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Advanced Technique for Implanting Two Stents in LMCA Distal Bifurcation Stenosis

Learn the SKS technique for simultaneous stent placement in LM to LAD and LCx, overcoming limitations and managing complications effectively in LMCA bifurcation stenosis.

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Advanced Technique for Implanting Two Stents in LMCA Distal Bifurcation Stenosis

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  1. Prof. D S GambhirMD, DM, FAMS, FCSI, FICC, FCAPSC FSCAI, FACC, (USA) Group Director Kailash Heart Institute NOIDA TECHNIQUE SPECIFIC PROBLEM SOLVINGSKS TECHNIQUE

  2. APPROACH FOR IMPLANTING TWO STENTS FORLMCA DISTAL BIFURCATION STENOSIS • Similar Size of LAD and LCx Brs • Combined Size of LAD and LCx. App. 2/3rd of Size of LMCA Bifucation Angle <70o SKS

  3. SKS TECHNIQUE SIMULTANEOUS PLACEMENT OF DESFROM LM TO LAD AND LCx TIPS • Alignment of Proximal Markers of Two Stents • Both Stents Inflated At The Same Time Using Moderate Pressure (12-14 atm) 9

  4. SKS TECHNIQUE SIMULTANEOUS PLACEMENT OF DESFROM LM TO LAD AND LCx TIPS • Alignment of Proximal Markers of Two Stents • Both Stents Inflated At The Same Time Using Moderate Pressure (12-14 atm) 9

  5. SKS LIMITATION AND PROBLEMS • Wrapping of Two Stents Around One-Another Due to Sharp Angle of One of the Branches • Barotrauma to Proximal MB • Dissection • Progression of Disease • Edge Restenosis • Proximal Dissection During Simultaneous Deployment – Difficult to Treat • High Incidence of Instent Restenosis • Difficulties in Treating Bifurcation Instent Restenosis

  6. SKS TECHNIQUEI. WRAPPING/INTERTWINING OF TWO STENTS • Difficult to Negotiate GWs into Distal Branches • Difficulties in Negotiating Balloons and Stents for Treatment of Intrastent Restenosis/Distal Vs. Disease

  7. SKS TECHNIQUE Difficulty in Treating a Dissection at the Proximal End of Two Stents Failure of Endothelialization of Neo-Carina and Stent Thrombosis LIMITATIONS (1)

  8. SKS PROBLEMSHOW TO MANAGE PROXIMAL DISSECTION • Deployment of Proximal Stent • Deployment of Two Stents Proximally Sandwitched into Previous Stents • Crushing One Stent in MB and Restenting the Proximal Segment with One Large Stent

  9. MANAGEMENT OF PROX. DISSECTIONDEPLOYMENT OF DES PROXIMAL TO BIFURCATION STENTS

  10. POST-STENT FINAL KBD

  11. FINAL RESULTSEALING OF LMCA DISSECTION

  12. SKS TECHNIQUE Difficulty in Distal Reintervention Due to Presence of Double Barrel Lumen Difficult to Treat Instent Restenosis in LMCA after SKS Stenting LIMITATIONS (2)

  13. BIFURCATION STENOSIS INVOLVING DISTAL LCx AND ORIGIN OF OM BRANCHES

  14. THE FINAL RESULT AFTER BIFURCATION STENTING AND POST DILATATION

  15. INSTENT RESTENOSIS OF PREVIOUSLY DEPLOYED DES INVOLVING ORIGIN OF BOTH OM BRANCHES Balloon Dilatation of Both Branches Strategy for PCI V-Stenting Using SES

  16. PCI FOR INSTENT BIFURCATION STENOSIS PLACEMENT OF GWs IN BOTH OM BRANCHES

  17. BALLOON DILATATION Successful Placement of Balloon in OM2 Inability to Advance Balloon in OM3

  18. RECREATION OF SINGLE LUMEN IN PROX. LCx BY SEQUENTIAL BALLOON DILATATION Upsizing the Balloon OM3 OM2

  19. RESULT AFTER SERIAL BALLOON DILATATIONS IN LCX-OM2 BY INCREMENTAL SIZES OF BALLOON Widely Patent LCx-OM2 Tight Stenosis in OM3 OM3 OM2

  20. RECROSSING THE OM3 STENOSIS WITH ANOTHER GUIDEWIRE Previous GW Being Withdrawn Another GW Placed in OM3 Thru the Struts of Previously Deployed Stents OM3 OM2

  21. KISSING BALLOON DILATATION OF OM BRANCHES OM3 OM2

  22. PLACEMENT OF DES IN OM2 AND OM3 FOR THE CRUSH TECHNIQUE

  23. THE FINAL RESULTWIDELY PATENT LCx AND BOTH OM BRANCHES

  24. FOLLOW-UP AFTER TWELVE MONTHSNO INSTENT RESTENOSIS

  25. CORONARY ANGIOGRAM(AFTER 6 YEARS) SHOWING THIRD TIME INSTENT RESTENOSIS STRATEGY • Reintervention Using DES • Restenting using TAP Technique 

  26. PLACEMENT OF GWs IN BOTH BRANCHES SEQUENTIAL BALLOON DILATATION

  27. FINAL RESULT AFTER TAP

  28. TAKE HOME MESSAGE Avoid SKS for Elective Two-Stent Strategy for Bifurcation Stenosis Because of: - Potential for Proximal MB Dissection - Difficulty in Treating Instent Restenosis Back-up Strategy Must be in Place in Case theFirst Strategy Fails Converting Double Barrel Lumen into Single Lumen in the MB by Serial Balloon Dilatations Feasible and Facilitates Restenting after SKS

  29. SKS TECHNIQUERECOMMENDED ONLY IN EMERGENCY CASES ADVANTAGES • Easy and Quick to Perform • Maintains Access to Both Branches Throughout the Procedure

  30. DISTAL LMCA BIFURCATION STENTING USING SKS TECHNIQUE AVS12

  31. THE FINAL RESULT AFTER SKS TECHNIQUE AVS24,25,26

  32. DEPLOYMENT OF LONG DES IN OM2 BRANCH USING TAP TECHNIQUE

  33. REPLACEMENT OF GW THROUGH LCX-OM2 STENT INTO OM3 BRANCH

  34. DEPLOYMENT OF DES IN OM3USING TAP TECHNIQUE

  35. FINAL RESULT

  36. ASSESSMENT OF FINAL RESULT DO NOT PUSH THE GUIDE DEEP INTO LMCA AFTER SKS TECHNIQUE

  37. POST DES IMPLANTATION USING SKS TECHNIQUE Note: Dissection in LMCA at the Proximal Ends of Two Stents

  38. PLACEMENT OF GUIDEWIRES IN LCx FOLLOWED BY LAD AVS3

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