3-dimensional computed tomographic imagings of bifurcation stenting · 2007-02-15 · conclusion in...

33--dimensional Computed dimensional Computed TomographicTomographicImagingsImagings of Bifurcation Stentingof Bifurcation Stenting

Yoshinobu Murasato MD, PhDYoshinobu Murasato MD, PhD

Division of Cardiovascular Medicine, Division of Cardiovascular Medicine, Chikuho Social Insurance HospitalChikuho Social Insurance Hospital

Coronary Physiology & Imaging Summit 2007, February 10

BackgroundBackground

►► In the drugIn the drug--eluting stent era, eluting stent era, various stenting techniques various stenting techniques have been proposed for thehave been proposed for thetreatment of left main treatment of left main coronary artery (LMCA) coronary artery (LMCA) bifurcation. bifurcation.

►► However, these techniques However, these techniques have not yet been have not yet been investigated systematically investigated systematically in a 3in a 3--dimensional (3D) dimensional (3D) structure. structure.

2D experiment

3D structure

Same results?

Stent+POBA T

Y or V“V”2

1

2

Culotte

1 2

Provision-T

Crush

2 1

Kissing

2

2

211

1

2

Crush stenting in swine LCX bifurcationCrush stenting in swine LCX bifurcationFinal kissing balloon inflation (+)Final kissing balloon inflation (+)

However, the crushed stent was rather squeezed at the ostium and extended proximally from lateral to myocardial site.

Murasato Y et al. Catheter Cardiovasc Interv. 2005; 66: 237

Adequate stent apposition

Real 3D structure affected the stent expansion and caused distortion.

26.0

7.8

15.012.2

0

10

20

30

LMCA LAD-Diag LCX-OM RCA AV-PDKawasaki T. Am J Cardiol. 2006; 97 (8B): 14D

(%)

Distribution of high bifurcated angles (> 80Distribution of high bifurcated angles (> 80°°))

LMCA bifurcation has an especially wide bifurcated angle.

RAO LAO

AP caudal spiderColumn: Ø7.5cm

polyvinyl chlorideLMCA-LAD tube: Ø4.0mmLCX tube: Ø3.0mmLMCA-LCX angle = LMCA-LAD angleLAD-LCX angle = 90 °

Fluoroscopy33--dimensional LMCA bifurcation modeldimensional LMCA bifurcation model

LMCA

LADLCX

90°

135°135°

Murasato Y. Catheter Cardiovasc Interv. Online, Jan 8, 2007

MethodsMethods►► The following stentings were performed in the LMCA The following stentings were performed in the LMCA

bifurcation model:bifurcation model:Crush stenting with final kissing balloon inflationCrush stenting with final kissing balloon inflationModified crush technique with double kissing balloon Modified crush technique with double kissing balloon inflation (DK crush stenting) inflation (DK crush stenting) Kissing stentingKissing stentingModified TModified T--stentingstenting

►► HighHigh--resolution computed tomographic (CT) observations resolution computed tomographic (CT) observations were performed to investigate the following aspects:were performed to investigate the following aspects:

Stent expansion Stent expansion Stent deformationStent deformationStent apposition to the vesselStent apposition to the vesselGap formationGap formation

LMCA

LAD

LCX

LAD

LCX LMCA

Balloon overlapping inside distal LMCABalloon overlapping inside distal LMCA

Red: LAD balloon(Arashi 3.5/20)

Blue: LCX balloon(Ryujin 3.0/20)

1. LAD balloon over LCX balloon1. LAD balloon over LCX balloon 2. LCX balloon over LAD balloon2. LCX balloon over LAD balloon

AP caudal

Spider


Crush stentingCrush stenting

Gap

Cross sectional viewCross sectional viewproximal

distal

(1) LAD stent over LCX stent(1) LAD stent over LCX stent

Crush stenting Crush stenting with with BxBx Velocity Velocity

Gap between the two stents

abcd

a

b

c

dCircle

Murasato Y. Catheter Cardiovasc Interv. In print


distalGap

Crush stenting Crush stenting with with BxBx VelocityVelocity

(2) LCX stent over LAD stent(2) LCX stent over LAD stent

abcd

a

b

c

dCircle


Crush stenting Crush stenting with Express IIwith Express II

Circle

Gap

Magnified view of the SB ostium

Adequate strut dilation at the SB ostium

SB stent MV stent

The gap at the SB ostium was larger compared with crush stenting with Bx velocity stent.

Absence of the strut

Strut configuration of MV stent at SB ostiumStrut configuration of MV stent at SB ostiumBx Velocity Express II

Better case

Worse case

DK crush stentingDK crush stenting►► AdvantagesAdvantages

Widely opened strut of Widely opened strut of the SB stent by first KBthe SB stent by first KBEasy reEasy re--crossing of the crossing of the guide wire and the guide wire and the balloon system before balloon system before second KB second KB Good apposition of the Good apposition of the stent to the vessel at stent to the vessel at the SB ostiumthe SB ostium

Jim MH, Catheter Cardiovasc Interv. 2006, 67, 403

1st KB

2nd KB

DK crush stenting DK crush stenting

After first KB inflationAfter first KB inflation

Dilated strut

Raised up strut

MV vascular bed

Circle

After MV stenting, is it possible to keep the dilated shape of the strut by first KB inflation?Maybe, but it has a low probability.

Crush stenting Crush stenting Worse caseWorse case

Circle

a b c dMagnified view of the SB ostium

a b c dCross sectional view

Absence of the strut of SB stent

Gap

63 y.o. Male, CTO in LCX P/S CABG (LITA-LAD, Ao-SVG-RCA: recurrent degenerative lesions)

Baseline CAG

Collateral flow from

RCA to LCX

After predilatationDK crush stenting

MV: OM branch to proximal LCX, Cypher 2.5/28 mm.

SB: middle LCX, Cypher 2.5/18 mm crushed at the proximal site.6-Mo follow up

Horiuchi M, Murasato Y. CCT, 2006

Kissing stentingKissing stenting

Stent overlapping created a gap beneath the Stent overlapping created a gap beneath the overlapped portion of the stent. overlapped portion of the stent.

LMT LMT

LAD LAD

LCXLCX

Gap

Murasato Y. J Invasive Cardiol. 2006, 18 :E279

LAD over LCXLAD over LCX

LAD: 3.5mmLCX: 3.0mm

LAD: 3.0mmLCX: 3.0mm

LCX over LADLCX over LAD

Kissing stenting using different size stents produced Kissing stenting using different size stents produced compression of the LCX stent at distal LM.compression of the LCX stent at distal LM.

LAD

LAD

LCXLCX

Stent distortion

Stent distortion

No remarkable difference in stent expansion between LAD and LCX

Murasato Y. J Inv Cardiol.

2006, 18 :E279


Cypher 3.5/23Cypher 3.0/28

75 y.o. Female, Unstable AP

Overlap of the two stents

LCX

LAD

LAD

LADLCX LCX


66--Mo follow upMo follow upA-P caudal RAO cranial

Spider


distal

Kissing stentingKissing stenting

Gap

Compressed LCX stent

Circle


Long kissing stenting Long kissing stenting in LMCAin LMCA

a

b

c

d

e

a

b

c

d

e

Cross sectional view

Circle

Multilink Zeta 4.0/33

Multilink Penta3.0/28

LCXLAD

Axis of LCX stent

Axis of LAD stent

LCXLAD

LMCA

myocardium

Differences in both longitudinal and circumferential Differences in both longitudinal and circumferential axes between LAD and LCX cause overlapping of axes between LAD and LCX cause overlapping of stent system in distal LMCA.stent system in distal LMCA.

Longitudinal sectionCircumferential section Murasato Y. Catheter Cardiovasc Interv. Online, Jan 8, 2007

PCI with DES deployment for LMCAPCI with DES deployment for LMCA

12Mo12Mo20Mo20Mo12Mo12Mo6Mo6Mo12Mo12MoF/U periodsF/U periods

DLMD 13%DLMD 13%NDLMD 3%NDLMD 3%

8%8%

NRNR

ValgimigliValgimigli44

38.0%38.0%10.0%10.0%12.9%12.9%2.0%2.0%TLRTLR

44.0%44.0%NRNR14.1%14.1%7.0%7.0%RestenosisRestenosis

2.0%2.0%4.0%4.0%3.5%3.5%0%0%Cardiac Cardiac mortalitymortality

PricePrice55LeeLee33ChieffoChieffo22ParkPark11

Crush SKS or V T Culotte

15%

24%

1%

0%

60%51%

20%

7%

8%

14%9%

6%

16%

18%

51%

40%

17%10%

0%

33%17%

74%

0%0%9%

Single stent

1. JACC 2005, 45, 3512. Circulation 2005, 111, 7913. JACC 2006, 47, 8644. JACC 2006, 47, 15305. JACC 2006, 47, 871

Modified TModified T--stentingstenting

1. Stent implantation in LCX

2. Balloon inflation in LM-LAD

3. Stent implantation in LM-LAD

4. Recross GW into the orifice of LCX stent and kissing balloon inflation

Stent distortion

5. Final fluoroscopy

Decrease in unstented segment

Minimum overlapping of the stents

Modified TModified T--stenting stenting

unstented segment

Gap


distal

Modified TModified T--stentingstenting

Metallic carina

Slice at lower horizontal level

Circle


The gap at the The gap at the epicardialepicardial site is likely to site is likely to be generated in a 3D structure.be generated in a 3D structure.

LCX

LAD

myocardium

The protrusion of the LCX stent is confirmed at the positioning.

LCX

LAD

However, the LCX stent is stretched straight after its dilation.

Gap

IVUS like view (1)IVUS like view (1)

►►The consecutive cross sectional view is The consecutive cross sectional view is available. available.

►►View from distal site of the side branch to View from distal site of the side branch to the main vessel with 0.1mm slice.the main vessel with 0.1mm slice.

►►Can you reconstruct this 3Can you reconstruct this 3--D image D image accurately?accurately?

View

IVUS like view (2)IVUS like view (2)

Absence of the strut

Incomplete crush

a

a

b

b

c

c

CypherCypherDistribution of stent strutDistribution of stent strut

a b c

a b c

TaxusTaxus ExpressExpressDilated cell

Absence of strut

ConclusionConclusion

►► In each double stenting on a 3In each double stenting on a 3--dimensional LMCA bifurcation dimensional LMCA bifurcation model, the style of stent overlap model, the style of stent overlap greatly affects stent expansion, greatly affects stent expansion, distortion and the potential for distortion and the potential for gap formation. gap formation.

►► 33--D CT imaging is very useful for D CT imaging is very useful for analyzing the condition of the analyzing the condition of the double stenting in detail.double stenting in detail.

Both plays are attractive. However, the cooperation is necessary for “Ren-jishi”.

“Sukeroku”with one

actor

“Ren-jishi”with two actors

3-dimensional computed tomographic imagings of bifurcation stenting · 2007-02-15 · conclusion in...

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