14th VNCC Danang 10-14 Oct 2014 SCAI Fellow Course 12 Oct 2014 Bifurcation PCI: Which lesion should be treated & how to treat for optimal outcomes Koh Tian Hai Senior Consultant, Dept of Cardiology Senior Advisor National Heart Centre, Singapore NEW NATIONAL HEART CENTRE BUILDING, S’PORE Conflicts of Interest None related to this presentation Many Bifurcation Stent Strategies Default Choice in Bifurcation Stenting: Provisional Side Branch Stenting • Progression to next step occurs only when there is severe sidebranch residual stenosis STEPWISE APPROACH Why Single Stent Strategy? KISSS Principle • KISSS: Keep it Simple, Swift & Safe • Potentially Reduced Stent Thrombosis • Side branch usually not as important / large • Reduce risk of Stent Complications / Dissections • Save Cost Why Two Stent Techique? T stent, Crush or Culotte • Risk of acute closure of involved large side branch • Reduce MACE events • Visually appealing • Technically satisfying When to T Stenting? • 90 degree angle branch take off – Eg LCX take off from LM/LAD • Advantages: – Provisional technique – Single drug layer • Risk of: – missing sidebranch ostium – stent strut protrusion into main stented vessel Colombo’s Stent Crush Technique J Ormiston CCVI 2004 When to Crush / Minicrush Stenting? • Shallow take off of sidebranch [...]... and the best long term technique for majority of cases • Choice of Bifurcation Technique depends upon take-off angle, branch vessel dimensions, familarity with stenting technique • For Large branches with true bifurcations: Two stent technique not inferior to provisional single stenting • Increased risk of Stent Thrombosis /MI with two stent techniques st 21 to th 24 January 2015 7 - 8 November 2014... Hospital Drive, Singapore 169609 Key Speakers and Guest Operators Masahiko OCHIAI Showa University Northern Yokohama Hospital 7 - 8 November 2014 (Friday - Saturday) National Heart Centre Singapore 5 Hospital Drive, Singapore 169609 Etsuo TSUCHIKANE Key Speakers and Guest Operators Toyohashi Heart Masahiko OCHIAI Etsuo TSUCHIKANE Center Showa University Toyohashi Heart Northern Yokohama Hospital Thank You... Bifurcation Stent Trials/Registries M Zimarino et al JACCIntv 2013: 6: 687-95 Nordic-Baltic Bifurcation III Trial Final Kissing vs No Kissing balloon 239 pts 238 pts M Niemela et al Circ 2011; 123; 79-86 ACCF/AHA/SCAI Guidelines on PCI: Bifurcation Lesions GN Levine et al CCVI 2011 ESC Guidelines on Revascularisation 2014 lesion subsets S Windecker , P Kolh et al EHJ 2014; 35: 2541-2619 EBC Consensus Statement... Technique 1 LAD Bifurcation lesion -LAO cranial view 2 Final- AP cranial When to do Culotte Stenting • Relatively equal sized branches • Shallow take off of branches < 70 degree angle • Advantages: – Compatible with Provisional sidebranch Stent strategy – Easier to recross as only single layer of struts • Issues: – More complex – 2 layers of drugs Some Technical Considerations during Bifurcation Stenting... Large Bifurcations N=221 simple N= 229 complex I Kumsars at TCT 2013 Which two stent technique is best? Nordic II: Crush vs Culotte Kari Kervinen - Presented at EBC London, Oct 2013 NORDIC II: Crush vs Culotte Study 36 mth follow-up MACE free Survival 209 Crush vs 215 Culotte P=0.32 Kari Kervinen et al JACCIntv 2013; 6: 160-5 Other Bifurcation Stenting Issues Stent Thrombosis & MI: Meta-analysis of Bifurcation. .. techniques and retrograde approach Tips and tricks for clinical use Managing complications of CTO interventions Case studies Live demonstrations • • Moderated case presentation sessions • Didatic lectures focusing on antegrade techniques and retrograde approach Tips and tricks for clinical use Managing complications of CTO interventions Case studies Who Should Attend • Interventional Cardiologists • Fellows... Balloon Sizing for Kissing Inflations Proximal ~2/3 of combined Balloon diameters GA Segueglia & B Chevalier JACCIntv 2012; 5: 803-11 Vessel Size (MB & Daughter Br) Estimation JF Lassen et al EuroIntv 2014; 10: 545-60 POT Technique to enlarge Stent Cell Size Reduce risk of wiring outside of stent Increase success of crossing into sidebranch N Foin et al EuroIntv 2013: 9:885-7 Main Stent Distortion with... distal sidebranch stent cell – Better sidebranch scaffolding • Always Kiss whenever sidebranch is inflated through the MB (main branch) stent – Prevents MB stent distortion Why don’t we do two stent techniques as a routine? Long term (5yr) followup Nordic I trial: single vs two stent technique 206 pts 207 pts M Maung et al JACC 2013; 62: 30-4 What about true (1,1,1) bifurcations with large sidebranch... use Managing complications of CTO interventions Case studies Who Should Attend • Interventional Cardiologists • Fellows and Drs-in-training • Cardiac Technologists • Nurses • Industry Professionals Who Should Attend • Interventional Cardiologists • Fellows and Drs-in-training • Cardiac Technologists • Nurses • Industry Professionals Thank You