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Coronary Bifurcation techniques in a nutshell

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AhmedElBorae1

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Two-stent strategies: A step by step approach Ahmed Elborae Assistant Lecturer, Cairo University Aswan Heart Centre, Magdi Yacoub Heart Foundation
Agenda • When ? • Which ? • How ?
Metanalysis of 21 RCT > Favoring provisional strategy with exception of DK-Crush
Two-stent was better 78% DK-Crush 82% Medina 1.1.1 62% LAD-D, 29% LMT Relative risk reduction 57 %
Heterogeneous Appropriate strategy for appropriate patient
When 1. Bail-out : Compromised SB during the provisional stenting strategy -More than 75% SB stenosis with impaired TIMI flow < 3 -Chest pain and ECG changes -Flow-limiting dissection -FFR < 0.8 (DK VI trial) Data from RCTs : Only needed in 5-20%
Accepted SB result Yes That’s it No Rewire-(PTCA/Kissing)-POT Accepted SB result That’s it Bailout 2-stents technique Provisional stenting Yes No “Provisional is a philosophy rather than technique”
TAP Culotte If a second stent needed
When 2. Elective : Complex bifurcation anatomy with predictors of important SB compromise “A Side branch you don’t want to lose” -Diameter >2.5 mm -Severe stenosis >5-10 mm beyond ostium -Unfavourable angle for recrossing
Coronary Bifurcation techniques in a nutshell
"IF YOU FAIL TO PLAN, YOU ARE PLANNING TO FAIL" “Benjamin Franklin’s”
• 1- The working view • 2- Respect the anatomy • 3-Optimal Kissing • 4-Ideal POT • 5- Know your tools Five Fundamentals of 2-stents strategy
Point of the SB take-off Not always the standard one No overlap No foreshortening Hyung Yoo et al.JACC 2017 1-The working view Need a 3rd eye ? > Intravascular imaging
2-Respect the anatomy 1. The 3 diameters of a bifurcation. Choosing strategy DMV= SB > Culotte technique Kissing balloon size PMV DMV SB Finet et al. Eurointervention.2007 POT balloon size MV stent size
2- Lesion length SB lesion length -Longer lesion length> more prone for occlusion, Favoring 2 stents- strategy -SB length>73 mm supply 10% myocardial mass PMV lesion length - Ensure enough stent length for POT PMV DMV DMV lesion length - Ensure enough stent length for kissing SB 2-Respect the anatomy
• 3. Bifurcation angle Hahn et al. Atherosclerosis. 2008 Dec Bifurcation angle B -More acute> More prone to SB compromise -Determine bifurcation strategy -Determine prognosis (Acute> worse) B A Bifurcation angle A -More acute> More difficult wiring and re-crossing Take care that angle might change after wiring or MV pre-dilatation 2-Respect the anatomy
3- Optimal Kissing Korean Circ J. 2018 Jun -SB 1st then Simultaneous in/deflation
Why? Darremont et al. Eurointervention.2015 Less struts in front of the SB
3-Optimal Kissing Korean Circ J. 2018 Jun -SB 1st then Simultaneous in/deflation -Short proximal overlap & respect Finet’s Law
Whenever kiss end with POT
4-Ideal POT Correction of mal-apposition in the proximal MB & facilitate rewiring COBIS II registry: a significant difference in terms of a combined endpoint (MACCE) at 36-month follow- up in favor of the POT group
4-Ideal POT • know the shortest available NC balloon 1:1 PMV • Positioning is crucial ( distal marker opposite to carina) Proximal optimisation technique in the bench with Kaname stent (Terumo, Tokyo, Japan)
5-Know your tools (Balloons) Shoulder at marker Shoulder distal to marker
5- Know your tools (Stents) Courtesy of Jean Fajadet
5- Know your tools (Stents)
5- Know your tools (Stents)
Agenda • When ? • Which ? • How ?
The best two-stent technique is the one you are familiar with
MADS classification D Double Provisional bailout I- Planned 2 stents
Preferred if the 2 branches are equal in size You can start with either branches Courtesy of E.Brilakis
Agenda • When ? • Which ? • How ?
Coronary Bifurcation techniques in a nutshell
POT before re-wiring Finish with a kiss POT after kiss General rule in all 2-stent strategies
Two-Stent Strategies • T-Stenting / TAP • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
T-Stenting • Advantages: - Suitable for angle 90 - Easy • Disadvantages: - Protrusion of SB stent - Ostial gap (Restenosis) Latib et al. EuroIntervention 2010 Rarely used nowadays
TAP-Technique • Ensure full ostium coverage • Bail-out” or Elective • Create new metallic carina Classic T Courtesy of Francesco Burzotta, EBC TAP Proximal view
TAP-Technique MB stent+ POT “Provisional” -Distal rewiring -SB stent+ minimal protrusion -Uninflated balloon in the MV FKB Final POT
-SB balloon should be deflated last during kissing inflation to avoid distortion by the MB balloon -If further SB/MB post-dilatation is needed , always finish with kissing/POT SB MB Important Tips
Wire Recross Courtesy of John Ormiston, EBC 2009 Allowing the projection of struts in the ostial segment of the SB opposite the carina Re-cross rule All distal re-cross Except crush
Two-Stent Strategies • T-Stenting / TAP • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
Classic crush (Too much protrusion) • 7 Fr guiding catheter (2 stents) • Rate of FKBI failure : 20% • Failed kiss  high rate of ST and ISR Ormiston et al.JACC: Cardiovascular Interventions,2018 Rarely used nowadays
Mini-Crush (Minimal protrusion) Latib et al. EuroIntervention 2010 • 7 Fr guiding catheter (2 stents) • Rate of FKBI failure : 20% • Failed kiss  high rate of ST and ISR Rarely used nowadays
Step mini-crush • Advantages: - 6F guide catheter (use MB balloon) - Complete coverage SB ostium - Secure SB 1st • Disadvantages: - Not suitable for wide angle - Difficult SB Recross for FKBI SB stent Angio +/- wire Crush Re-cross Prox. MB stent Kissing
DK-Crush • DK-Crush I : Less TLR and MACE (DK-Crush vs. classic Crush) • DK-Crush II : Less TLR but not MACE (DK-Crush vs. Provisional T) • DK-Crush III : Less MACE (DK-Crush vs. Culotte) • DK-Crush V : Less TLR in LMT (DK-Crush vs. Provisional) • DK-Crush VIII: Ongoing (IVUS guided vs angiographic guided DK crush)
Coronary Bifurcation techniques in a nutshell
SB stent Angio +/- wire Crush Re-cross Prox. 1st Kissing MB stent 1st POT Re-cross Prox. 2nd Kissing 2nd final POT DK-Crush Sawaya et al. ACC: Cardiovascular Interventions,2016
Two-Stent Strategies • T-Stenting • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
Culotte Technique • Advantages: - Complete SB ostial coverage - You can start with either branches (Classic= MB 1st) • Disadvantages: - Excess metal proximal MB (Mini-Culotte) - Not suitable for large size mismatch - Multiple rewiring (DK Culotte might facilitate?) Latib et al. EuroIntervention 2010
Wiring both MB stent 1st POT Re-wiring SB SB balloon Or Kiss SB Stent 2nd POT Re-wiring MB Kissing 3rd final POT Culotte Technique
Two-Stent Strategies • T-Stenting • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
V-Stenting • Advantages: - Suitable for normal proximal MB (rare) - No need for rewiring - Emergency technique • Disadvantages: - Geographic miss in proximal MB - Large guiding 7 or 8 Fr Latib et al. EuroIntervention 2010
Two-Stent Strategies • T-Stenting • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
SKS-Technique • Advantages: - Suitable for large proximal MB - No need for rewiring -Emergency technique • Disadvantages: - Large guiding 7 or 8 Fr - Diaphragmatic membrane -Challenging dealing with stent failure A B C
Recommended
• Where possible, keep it Simple, Swift and Safe • Be familiar with 1 or 2 techniques , remember “ The one you know is the better one” • Angiography is half of the truth and intravascular imaging is the other half • Know your kit “balloons and stents” and more importantly respect it • Always POT before re-wiring and re-POT after kiss Take home message
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Coronary Bifurcation techniques in a nutshell

  • 1. Two-stent strategies: A step by step approach Ahmed Elborae Assistant Lecturer, Cairo University Aswan Heart Centre, Magdi Yacoub Heart Foundation
  • 2. Agenda • When ? • Which ? • How ?
  • 3. Metanalysis of 21 RCT > Favoring provisional strategy with exception of DK-Crush
  • 4. Two-stent was better 78% DK-Crush 82% Medina 1.1.1 62% LAD-D, 29% LMT Relative risk reduction 57 %
  • 6. When 1. Bail-out : Compromised SB during the provisional stenting strategy -More than 75% SB stenosis with impaired TIMI flow < 3 -Chest pain and ECG changes -Flow-limiting dissection -FFR < 0.8 (DK VI trial) Data from RCTs : Only needed in 5-20%
  • 7. Accepted SB result Yes That’s it No Rewire-(PTCA/Kissing)-POT Accepted SB result That’s it Bailout 2-stents technique Provisional stenting Yes No “Provisional is a philosophy rather than technique”
  • 8. TAP Culotte If a second stent needed
  • 9. When 2. Elective : Complex bifurcation anatomy with predictors of important SB compromise “A Side branch you don’t want to lose” -Diameter >2.5 mm -Severe stenosis >5-10 mm beyond ostium -Unfavourable angle for recrossing
  • 11. "IF YOU FAIL TO PLAN, YOU ARE PLANNING TO FAIL" “Benjamin Franklin’s”
  • 12. • 1- The working view • 2- Respect the anatomy • 3-Optimal Kissing • 4-Ideal POT • 5- Know your tools Five Fundamentals of 2-stents strategy
  • 13. Point of the SB take-off Not always the standard one No overlap No foreshortening Hyung Yoo et al.JACC 2017 1-The working view Need a 3rd eye ? > Intravascular imaging
  • 14. 2-Respect the anatomy 1. The 3 diameters of a bifurcation. Choosing strategy DMV= SB > Culotte technique Kissing balloon size PMV DMV SB Finet et al. Eurointervention.2007 POT balloon size MV stent size
  • 15. 2- Lesion length SB lesion length -Longer lesion length> more prone for occlusion, Favoring 2 stents- strategy -SB length>73 mm supply 10% myocardial mass PMV lesion length - Ensure enough stent length for POT PMV DMV DMV lesion length - Ensure enough stent length for kissing SB 2-Respect the anatomy
  • 16. • 3. Bifurcation angle Hahn et al. Atherosclerosis. 2008 Dec Bifurcation angle B -More acute> More prone to SB compromise -Determine bifurcation strategy -Determine prognosis (Acute> worse) B A Bifurcation angle A -More acute> More difficult wiring and re-crossing Take care that angle might change after wiring or MV pre-dilatation 2-Respect the anatomy
  • 17. 3- Optimal Kissing Korean Circ J. 2018 Jun -SB 1st then Simultaneous in/deflation
  • 18. Why? Darremont et al. Eurointervention.2015 Less struts in front of the SB
  • 19. 3-Optimal Kissing Korean Circ J. 2018 Jun -SB 1st then Simultaneous in/deflation -Short proximal overlap & respect Finet’s Law
  • 20. Whenever kiss end with POT
  • 21. 4-Ideal POT Correction of mal-apposition in the proximal MB & facilitate rewiring COBIS II registry: a significant difference in terms of a combined endpoint (MACCE) at 36-month follow- up in favor of the POT group
  • 22. 4-Ideal POT • know the shortest available NC balloon 1:1 PMV • Positioning is crucial ( distal marker opposite to carina) Proximal optimisation technique in the bench with Kaname stent (Terumo, Tokyo, Japan)
  • 23. 5-Know your tools (Balloons) Shoulder at marker Shoulder distal to marker
  • 24. 5- Know your tools (Stents) Courtesy of Jean Fajadet
  • 25. 5- Know your tools (Stents)
  • 26. 5- Know your tools (Stents)
  • 27. Agenda • When ? • Which ? • How ?
  • 28. The best two-stent technique is the one you are familiar with
  • 30. Preferred if the 2 branches are equal in size You can start with either branches Courtesy of E.Brilakis
  • 31. Agenda • When ? • Which ? • How ?
  • 33. POT before re-wiring Finish with a kiss POT after kiss General rule in all 2-stent strategies
  • 34. Two-Stent Strategies • T-Stenting / TAP • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
  • 35. T-Stenting • Advantages: - Suitable for angle 90 - Easy • Disadvantages: - Protrusion of SB stent - Ostial gap (Restenosis) Latib et al. EuroIntervention 2010 Rarely used nowadays
  • 36. TAP-Technique • Ensure full ostium coverage • Bail-out” or Elective • Create new metallic carina Classic T Courtesy of Francesco Burzotta, EBC TAP Proximal view
  • 37. TAP-Technique MB stent+ POT “Provisional” -Distal rewiring -SB stent+ minimal protrusion -Uninflated balloon in the MV FKB Final POT
  • 38. -SB balloon should be deflated last during kissing inflation to avoid distortion by the MB balloon -If further SB/MB post-dilatation is needed , always finish with kissing/POT SB MB Important Tips
  • 39. Wire Recross Courtesy of John Ormiston, EBC 2009 Allowing the projection of struts in the ostial segment of the SB opposite the carina Re-cross rule All distal re-cross Except crush
  • 40. Two-Stent Strategies • T-Stenting / TAP • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
  • 41. Classic crush (Too much protrusion) • 7 Fr guiding catheter (2 stents) • Rate of FKBI failure : 20% • Failed kiss  high rate of ST and ISR Ormiston et al.JACC: Cardiovascular Interventions,2018 Rarely used nowadays
  • 42. Mini-Crush (Minimal protrusion) Latib et al. EuroIntervention 2010 • 7 Fr guiding catheter (2 stents) • Rate of FKBI failure : 20% • Failed kiss  high rate of ST and ISR Rarely used nowadays
  • 43. Step mini-crush • Advantages: - 6F guide catheter (use MB balloon) - Complete coverage SB ostium - Secure SB 1st • Disadvantages: - Not suitable for wide angle - Difficult SB Recross for FKBI SB stent Angio +/- wire Crush Re-cross Prox. MB stent Kissing
  • 44. DK-Crush • DK-Crush I : Less TLR and MACE (DK-Crush vs. classic Crush) • DK-Crush II : Less TLR but not MACE (DK-Crush vs. Provisional T) • DK-Crush III : Less MACE (DK-Crush vs. Culotte) • DK-Crush V : Less TLR in LMT (DK-Crush vs. Provisional) • DK-Crush VIII: Ongoing (IVUS guided vs angiographic guided DK crush)
  • 46. SB stent Angio +/- wire Crush Re-cross Prox. 1st Kissing MB stent 1st POT Re-cross Prox. 2nd Kissing 2nd final POT DK-Crush Sawaya et al. ACC: Cardiovascular Interventions,2016
  • 47. Two-Stent Strategies • T-Stenting • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
  • 48. Culotte Technique • Advantages: - Complete SB ostial coverage - You can start with either branches (Classic= MB 1st) • Disadvantages: - Excess metal proximal MB (Mini-Culotte) - Not suitable for large size mismatch - Multiple rewiring (DK Culotte might facilitate?) Latib et al. EuroIntervention 2010
  • 49. Wiring both MB stent 1st POT Re-wiring SB SB balloon Or Kiss SB Stent 2nd POT Re-wiring MB Kissing 3rd final POT Culotte Technique
  • 50. Two-Stent Strategies • T-Stenting • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
  • 51. V-Stenting • Advantages: - Suitable for normal proximal MB (rare) - No need for rewiring - Emergency technique • Disadvantages: - Geographic miss in proximal MB - Large guiding 7 or 8 Fr Latib et al. EuroIntervention 2010
  • 52. Two-Stent Strategies • T-Stenting • Mini-Crush (Step Crush/DK Crush) • Culotte technique • V-Stenting • Simultaneous Kissing Stenting (SKS technique)
  • 53. SKS-Technique • Advantages: - Suitable for large proximal MB - No need for rewiring -Emergency technique • Disadvantages: - Large guiding 7 or 8 Fr - Diaphragmatic membrane -Challenging dealing with stent failure A B C
  • 55. • Where possible, keep it Simple, Swift and Safe • Be familiar with 1 or 2 techniques , remember “ The one you know is the better one” • Angiography is half of the truth and intravascular imaging is the other half • Know your kit “balloons and stents” and more importantly respect it • Always POT before re-wiring and re-POT after kiss Take home message