderated case presentation sessions

• Didatic lectures focusing on antegrade

techniques and retrograde approach

• Tips and tricks for clinical use

• Managing complications of CTO interventions

• Case studies

Thank You

Thank You

Does it apply to Unprotected LM Bifurcation lesions?

DKCrush III Protocol

SL Chen

DK Crush III: MACE Results (1 endpt)

Double Crush

Vs Culotte

DK Crush

Is better!

MEDINA Classification

JF Lassen et al EuroIntv 2014; 10: 545-60

Which Stent technique to use?