Bifurcation coronary stenting: State 0f the Art

Mazhar M Khan

Consultant Cardiologist

Royal Victoria Hospital Belfast, N.Ireland

Percutaneous intervention of coronary bifurcation lesion, like marriage, is easy to do but difficult to get out

David Holmes

Problems of Bifurcation Stenting

• “Stent jail” of side branch

• “Snow plough” effect

• Stent deformity

• Difficult re-crossing

• Lower Success and higher complication rate

• High Restenosis

• Over all incidence of 15% of PCI

“ Stent Jail of the side branch is a low security prison”

Caputo et al

Bifurcation lesion location remains a predictor of adverse late outcomes in multiple (DES) trials Controversies exist among differing strategies using standard stents:

Is long term efficacy improved when a SB stent is placed? Is the SB compromised in provisional techniques?When 2 stents are needed, what is the safety impacts of multiple stent layers and mechanical distortions in T-, crush, culotte, V-, or SKS? Which technique is best?

The Problem

Khan et al International J of Cardiovascular

Intervent;2002 (1+1+1)*

(1+1+0)* (1+0+1)*

(0+1+1)* (0+1+1)

Need for stent?

Published in 2010 Circ.

PCI of Bifurcation coronary lesionOne stent or two stents*

2 stents One stents P value

Procedure 59%

(T or Y)

41% 0.13

Kissing Balloon

27 (94%) 21 (75%) Ns

success 100% 92% (8% Crossover)

Ns

TLR 23% 16% 0.03

MACE 6% 8.3% Ns

* Khan et al Int. Journal of cardiovascular intervention 2002

Duration of PCI

Contrast

Stress

MI

And Keep it Safe

Keep it Simple

And How

Khan et al Int J of Cardiovasc

intervention:2001

p=0.26 p=0.12 p=0.47 p=0.34

Crush technique

(A) Crush stent SB stent first then main branch

(B) final double balloon inflation

(A) Pre(B) Post crush

If you have a crush end with a kiss

MACE

GREAT!

Simple strategy with 5F Guide

Double vessel Stent

After TWO DES

Role of ”jailed” wire

• Identification of side branch ostium after Stent placement – a “road map”

• Favourable modification of side branch origin and angulations

• May maintain patency of side branch

New specific bifurcation stents

• View Stent (Advance Stent Technology)• Double Driver on single shaft (Medtronic)?• Devax system• Invatec Bifurcation stent• Clear Way Bifurcation Stent• Free Path Bifurcation Stent• Tryton• Kapella

Key Message• Recent studies and our own observation show that

that there is no additional benefit of routine stenting of both arms

• Final double balloon (kissing) is essential to reduce the stent malformation and to improve long term outcome after side branch access through the stent

• Double stenting should be reserved for large branch, reduced flow or significant dissection of SB. While stenting side branch, keep balloon in main branch.

Conclusions• Bifurcation coronary lesions are not

uncommon (about 15%). Current technological advance with stenting offers a safe and efficient Revascularisation strategy for such complex lesion.

• New design of stents specific for bifurcation may be further helpful but have been disappointing so far due to anatomical variation.

Conclusions (cotd)• Technical approach depending on the

anatomy and the final use of double (kissing) balloon ensure immediate and long-term success for such lesions.

• Drug eluting stents covering both arms have reduced TLR but MACE is not reduced. Recent studies are also indicative of this approach.

• Double stenting should be reserved for selective anatomical sub set

‘Light at the end of a tunnel may well be the headlight of the in coming train’

Murphy