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Goran Stankovic

5 th European Bifurcation Club 16-17 September 2009 - BERLIN. Goran Stankovic. What we have learned during this 2 days ?. Hot news. Lessons from DK crush studies New technique to solve the problem of SB occlusion Stent thrombosis in bifurcation and left main disease, insight from J Cypher

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Goran Stankovic

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  1. 5th European Bifurcation Club 16-17 September 2009 - BERLIN Goran Stankovic What we have learned during this 2 days ?

  2. Hot news • Lessons from DK crush studies • New technique to solve the problem of SB occlusion • Stent thrombosis in bifurcation and left main disease, insight from J Cypher • News from Asian bifurcation club • Stent fracture in bifurcation lesions • Bifurcation stenting expertise by simulation ? • Balloon specifically designed for the POT technique • Balloon inflation time for kissing: 5 seconds of inflation is not enough • Bifurcation stenting in AMI with self expendable stent ?

  3. * To limit the carina/plaque shift by increasing the spatial occupation of the MV NOVEL APPROACH TO TRY REDUCE THE RISK OF SB CLOSURE Jailed Balloon Protection • Proposed for SB at high risk of closure after MV stenting… • Alternative approach: Use short low-profile balloon on a jailed wire if SB occludes)

  4. New fractal Balloon for the POT : BELUGA Objective : adapt stenting to anatomy and put less and less metal in bifurcation! (3.0 + 2.5) x 0.678 = 3.72

  5. Stent Fracture in Bifurcation Lesions • Stent fracture result of “metallic fatigue”; • Depends on vessel angle and vessel motion and is not specifically related to stent type; • Cypher Taxus

  6. Balloon inflation time for kissing: 5 seconds of inflation is not enough • Longer and repeated balloon inflations improve bench result: increased minimal CSA and lower acute recoil; • In practice eyeballing-guided balloon inflation (toping-up the pressure) should be done Stent Recoil % Cross-Sectional Area mm2

  7. Breaking the Consensus • Biomarkers are only endpoint for studies, not for life; • Medina Classification has to be changed before it is widely adopted; • Atheroma is on the carina; • Final kissing as a complication factor; • Provisional strategy for systematic side branch stenting;

  8. SB Diameter as an Index of MI %Infarctartery = MSB/MMP x100 = (CSASB/CSAMP)4/3 x 100 where SB-Side branch; MP-Most proximal artery (e.g., LAD, LCx or RCA) • A quantitative relation between SB diameter/area and %Infarct (relative to main artery or entire heart) exists in swine hearts and needs to be established in patients • Correlate with clinical biomarkers (biological, molecular, imaging, etc.)

  9. Medina Classification: Shouldwe change? • Description of bifurcational lesion characteristics • Still the best qualitative classification • Subject to moderate interobserver variability • Can be extended to IVUS and FFR-Medina • Definition of strategy and prediction of acute and late results • SB size and lesion length and severity determines strategy; • No prognostic validation; Yes! No!

  10. Consensus Prague 2008 Is the carina free of plaque in coronary bifurcation lesions? "No !  carena is not always free of disease ! is it important or not? Plaque at the carina 63/195 (32%) {1,1,0} LAD Bx LM LAD LM * LCx Cx/Bx plaque grows circumferentially from low shear stress regions into the high shear stress carina MSCT: Plaque at the carina (31%)

  11. Presence of plaque at the carina 63/195 (32%) n:46 n:7 n:23 n:50 0% 69% 15% 36% n:13 n:50 n:6 0% 40% 33% Plaque at the carina • The presence of plaque at the carina does not influence procedural outcome in simple, provisional SB stenting; • No data regarding complex, two-stent strategies; • Involvement of basic sciences (flow mechanics, physiology, etc.) crucial for understanding underlying mechanisms;

  12. CONCLUSIONS for KISSING Randomized studies • Side branch stenosis >50% post PCI (assessed by 3D-QCA) is associated with ischemia at stress-test done at 6 months (SEE-SIDE study); • Simple approach in provisional stenting (stepwise approach) has similar 1-year clinical outcome as simultaneous final kissing balloon or isolated SB balloon post-dilation (CORPAL-KISS); Limitations: IVUS-guidance in 50% pts and proximal stent optimization done.

  13. Implications NORDIC KISS Final Kissing is optional (left to the operators descreation) Side branch preparation (therapeutic dilatation, if needed) could be done before implanting the main vessel stent Change the stepwise strategy of provisional stenting of the sidebranch Limitations: Short observation period, Visually assessed implantation angiograms only; CONCLUSIONS for KISSING

  14. CONCLUSIONS for KISSING • No systematic kissing should be done in single stent technique; NORDIC confirmed no harm of kissing; • protective wire in SB and Stepwise approach recommended; • Kissing If you have an eyeball 75% diameter stenosis of SB ostium; we need more FFR-guided interventions; • When SB is big (LMCA) kissing important; • If kissing is done should be optimal; We recommend proximal optimization after kissing based on bench testing data and OCT;

  15. When we need treatment of bifurcation lesion with two stents? • Elective bifurcation stenting as the intention to treat when : - Diffuse disease on side branch - Marked SB Tortuosity - Difficult access to SB - Risk of abrupt closure following Predilatation - Hemodynamic instability ( Distal LM patients) • Functional Evaluating by pressure wire (FFR) can select those who need a second stent at SB. • Elective stenting in bifurcation, when needed, is safe and effective

  16. Why Not Using a Provisional SB Approach Even When SB Stenting is Planned? • By stenting the SB first we increase the complexity of the procedure and may compromise the result in the MB. • Stenting the MB first following the rules of provisional SB stenting approach may simplify the procedure, improve the MB result and decrease the need for SB stenting in relatively short SB lesions (< 5 mm). • This approach will be evaluated in the EBC 1 randomized study.

  17. Is bifurcation stenting a predictor of stent thrombosis? • The association of bifurcation with DES thrombosis has been frequent but not consistent across the studies with DES • Bifurcation has been related specially with early thrombosis or even with late 1-12 months but not with very late thrombosis • The use of complex techniques (2 stents) could increase the risk of thrombosis, specially in the setting of ACS.

  18. Stent thrombosis: The risk with complex stenting is higher Meta-analysis Bifurcations with DES Two stents vs Provisional Brar SS et al. Eurointervention 2009;5:475:84.

  19. LAD Distal angle Prox angle LCX Does the bifurcation angle matter? Chen et al • Assessment of bifurcation angles needs to be standardized and we need prospective studies; • YES: • 2D: A high bifurcation angle is associated with a greater risk of long-term MACE in patients undergoing crush stenting especially if final kissing is not performed. • 2D+3D: distal BA values, pre PCI, have an impact on very long-term outcome measures. The larger the angle, the worse the outcome; Džavik et al 2D versus 3D

  20. Which techniques have to be avoided for wide angle bifurcations? • Less favorable results with crush/culotte at wide BA; • Provisional T-stenting more suitable; • Some dedicated devices can accomodate well to wide BA;

  21. Thank you!

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