1. Strategy planning in coronary bifurcation stenting
IN THE NAME OF GOD
Strategy planning in coronary bifurcation stenting
OSTOVAN MD
SHIRAZ medical School

2. Points and debates in bifurcation stenting
Outcome : MACE ,stent thrombosis, TLR,…
Wire protection in all cases?
SB predilation?
POT
Significancy: Discrepancy between QCA and FFR.
Selection of technique ,case based approach
Preferred 2 stent technique?
Modalities avoiding 2 stent strategy
IVUS in bifurcation?
BVS in bifurcation ?

3. Outcome

4. Wire protection in all cases?
Chance of SB compromise is less when plaque burden is toward contralateral wall , or if its not a true bifurcation lesion.
Protect from closure .
Keeps SB open ,when dissection behind MB stent propagate into SB.
You can see the site of SB take off ,so make recrossing easier with less contrast use .
Modify the angle of take off ,so make it easier to recross.
POT and high pressure inflation is safe with a jailed wire (nonhydrophilic wires).

7. SB predilation
DON’T predidate the sidebranch ; even if very critically diseased, because you may face a SB dissection and and manipulating to Cross the wire into a dissected SB usually close it, if decide to do ,do it with a noncompliant balloon .
Predilation effect usually vanishes after MB stenting

8. POT Optimise proximal MB
Bows stent toward the SB , protect SB ostium from dissection and recoil .
Makes wiring and balloon passage much easier.
Limits risk of wiring under the stent struts
POT and high pressure inflation is safe while keeping wire jailed (nonhydrophilic wires).

10. QCA and FFR
Most of ostial compromise is due to geometric change , shift of carina and flow divider toward SB ostium ,so its not a true stenosis.

11. Kissing balloon If you decide to do a kiss :
Recross by pulling back a j wire to cross distal cells (except in DK crush ).(slide 15)
For difficult wire crossing : hydrophilic soft wire first , then more stronger like miracle ….
Failure to cross the balloon to SB: 1- SB wire behind the MB struts ? 2- do POT 3- delicate CTO balloons with one marker 4-balloon anchoring technique 5- recross SB from another strut .
Do kissing with noncompliant balloons .
2 step kissing is preferred.(slide 16)
SMS technique when simultaneous kissing impossible .
Balloon size 1:1 for SB and distal MB .
Role of cutting , scoring balloon?
Role of DEB for side branch patency?

12. Proximal vessel sizing

13. Techniques for 2 stenting
T stenting variants : classical, provisional , modified , TAP .
Crush technique variants : classic , minicrush , step crush , reversed (internal) minicrush , DK crush
V stenting
skirt technique
SKS
Culotte

14. Anatomical consideration in strategy planning
Bifurcation angle and SB access difficulty
Consider both Side branch size and length.
Diffuseness of SB disease more than 6-10 mm from ostium .
Emergency CASES (faster techniques)
Discrepancy between MB and SB size .
Which vessel to be treated first ?(take care of a gambling during your strategy selection!!!!)
Your experience!!!

15. T stenting: angle more than , simple , leave a Gap, TAP a good solution for all cases except very acute angle

16. Classic T

17. Classic T

19. TAP

21. Crush : a simple and rapid technique good for emergency situation, guaranty acute SB patency in cases with difficult SB access, but needs 7F guiding , 3 layer metal make final kiss difficult

22. Minicrush with final 2 step kiss

23. Minicrush with final 2 step kiss

24. D1 dissection after LAD predilation ,switch to DK crush

26. DK crush, final kissss

29. Culotte technique

30. V stenting for medina 0-1-1

31. SKS Technique : Very simple ,good for emergent cases like LMT Dissection ,good for or even when great discrepancy in size between prox MB and distal trunks and angle less than 90, neocarina ,excess metal , restenosis difficult to treat

34. 6 month coronary angio SKS technique

40. For very big prox MB : SKS
* For very big prox MB : SKS ** When SBA < 60 DK minicrush better than TAP

42. Tryton stent trial

46. Tips and tricks in difficulties

47. Tips and tricks in difficulties

49. Objectives The present study aimed to investigate the difference in major adverse cardiac events (MACE) at 12 months in patients with coronary bifurcation lesions after double kissing double crush (DK crush) or provisional stenting (PS) techniques.
Background Provisional side branch (SB) stenting is preferable to DK crush because it has been associated with fewer complications. It is unknown which strategy would provide the best results.
Methods From April 2007 to June 2009, 370 unselected patients with coronary bifurcation lesions from 7 Asian centers were randomly assigned to either the DK or the PS group. Additional SB stenting in PS was required if final results were suboptimal. The primary end point was the occurrence of MACE at 12 months, including cardiac death, myocardial infarction, or target vessel revascularization (TVR). Secondary end point was the angiographic restenosis at 8 months.
Results There were 3 procedural occlusions of SB in the PS group. At 8 months, angiographic restenosis rates in the main vessel and SB were significantly different between the DK (3.8% and 4.9%) and the PS groups (9.7% and 22.2%, p = and p < 0.001, respectively). Additional SB stenting in the PS group was required in 28.6% of lesions. TVR was 6.5% in the DK group, occurring significantly less often than in the PS group (14.6%, p = 0.017). There were nonsignificant differences in MACE and definite stent thrombosis between the DK (10.3% and 2.2%) and PS groups (17.3%, and 0.5%, p = and p = 0.372, respectively).
Conclusions DK crush was associated with a significant reduction of TLR and TVR in this unselected patient population. However, there was no significant difference in MACE between DK and the PS groups. (Randomized Study on DK Crush Technique Versus Provisional Stenting Technique for Coronary Artery Bifurcation Lesions; ChicTR-TRC )

53. Objectives The study aimed to investigate the difference in major adverse cardiac event (MACE) at 1-year after double kissing
(DK) crush versus culotte stenting for unprotected left main coronary artery (UPLMCA) distal bifurcation lesions.
Background DK crush and culotte stenting were reported to be effective for treatment of coronary bifurcation lesions. However,
their comparative performance in UPLMCA bifurcation lesions is not known.
Methods A total of 419 patients with UPLMCA bifurcation lesions were randomly assigned to DK (n ! 210) or culotte (n !
209) treatment. The primary endpoint was the occurrence of a MACE at 1 year, including cardiac death, myocardial
infarction, and target vessel revascularization (TVR). In-stent restenosis (ISR) at 8 months was secondary endpoint,
and stent thrombosis (ST) served as a safety endpoint. Patients were stratified by SYNTAX (Synergy between Percutaneous
Coronary Intervention with Taxus and Cardiac Surgery) and NERS (New Risk Stratification) scores.
Results Patients in the culotte group had significant higher 1-year MACE rate (16.3%), mainly driven by increased TVR
(11.0%), compared with the DK group (6.2% and 4.3%, respectively; all p " 0.05). ISR rate in side branch was
12.6% in the culotte group and 6.8% in the DK group (p ! 0.037). Definite ST rate was 1.0% in the culotte
group and 0% in the DK group (p ! 0.248). Among patients with bifurcation angle !70°, NERS score !20, and
SYNTAX score !23, the 1-year MACE rate in the DK group (3.8%, 9.2%, and 7.1%, respectively) was significantly
different to those in the culotte group(16.5%, 20.4%, and 18.9%, respectively; all p " 0.05).
Conclusions Culotte stenting for UPLMCA bifurcation lesions was associated with significantly increased MACEs, mainly due to the
increased TVR. (Double Kissing (DK) Crush Versus Culotte Stenting for the Treatment of Unprotected Distal Left Main
Bifurcation Lesions: DKCRUSH-III, a Multicenter Randomized Study Comparing Double-Stent Techniques;
ChiCTR-TRC ) (J Am Coll Cardiol 2013;xx:xxx) © 2013 by the American College of Cardiology Foundation