Ic - Bifurcation Lesions

Ostial & Bifurcation Lesions Interventional Fellow Lecture Series

Bifurcation Lesions • • • •

20% of all PCI procedures Higher Acute Complication Rates Lower Success Rates Higher restenosis and TLR rates – Restenosis Rate 21-57% – TLR 8-43%

Bifurcation Lesions Classification

Syntax Trial Classification

Medina Classification of Bifurcation Lesions

Latib, A. et al. J Am Coll Cardiol Intv 2008;1:218-226

Bifurcation Lesions Stenting Techniques

Provisional Approach

Main Vessel Sidebranch

Double Wire

Predilatation Usually only main branch dilatation

1. The first step is to wire both the MV and the SB. 2. Next step is to decide the pre-dilation device for the MV and/or the SB.

Stent Main Branch

Remove Wire

Rewire Sidebranch

3. Then, a stent is placed in the MV. The stent should be deployed at a pressure of 12–18 atm while leaving the SB wire to prevent plaque shift, closure or dissections in the ostium. Rarely, post-dilation with a high-pressure balloon may be needed at the area of maximal plaque burden for full stent expansion.

Kissing Postdilatation

Ideal Final Result

4. If angiographic results in the MV and SB are satisfactory, the procedure is completed and trapped guidewire in the SB behind the stent struts can be removed gently.

The classic “T” technique consists of positioning a stent first at the ostium of the SB, being careful to avoid stent protrusion into the MV Some operators leave a balloon in the MV to help further locating the MV. After deployment of the stent and removal of the balloon and the wire from the SB, a second stent is advanced in the MV. A wire is then re-advanced into the SB, and final kissing balloon inflation is performed.

Advantages This technique is simple and technically less demanding. It can be used for the coverage of lesions located proximal tothe bifurcation. Disadvantages In almost all cases, this technique leads to incomplete coverage of the ostium of the SB.

The culottes technique uses two stents and leads to full coverage of the bifurcation at the expense of an excess of metal covering of the proximal end Both branches are predilated. First a stent is deployed across the most angulated branch, usually the SB. The non-stented branch is then rewired through the struts of the stent and dilated. A second stent is advanced and expanded into the nonstented branch, usually the MV. Finally, kissing balloon inflation is performed.

Culotte Advantages This technique is suitable for all angles of bifurcations and provides near-perfect coverage of the SB ostium. Disadvantages This technique leads to a high concentration of metal with a double-stent layer at the carina and in the proximal part of the bifurcation. The main disadvantage of the technique is that rewiring both branches through the stent struts can be difficult and time consuming.

V Technique consists of the delivery and implantation of two stents together. One stent is advanced in the SB, the other in the MV, and the two stents touch each other, forming a small proximal carina When the carina extends a considerable length (usually 3 mm) into the main vessel, this technique is called simultaneous kissing stents (SKS)

SKS • Advantages The main advantage of these techniques is that the access to either of the two branches is never lost. • In addition, when a final kissing inflation is performed, there is no need to recross any stent. Also, these techniques provide a definite SB coverage, irrespective of the angulation. • Disadvantages Potential of leaving a gap. • Does not work for all angles

Crush: Stent of the SB is deployed, and its balloon and wire are removed. The stent subsequently deployed in the MV flattens the protruding cells of the SB stent Wire recrossing and dilation of the SB with a balloon of a diameter at least equal to that of the stent, and then final kissing balloon inflation, is recommended.

Advantages The main advantage of the crush technique is that the immediate patency of both branches is assured. In addition, this technique provides excellent coverage of the ostium of the SB. Disadvantages The main disadvantage is that the performance of the final kissing balloon inflation makes the procedure more laborious because of the need to re-cross multiple struts with a wire and a balloon.

The Reverse Crush The main indication for performing the reverse crush is to allow an opportunity for provisional SB stenting. A stent is deployed in the MV, and balloon dilation with final kissing inflation toward the SB is performed. It is assumed that the result of the SB is suboptimal and hence stent placement will be needed. A second stent is advanced into the SB and left in position without being deployed. Then a balloon of the size matching the diameter of the MV is positioned at the level of the bifurcation, making sure to retain inside the previously deployed MV stent. The stent in the SB is retracted about 2–3 mm into the MV and deployed, the deploying balloon is removed, and an angiogram is obtained to ascertain whether a good result is present at the SB (no further distal stent in the SB is needed). If this is the case, the wire from the SB is removed and the balloon in the MV is inflated at high pressure, with final steps involving re-crossing into the SB, performing SB dilation, and final kissing balloon inflation.

The Y Technique This technique involves an initial pre-dilation, followed by stent deployment in each branch If the results are not adequate, a third stent may also be deployed in the MV. This technique is not commonly used at the present. Advantages This technique is a last resort for treating such demanding bifurcations in which there is a need to maintain wire access to both branches. Disadvantages The major limitation of this approach is inadequate coverage of MV and SB

Bifurcation Lesions Trial Data

Concepts in Bifurcation Lesions •

Appropriate use of drug-eluting stents (DES)

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Randomized-controlled trials specifically in bifurcations

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Selective usage of 2 stents as intention-to-treat

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Acceptance of a suboptimal result in the side branch (SB), i.e., one stent only on the main branch (MB), when treating bifurcations involving a minor SB

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Better performance of any 2-stent technique – (high pressure post-dilation, kissing inflation, and possibly intravascular ultrasound)

Registry Studies •

DES have become the preferred stent platform for the treatment of coronary bifurcations.

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Marked reductions in MACE and target lesion revascularization (TLR) rates compared with historical BMS controls.

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1-stent strategy (MACE: 5.4% vs. 38%; TLR: 5.4% vs. 36%) 2-stent strategy (MACE: 13.3% vs. 51%; TLR: 8.9% vs. 38%)

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BMS indications: – 1) contraindications to prolonged dual antiplatelet therapy; – 2) Possibly in acute myocardial infarction due to concerns about a higher risk of stent thrombosis

1 vs 2 Stents Strategy

Nordic Trial • Evaluate stenting of the main vessel and side branch compared with a strategy of stenting of the main vessel only and optional stenting of side branch • Drugs/Procedures Used – Stenting of the main vessel and side branch (MV+SB; n = 206) – Stenting of the main vessel and optional stenting of side branch (MV; n = 207) – Following main vessel stenting, the side branch was dilated in patients in the MV+SB group if TIMI flow grade was <3. – If TIMI flow grade was 0 after dilation, the side branch was then stented. – Repeat angiography was performed at 8 months.

No significant statistical differences between provisional stenting and comitted 2 stent strategy. Differences in crossover related to definition of mandatory SB stenting.

Importance of Sidebranch • Koo et a. JACC 2005: – FFR measurements on 94 jailed SB lesions after stent implantation on the MB. – No lesion with a 50% and <75% stenosis had a FFR <0.75. – Among 73 lesions with >75% stenosis, only 20 lesions were functionally significant.

2 Stent Technique • Niemela et al.: The Nordic Stent Technique Study: • A Randomized Study of Crush vs. Culotte Stent Techniques with Sirolimus Eluting Stents in Bifurcation Lesions – Randomized study comparing 2 different 2DES techniques (Culotte vs. Crush). – No difference in clinical outcomes at 6 months – No long-term follow-up

Kissing Inflation

2 Stent Technique • Insufficient randomized data • Multiple proposed algorithms to approach bifurcation lesions • Provisional stenting is preferred method • 2 Stent Strategy for “true” bifurcation lesions and large SB

Proposed Algorithm for Treating Coronary Bifurcations

Latib, A. et al. J Am Coll Cardiol Intv 2008;1:218-226

Medina Classification of Bifurcation Lesions

Latib, A. et al. J Am Coll Cardiol Intv 2008;1:218-226

General Current Approach •

Two wires should be placed in most bifurcations, and the SB wire should be "jailed" in the majority after the deployment of the stent on the MB.

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This approach is important in protecting the SB from closure as the result of plaque shift and/or stent struts during MB stenting.

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The jailed SB wire also facilitates rewiring of the SB

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TULIPE (Provisional T-stenting for Coronary Bifurcation Lesion Prospective Evaluation) study: absence of jailed wire in sidebranch was associated with a greater rate of reinterventions

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There is no need to remove the jailed wire during high-pressure stent dilation in the MB.

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Avoid jailing hydrophilic guidewires because there is a risk of removing the polymer coating.

Ostial Disease

Main Branch Ostial Disease • Important to accurately place stent to cover the lesion entirely without protruding into the main branch. • Intravascular ultrasound may be helpful to facilitate appropriate stent placement. • Two general approaches to treating these lesions: – (a) placement of a stent at the ostium of the main vessel with a balloon protecting the SB and with inflation of the SB balloon, and kissing balloon only if plaque shift occurs – (b) placement of a stent in the main vessel covering the origin of the SB and then wiring the SB and performing kissing balloon inflation in case the ostium of the SB deteriorates.

Side Branch Ostial Disease • Isolated ostial lesions of SB: – The most common approach in treating these lesions is to place a stent at the ostium of the SB, frequently with a low pressure balloon inflated in the MV (stent pull-back technique)

• If there is deterioration of the main vessel at the site of the bifurcation after stent placement, the balloon in the main vessel is inflated, protecting the stent by a simultaneous inflation of the stent delivery balloon. • In cases of suboptimal angiographic results in the main vessel, a stent can be deployed with final kissing balloon dilation.

Aorto-Ostial Disease • Prior to any PCI intracoronary Nitroglycerin should be administered to rule out catheter induced spasm. • Judkins Catheter is generally employed, side-hole catheter in case of damping. Coaxial alingment and avoidance of deep intubation.

Aorto-Ostial Disease

Aorto-Ostial Disease

Aorto-Ostial Disease • A series of small studies, no major randomized trials • One study (Iakouvou et al.) reported benefit in TLR for Cypher (6.3% vs 28%) and angiographic restenosis (11% vs 51%) • Some small studies comparing stents to lasers, atherectomy, cutting balloon, but none showed superiority to stenting

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