1. 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

2. 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.

3. TCT 2012 Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease Where are we? Who are the candidates? What technique should we use?

4. Left Main and PCI Background 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)

5. Left Main and PCI Background

6. D. Capodanno et al. J Am Coll Cardiol 2011;58:1426–32

7. Any of them have power to detect differences in death/MI/CVA

8. Left Main and PCI Background CABGPCI Left Main (isolated or 1VD, ostium/shaft) IAIIa B Left Main (isolated or 1VD, distal bifurcation) IAIIb B Left main + 2VD or 3VD, SYNTAX score ≤ 32 IAIIb B Left main + 2VD or 3VD, SYNTAX score ≥ 33 IAIII B

9. TCT 2012 Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease Where are we? Who are the candidates? What technique should we use?

10. Left Main and PCI Who are the candidates?

15. TCT 2012 Revascularization Strategies for Complex Left Main Disease and Left Coronary Ostial Disease Where are we? Who are the candidates? What technique should we use?

16. Left Main and PCI What technique should be use?

17. Stenting techniques conventional 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.

18. Left Main and PCI What technique should be use?

19. 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. Left Main and PCI What technique should be use?

20. Culotte Technique 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.

21. Left Main and PCI What technique should be use?

22. T-stenting and modified T-stenting techniques The classic T-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

23. With provisional “T” stenting… … and should not be too proximal potentially obstructing main branch Side branch stent should not be too distal leaving gaps Left Main and PCI What technique should be use?

24. 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.

25. Left Main and PCI What technique should be use?

26. 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).

28. 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. 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. Take Home Message

29. Left Main and PCI Always IVUS Park SJ, et al. Circ Cardiovasc Intervent 2009;2:167-177