Bifurcation and Stent Thrombosis Debriefing Chair C Rouguelov

Bifurcation and Stent Thrombosis “Debriefing” Chair C. Rouguelov, F. Perreira Machado, G. Stankovic Bifurcation stent is a predictor of stent thrombosis? BK Koo Is there a biological problem ? S Hoffamn VASP guided LM stenting ? O Darremont Can we decrease stent thrombosis in bifurcation ? B De Bruyne Bernard De Bruyne, MD, Ph. D Cardiovascular Centre, Aalst www. cardio-aalst. be bernard. de. bruyne@olvz-aalst. be

Everything you always wanted to know about Bifurcation and Stent Thrombosis but were afraid to ask 1. What we know 2. What we thought we knew 3. What we don’t know 4. What we would like to know

Bifurcation and Stent Thrombosis What we know 1. Bifurcation stenting is technically more challenging than an average lesion 2. The bifurcation is a paradigm of Virchow’s triad (abnormal vessel wall, rheology and coagulation) which create a thrombogenic evironment 3. There is an inverse relationship between procedure complexity and clinical outcome: • One stent > two (less is more) • KISSSSS principle (keep it simple swift and safe, surely with stents) • Teaching is important

Bifurcation and Stent Thrombosis What we know Cardiac Output The Starling curve LV Preload

Bifurcation and Stent Thrombosis What we know Good Clinical Outcome The Starling curve Poor Clinical Outcome Complex Simple 1 Wire + 1 Stent 2 Wires + 1 Stent + kissing 3 Wires + Predil SB + 1 Stent + kissing Wires + Predil SB + 2 Stents + kissing Crush Culotte

Everything you always wanted to know about Bifurcation and Stent Thrombosis but were afraid to ask 1. What we know 2. What we thought we knew 3. What we don’t know 4. What we would like to know ?

Can we decrease the risk of stent thrombosis in bifurcation stenting? Bifurcation as a potent, independent risk factor for stent thrombosis Iakovou et al n RR 95% CI FU 2229 5. 96 1. 90 - 18. 68 Subacute 2229 8. 11 2. 50 - 26. 26 Late 1017 3. 00 1. 30 - 6. 80 6 mo 2974 4. 40 1. 96 - 10. 00 12 mo 2551 3. 70 1. 80 - 7. 60 10. 21 4. 75 – 21. 92 JAMA 2005 Ong et al JACC 2005 Kuchulakanti et al Circulation 2006 French Registry EBC 2007 Hwang + Koo TCT 2006 Late

Can we decrease the risk of stent thrombosis in bifurcation stenting? Nordic Trial: ST at 14 months Stent Thrombosis (%) MV (n=199) MV+SB (n=196) 2. 0 0. 5 NS 5/395 = 1. 2 % (Bern-R’dam registry: ± 1. 75% at 14 months) J. Lassen, personal communication

Can we decrease the risk of stent thrombosis in bifurcation stenting? One-year clinical outcome of PCI of bifurcation lesions in ARTS II 607 patients with multivessel SES of whom • 324 had at least 1 bifurcation lesion • 283 no bifurcation lesion Non-Bifurcation n=283 Bifurcation n=324 P-value Death 1. 1 0. 9 1 Q-wave MI 0. 7 0. 9 1 Non-Q wave MI 2. 5 4. 9 0. 14 MACCE 11 13 0. 46 Stent Thrombosis 0. 7 1. 5 0. 46 Tsuchida et al, EHJ 2007

Can we decrease the risk of stent thrombosis in bifurcation stenting? Bern-Rotterdam registry (n=8146 patients) Multivariate Cox proportional hazards model to identify the presence of a bifurcation lesion as an independant predictor of stent thrombosis Early ST 2. 52 (1. 26 -5. 02) * Late ST 0. 22 (0. 03 -1. 71) Overall ST 1. 47 (0. 79 -2. 72) Daemen et al, Lancet 2007

Bifurcation and Stent Thrombosis What we thought we knew Bifurcation is a potent, independent risk factor for stent thrombosis Late stent thrombosis is rare when up-to-date principles of ‘good stenting’ are applied

Bifurcation and Stent Thrombosis What we thought we knew Inhibition of Platelet Aggregation 80 (%) Goal : VASP < 50 % % of Pts 60 40 20 0 300 mg 600 mg Clopidogrel Hoffmann ESC 2005 Clopidogrel loading dose

Can we decrease the risk of stent thrombosis in bifurcation stenting? Variable responsiveness to Clopidogrel 135 patients receiving Plavix (75 mg/d) and Aspirin (100 mg/d) > 1 month ± 50% of patients have less than 50% reduction of platelet aggregation by LTA after 1 month of Pla/Asp J Angiollilo et al JACC 2007

Bifurcation and Stent Thrombosis *Responder = 25% IPA at 4 and 24 h 100. 0 60. 0 40. 0 20. 0 -20. 0 Interpatient variability 80. 0 Response to clopidogrel Interpatient variability Inhibition of platelet aggregation (%) What we thought we knew Response to prasugrel Brandt et al. ACC 2005

Everything you always wanted to know about Bifurcation and Stent Thrombosis but were afraid to ask 1. What we know 2. What we thought we knew 3. What we don’t know 4. What we would like to know

Bifurcation and Stent Thrombosis What we don’t know Is final kissing always mandatory?

Can we decrease the risk of stent thrombosis in bifurcation stenting? Thrombogenicity of the stent John Ormiston

Bifurcation and Stent Thrombosis FFR Diameter Stenosis (%) The angio cut-off value for (jailed) side branches is 75% DS - DS<75%: high NPV - Reason: - radiographic artefact (white halo) - small branches, small myocardial mass, low flow - Most likely idem with non-jailed SB - Oedema ? Like at day one after IMA implantations Bon-Kwon Koo et al JACC 2005

Changes in functional status of jailed SB Fractional Flow Reserve - No intervention group (n=46) - Koo BK, EHJ, in Revision

Everything you always wanted to know about Bifurcation and Stent Thrombosis but were afraid to ask 1. What we know 2. What we thought we knew 3. What we don’t know 4. What we would like to know

Bifurcation and Stent Thrombosis What we would like to know Is final kissing always mandatory? NORD-BIF III “Nordic kiss” main branch stenting only versus main branch stenting and final kissing balloon • • • N = 450, MV > 2. 5 mm, SB > 2. 25 mm 1 and 6 month clinical- and 8 month angiographic follow up. 14, 24 and 36 month safety follow up FFR measurement in side branch (sub study) Inclusion from April 1 2007.

Bifurcation and Stent Thrombosis What we would like to know - Is final kissing always mandatory? - What is the rate of distal LM LST (Syntax LM patients) - Is clinical outcome influenced by dedicated stent? -Is platelet aggregation testing clinically useful or will it be overuled by newer P 2 Y 12 receptor blockers (Prasugrel, Cangrelor)