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TCT 2012 Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease. Alfredo E. Rodriguez, MD, PhD, FACC, FSCAI Centro de Estudios en Cardiología Intervencionista – CECI Sanatorio Otamendi y Miroli Sanatorio Las Lomas Clinica IMA.
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TCT 2012Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease Alfredo E. Rodriguez, MD, PhD, FACC, FSCAI Centro de Estudios en Cardiología Intervencionista – CECI Sanatorio Otamendi y Miroli Sanatorio Las Lomas Clinica IMA
Disclosure Statement of Financial Interest I, Alfredo E. Rodriguez DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.
TCT 2012Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease Where are we? Who are thecandidates? Whattechniqueshouldwe use?
LeftMain and PCIBackground Class IIb: PCI of the left main coronary artery with stents as an alternative to CABG may be considered in patients with anatomic conditions that are associated with a low risk of PCI procedural complications and clinical conditions that predict an increased risk of adverse surgical outcomes (21,138,139).*(Level of Evidence: B)
LeftMain and PCIBackground D. Capodanno et al. J Am CollCardiol2011;58:1426–32
TCT 2012Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease Where are we? Who are thecandidates? Whattechniqueshouldwe use?
TCT 2012Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease Where are we? Who are thecandidates? Whattechniqueshouldwe use?
LeftMain and PCIWhattechniqueshould be use? Stenting techniquesconventional with provisional SB stent • Most common • Wiring SB first and the MV • Predilation of MV and then the SB • Stent deployed leaving the SB wire • If SB ostium narrowed or dissected – wire inti SB across the MV stent- wire drapped behind the stent as a marker. • Dilatation of SB • Kissing balloon inflation in the MV and SB • If the SB result is satisfactory (even with a 50%–70% residual obstruction but no dissection), the stenting procedure is complete. • If the SB result is suboptimal, stenting of the SB is performed in a ‘‘reverse T’’ approach, advancing the stent via the MV stent struts with final kissing balloon inflation.
LeftMain and PCIWhattechniqueshould be use? • The culotte technique uses 2 stents and leads to full coverage of the bifurcation at the expense of an excess of metal covering of the proximal end. • First, a stent is deployed across the most angulated branch, usually the SB. • The nonstented 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.
LeftMain and PCIWhattechniqueshould be use? CulotteTechnique ADVANTAGES all angles of bifurcations provides near-perfect coverage of the SB ostium DISADVANTAGES Rewiring both branches through the stent struts can be difficult and time consuming.
LeftMain and PCIWhattechniqueshould be use? T-stenting and modified T-stenting techniques • The classicT-stenting technique consists of positioning a stent first at the ostium of the SB, being careful to avoid stent protrusion into the MV • Modified T-stenting is a variation performed by simultaneous positioning of stents at the SB and the MV. • The SB stent is deployed first, and then after wire and balloon removal from the SB, the MV stent is deployed
Left Main and PCIWhat technique should be use? With provisional “T” stenting… … and shouldnot be too proximal potentiallyobstructingmainbranch Sidebranchstentshouldnot be too distal leaving gaps
LeftMain and PCIWhattechniqueshould be use? In the crush technique, 2 stents are placed in the MV and the SB, with the former more proximal than the latter. The 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, hence the name crushing or crush technique Wire recrossing and dilatation of the SB with a balloon of a diameter at least equal to that of the stent followed by final kissing balloon inflation is recommended.
LeftMain and PCIWhattechniqueshould be use? • The V technique consists of the delivery and implantation of 2 stents together. • One stent is advanced in the SB, the other in the MV, and the 2 stents touch each other, forming a small proximal stent carina (<2 mm). • When new stent carina extends a considerable length (3 mm or more) into the MV, this technique is called SKS, with its modified alternative (‘‘trouser SKS,’’ for the long proximal lesions (to avoid new long carina).
Take Home Message • For patients with LMD revascularization with PCI has comparable safety and efficacy outcomes to CABG • PCI is therefore a reasonable treatment alternative in this patient population, in particular, when SYNTAX score is low or intermediate (≤32) • The elected technique depends on lesion location. • If more than one stent is intended to use, the elected bifurcation´s technique must be the most “operators friendly” one. • Expertise and Experience is a key point. • IVUS after deployment , if it´s available.
Left Main and PCIAlways IVUS Park SJ, et al. Circ Cardiovasc Intervent 2009;2:167-177
