STRATEGIES OF HANDLING SIDE BRANCH

DURING PCI

Dr

manjunath

INTRODUCTION

Coronary bifurcations are prone to develop atherosclerotic

plaque due to turbulent blood flow and high shear stress.

Bifurcation lesions account for approximately 15% to 20% of

all percutaneous coronary interventions (PCI).

In comparison to other PCIs, bifurcation interventions have

lower rates of procedural success, higher cost, higher

resource utilization, longer hospitalization, and higher rates

of clinical and angiographic restenosis

Coronary bifurcations have been classified according to the

angulation between the MV and the SB, and according to

the location of the plaque burden

ANATOMICAL CONSIDERATIONS

LOCATION OF ATHEROSCLEROTIC PLAQUE

15-20 % of all PCIs involve bifurcations of importance

Lower initial success rate

Higher restenosis rate

Higher thrombosis rate

EPIDEMIOLOGY:

LIMITATIONS OF

THE MEDINA CLASSIFICATION

Does not take into account

1. Length of disease in the ostium of the SB

2. Length of the LMCA before the bifurcation

3. Trifurcation

4. Vessel angulation

The LMCA differs from many other bifurcation

lesions due to the importance of the SB (LCx)

DUKE CLASSIFICATION OF BIFURCATION LESIONS

RISK

The risk of side-branch closure with an ostial

narrowing approaches 15%

PCI across an uninvolved side branch

carries a less than 1% risk of occlusion

A) If the side branch is significantly diseased at

its ostium or nearby, it is sufficiently large to

be stented, safety and duration of PCI are an

issue: 2 stents

B) In all other conditions 1 stents and then

evaluate

PROVISIONAL OR ELECTIVE

GENERAL APPROACH OF BIFURCATION LESION

1)Provisional

Mainvessel stenting ± sidebranch angioplasty

(Provisional) T-stenting, TAP,

REVERSE INTERNAL CRUSH, REVERSE CULOTTE.

2) elective

Culotte-stenting

Crush technique (reverse crush)

T TECHNIQUE AND TAP

V STENTING

Y STENTING(SKS technique)

STENTING OF BIFURCATION LESIONS

GUIDE CATHETER 7 F or 8 F guiding catheter should be selected if the

operator anticipates using two stents

A 6 F guiding catheter can accommodate only two monorail balloon

8 F guiding catheter can accommodate two stent systems as well as other large-diameter PCI devices such as the Rotablator or the Flextome Cutting Balloon

The maximum Rotablator burr that can be used with a 6 F guiding catheter is 1.5 mm

It may be prudent to “upsize” guiding catheters when approaching any bifurcation lesion so that all options remain available if trouble occurs during the procedure

GUIDEWIRE

To protect the side branch, two guidewires are placed, one in the side branch and one in the main vessel

The order of inflation is relatively unimportant

Wire markers or using two different wire types is helpful to reduce confusion during balloon inflations and wire repositioning

When using a two-guidewire system, the guidewiresmay become entangled after multiple wire manipulations

. Efforts should be made to avoid guidewireentanglement, which will prevent advancement of the balloon and may result in failure to recross the stenosis.

BALLOON

Standard balloon use

Different balloon sizes may be required for each branch

Sequential balloon inflations or simultaneous “kissing” balloon inflations can be performed with elimination of plaque shifting being the advantage of the latter

It is important to make sure that the main vessel can accommodate both balloon diameters when performing kissing balloon inflations (proximal vessel should be at least two thirds of the combined balloon diameters)

After stent placement in the main branch and the side branch, simultaneous kissing balloon inflations are critical to restore the circular and fully expanded stent to each lumen

Failure to perform final kissing balloon inflation will likely lead to restenosis

PROVISIONAL STENTING OF BIFURCATIONS:

TECHNIQUE

FALSE BIFURCATION-POSSIBILITY OF PROXIMAL

CROSS IS MORE

- ? POSSIBLE PROXIMAL CROSSUTILITY OF VERY SHORT OVER SIZED

BALOON TO DISCOVER PROXIMAL CROSS

AVOID PRE - DILATION OF SB

FINAL KISSING BALOON INFLATION:

1) dilating the main branch with baloon on the basis of rationale that plaque modification and hopefully , a favourable plaque shift will faciliatate access toward SB

2)Performing rotational atherectomy

3) using venture wire control catheter – low profile catheter with a tip that can be deflected to 90 degree.

4) Abort the procedure

DIFFICULT ACCESS TO SIDE BRANCH: OPTIONS

ELECTIVE DOUBLE VESSEL STENTING

Pt selection

D.E.S. is considered default strategy for

E.D.S.technique.

Should undergo at least 12 mnth antiplatelet

treatment.

So avoided in pts non compliant with

medications and at high risk for bleeding.

E.D.S.

SECOND STENT IN SIDE BRANCH AFTER

PROVISIONAL APPROACH

T technique

Modified T

technique—SB stent

first, when angle

between MB & SB is

near 90 degrees

CRUSH TECHNIQUE

REVERSE

CRUSH

TECHNIQUE Minimize

any

possible

gap b/w

MB & SB

STEP CRUSH

DK CRUSH

In the DK crush, kissing balloon (KB) inflation is performed after crushing the SB stent with a balloon. This technique facilitates access to the SB in addition to optimising stent apposition at the SB ostium.

It has been shown to perform favourablyagainst provisional stenting in a randomisedtrial.

CULOTTE TECHNIQUE

THE V-STENTING TECHNIQUE

SKS TECHNIQUE

THE “SIMULTANEOUS KISSING STENTS” TECHNIQUE

1. Inability to wire the SB. Make Sure That The Wire Is Directed Towards The Distal Part

But Not The Proximal Part.

If The Primery Guide Wire Failes Try Hydrophilic Wires. If

They Also Fail Consider Tapered Tip Wires(MIRACLE).

2. INABILITY TO PASS BALOON IN TO SB. USE COMPLIANT MONORAIL 1.5 MM BALOON.

IF FAILS REWIRE SB THROUGH A DIFFERENT SITE AND

RE ATTEMT BALOON CROSSING.

IF FAILS THEN USE FIXED WIRE BALOON SYSTEMS.

POTENTIAL FAILURE MODES OF CRUSH AND SUGGESTED

SOLUTIONS

L.M.C.A. BIFURCATION STENTING

Double confirm about compiance of

antiplatelts.

7/8 fr sheath.

Elective I.A.B.P PUMP if required Low E.F

HEMODYNAMIC SHOCK

OLD AGE.

FEMORAL ROUTE PREFFERED.

L.M.C.A. BIFURCATION STENTING

Role of intravascular ultrasound

Intravascular ultrasound (IVUS) is a useful modality to help in selecting treatment strategies as well as optimizing stent deployment and outcomes even in the DES era

Role of fractional flow reserve

Physiologic flow assessment is a novel method to

assess reliably the functional flow in the SB.

FFR is measured when the functional severity of SB stenosis is not adequately assessed by morphological analysis.

1.Nordic I: provisional T stenting as good as systematic side branch stenting

2.Nordic II: Culotte better than Crush

3. Cactus: provisional T stenting not worse than crush

4 . BBC ONE: step wise approach with provisional T stenting

better than initial complex procedures

5.Bad Krozingen: no difference provisional vs systematic T

6.Double Kiss Crush Study: DK Crush better than conv. crush

RANDOMIZED TRIALS IN BIFURCATION STENTING SUPPORT

THE CONCEPT OF INITIAL SIMPLE PROCEDURES WITH ONLY

PROVISIONAL SIDE BRANCH STENTING

Steigen Circulation 2006; 114:1955; Erglis TCT 2008; Hildick-Smith TCT 2008

Ferenc EHJ 2009; Chen J Interv Cardiol 2009; 22:121-27

Randomized Trial of Simple Versus Complex Drug-Eluting

Stenting for Bifurcation Lesions

The British Bifurcation Coronary Study: Old, New, and

Evolving Strategies

David Hildick-Smith, MD, FRCP; Adam J. de Belder, MD, FRCP; Nina Cooter, MSc;

Nicholas P. Curzen, PhD, FRCP; Tim C. Clayton, MSc; Keith G. Oldroyd, MD, FRCP;

Lorraine Bennett, MSc; Steve Holmberg, MD, FRCP; James M. Cotton, MD, FRCP;

Peter E. Glennon, PhD, FRCP; Martyn R. Thomas, MD, FRCP; Philip A. MacCarthy, PhD, FRCP;

Andreas Baumbach, MD, FRCP; Niall T. Mulvihill, MD; Robert A. Henderson, DM, FRCP;

Simon R. Redwood, MD; Ian R. Starkey, BSc, FRCP; Rodney H. Stables, DM, FRCP

Circulation. 2010;121:1235-1243

BRITISH BIFURCATION CORONARY STUDY

Conclusions

For treatment of coronary bifurcation lesions, a systematic 2-stent technique results in longer procedures, higher x-ray doses, more procedural complications, and a higher rate of in-hospital and 9-month MACE.

The provisional T-stent strategy should be the default treatment for most bifurcation lesions; however, there may be subtypes of coronary bifurcation that nonetheless merit a systematic 2-stent strategy.

Randomized Study of the Crush Technique Versus

Provisional Side-Branch Stenting in True

Coronary Bifurcations

The CACTUS (Coronary Bifurcations: Application of the Crushing

Technique Using Sirolimus-Eluting Stents) Study

Antonio Colombo, MD; Ezio Bramucci, MD; Salvatore Saccà, MD; Roberto Violini, MD;

Corrado Lettieri, MD; Roberto Zanini, MD; Imad Sheiban, MD; Leonardo Paloscia, MD;

Eberhard Grube, MD; Joachim Schofer, MD; Leonardo Bolognese, MD; Mario Orlandi, MD;

Giampaolo Niccoli, MD; Azeem Latib, MD; Flavio Airoldi, MD

(Circulation. 2009;119:71-78.)

CACTUS STUDY

Conclusions

In most bifurcation lesions with a significant

stenosis in

both branches, a strategy to stent the MB is

effective, with the need to implant a second stent

in the SB occurring approximately one third of the

time.

The implantation of 2stents does not appear to be

associated with a higher incidence of adverse

events, taking into account that the follow-up was

limited to 6 months and that most patients were

still on

dual-antiplatelet therapy.

Randomized Comparison of Coronary Bifurcation Stenting

With the Crush Versus the Culotte Technique Using

Sirolimus Eluting Stents

The Nordic Stent Technique Study

Andrejs Erglis, MD; Indulis Kumsars, MD; Matti Niemela¨, MD; Kari Kervinen, MD;

Michael Maeng, MD; Jens F. Lassen, MD; Pål Gunnes, MD; Sindre Stavnes, MD; Jan S.

Jensen, MD;

Anders Galløe, MD; Inga Narbute, MD; Dace Sondore, MD; Timo Ma¨kikallio, MD; Kari Ylitalo,

MD;

Evald H. Christiansen, MD; Jan Ravkilde, MD; Terje K. Steigen, MD; Jan Mannsverk, MD;

Per Thayssen, MD; Knud Nørregaard Hansen, MD; Mikko Syvänne, MD; Steffen Helqvist, MD;

Nikus Kjell, MD; Rune Wiseth, MD; Jens Aarøe, MD; Mikko Puhakka, MD;

Leif Thuesen, MD; for the Nordic PCI Study Group

Circ Cardiovasc Intervent. 2009;2:27-34.

NORDIC TRIAL

Conclusions

In conclusion, excellent 6 months clinical and 8

months angiographic results can be obtained

with the crush and culotte stenting of de novo

coronary artery bifurcation lesions using SES.

Culotte-stented lesions tended to have lower

angiographic restenosis rates making this

technique an attractive bifurcation stenting

technique in feasible bifurcation lesion

anatomies.

CORONARY ARTERY BIFURCATION LESIONS: A REVIEW OF CONTEMPORARY TECHNIQUES IN PERCUTANEOUS CORONARY INTERVENTION

Felipe Fuchs, *Vladimír Džavík Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada

Citation: EMJ Int Cardiol. 2014;1:73-80.

WHY WE NEED DEDICATED STENT.PROVISIONAL ASSOCIATED WITH S.B

CLOSURE

E.D.S . Is complex, time consuming, need one more

stent

What are desired featuresLow profile

Less cost

Easy trouble

If the side branch is significantly diseased at its

ostium or nearby, it is sufficiently large to be

stented, safety and duration of PCI are an issue: 2

stents

In all other conditions 1 stents and then evaluate

CONCLUSION: PROVISIONAL OR ELECTIVE

Thank u