distal left main bifurcation: assessing the LCX ostium TCTAP 2013 - - PowerPoint PPT Presentation

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distal left main bifurcation: assessing the LCX ostium TCTAP 2013 - - PowerPoint PPT Presentation

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One stent cross over technique for a complex distal left main bifurcation: assessing the LCX ostium TCTAP 2013 MC MORICE MD, FESC, FACC Institut Cardiovasculaire Paris Sud Massy , FR I have no conflict of interest to disclose 70 y.o. male

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MC MORICE MD, FESC, FACC Institut Cardiovasculaire Paris Sud Massy , FR

One stent cross over technique for a complex distal left main bifurcation: assessing the LCX ostium TCTAP 2013

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I have no conflict of interest to disclose

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70 y.o. male

Risk Factors

Diabetes mellitus Hypertension,

Presentation

Stable angina (CCS 2)

Clinical Data

Height: 164 cm, Weight: 70 kg (BMI: 26) Creatinine clearance 50ml/min

Coronary Data

Stenosis of distal LM (Medina 1-0-0) 50% in Mid LAD 70% in OM; RCA normal

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LM,LAD1,Cx1 1,0,0

From J. Wentzel, P. Mortier

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What do we do at ICPS?

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Distal LM PCI

Stent POT Kiss

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Protocol (Xience Prime)

4 1 2 3 POT 4.5mm Kissing 3.5 and 3.0 at 12atm Stent 3.5mm Recrossing distal strut Courtesy of O. Darremont

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XIENCE Prime 3.5 mm

Courtesy of O. Darremont

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Why, always provisional, POT, Kiss And second stent only if bad dissection or positive FFR?

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Flow Patterns and Spatial Distribution of Atherosclerotic Lesions in Human Coronary Arteries

High wall shear stress = antiatherogenic

Asakura, Circulation Research 1990; 66:1045- 1066

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Flow Patterns and Spatial Distribution of Atherosclerotic Lesions in Human Coronary Arteries

Low wall shear stress = proatherogenic

Asakura, Circulation Research 1990; 66:1045- 1066

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LM bifurcation

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Low wall shear stress and atheroma in bifurcation

Virmani, Chatzizisis

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0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa] 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 0.0 0.4 0.8 1.2 1.6 Diameter [mm] Pressure [Mpa]

Endeavour micro CT and model Rotational angiography Finite elements: hexahedral discretization

Mean fiber directions for finite elements

Circumferential stress

  • Mortier. Annals of Biomedical Engineering 2010

Jan;38(1):88-99

A Novel Simulation Strategy for Stent Insertion and Deployment in Curved Coronary Bifurcations

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LM,LAD1,Cx1 1,0,0

From J. Wentzel, P. Mortier

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Restauration of initial flow (+ stent turbulences)

WSS < 0.5 Pa = risk of restenosis Ku 1997, Malek et al. 1999

Flow mediated NIH and neo-atheroma

Virmani, Mintz …

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LM Predilatation (3 mm)

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LM stenting: LM to LAD, 3.5X23 Xience Prime

From J. Wentzel, P. Mortier

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Why, even when prox LAD look smaller we always use à 3.5mm stent?

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Element Xience V Taxus Integrity Biomatrix Cypher

2.25 Very Small

  • workhorse. max

exp: 2.75mm Medium Workhorse (6 crowns , 3 cells)

  • max. expansion:

to 3.5mm Small workshorse (2 cells) max expansion: 3.5mm Small workhorse (7crowns, 2 cells*) max expansion: 3.2mm *1.5 cell in Resolute Medium workhorse (6 crowns, 2 cells) max expansion: 3.5mm Medium workhorse (6 cells) max expansion: 3.75mm 2.50 Small workshorse (8 crowns, 2 cells) max expansion : 3.5mm 2.75 Medium Workhorse (3 cells) max expansion: 4.25mm 3.00 Medium Workhorse (8 crowns, 2 cells) max expansion : 4.25mm Medium workhorse (10 crowns, 2 cells) max expansion : 4.4mm 3.50 Large workhorse: (9 crowns , 3 cells) max expansion : 4.5mm Large workhorse (9 crowns, 3 cells) max expansion: 4.5mm Large workhorse (7 cells) max expansion: 4.75mm 4.00 Large workhorse (10 crowns, 2 cells) max expansion: 5.75mm Large workhorse (3 cells) max expansion: 4.5mm 4.50 5.00

Maximal Expansion Capacity and Workhorse Designs

Foin et al. EBC 2011

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LM post stenting

From J. Wentzel, P. Mortier

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From J. Wentzel, P. Mortier

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POT technique: 1 stent = 2 diameters 4.5 short balloon

From J. Wentzel, P. Mortier

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From J. Wentzel, P. Mortier

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From J. Wentzel, P. Mortier

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Why, even when results seems optimal We always Kiss? To give acces to the Circ if needed in the future

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Bioresorption at jailed side branch is real

Okamura et al., EHJ, 2010

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Wire exchange: LAD wire in Cx

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Wire exchange: Cx wire in LAD

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Kissing balloon inflation (Hiryu NC 3,5X10, 3X10) just the nose in the CX

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From J. Wentzel, P. Mortier

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Post Kissing balloon inflation

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Correlation Between FFR and % Stenosis (QCA) in Jailed SB

No lesion with <75% stenosis had FFR<0.75. Among 73 lesions with ≥75% stenosis, only 20 lesions were functionally significant.

Koo BK et al J Am Coll Cardiol 2005;46:633–7)

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Post Kissing balloon inflation, FFR mesurment: 0.90

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Why 1 stent as often as possible?

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Double vs Single Stenting for (non LM) Coronary Bifurcation

Kastritsis Circ Cardiovasc Intervent. 2009;2:00-00

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A metaanalysis on 1274 patients with DES for ULM disease: Stenting technique and MACE rate

Rate of complex stenting technique (%)

100 80 60 40 20

  • ,2
  • ,4
  • ,6
  • ,8
  • 1,0
  • 1,2
  • 1,4

De Lezo Christiansen Agostoni Lee Sheiban Park Han Carrié Palmerini Chieffo Migliorini Price Dudek

P=0.05

Risk of MACE at follow-up

(Log10 of the actual rate)

←Lower risk Higher risk→

Patients treated with 2 stents are significantly more likely to have MACE

  • I. Sheiban, EBC 2008
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SYNTAX, MACCE to 12 Months

LM PCI Subset

ITT population Event Rate ± 1.5 SE, *Fisher exact test

6 12 20 40 Months Since Allocation Cumulative Event Rate (%) P=0.03* 22.4% 10.4%

Provisional T-stenting (n=135) 2-stent strategy (n=49)

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3Y Outcomes After SES Implantation for ULM Coronary Artery Disease: Insights From the j-Cypher Registry

Cardiac death and TLR in pts treated for ULMCA / distal bifurcation stenting strategy Toyofuku Circulation 2009;120;1866-1874;

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Final

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Left main Taxus/Xience French Registry

MACCE (Death + MI + clinically-driven TLR + CABG + Stroke)

Garot et al. TCT 2010

15.8 in Syntax

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Case

  • 76 y.o. male
  • Presentation Hx

– Class II angina – NYHA II

  • Cardiovascular Risk Factors

– Hypertension – Dyslipidemia

  • Cardiovascular Hx

– Nil

  • Medical Hx

– Nil – BMI 25

  • Laboratory Results

– Creatinine Clearance 90

  • Dobutamine Stress

Echocardiography – Anterior apical and inferobasal wall hypokinesis Coronary Angiogram planned

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  • Distal LM Bifurcation

Medina 1.1.0

  • Proximal Cx stenosis
  • Proximal RCA CTO
  • AV fistula

– LCA-Pulm. Artery Syntax score: 30 STRATEGY???

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Runthrough NS floppy x2 EBU 4.0 6F

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Predilatation

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Predilatation

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Predilatation

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Cx: Xience Prime 2.5 x 15mm

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Intermediate: Xience 2.25 x 15

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Intermediate: Xience 2.25 x 15

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LM + Ostial LAD Xience Prime: 3.5 x 28mm

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LM + Ostial LAD Xience Prime: 3.5 x 28mm x 12atm

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LM + Ostial LAD Xience Prime: 3.5 x 28mm

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POT Hiryu 5.0 x 10mm x 10atm

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POT Hiryu 5.0 x 10mm x 10atm

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POT Hiryu 5.0 x 10mm x 10atm

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Kissing Balloon Angioplasty LAD - Hiryu 3.5 x 10mm Cx - Hiryu 3.5 x 10mm

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Kissing Balloon Angioplasty LAD - Hiryu 3.5 x 10mm x 10atm Cx - Hiryu 3.5 x 10mm x 10atm

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Final Result

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1 month later PCI of CTO

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Final Result