How to Handle a Complex Bifurcation Lesion Curtiss

How to Handle a Complex Bifurcation Lesion Curtiss T. Stinis, M. D. , F. A. C. C. , F. S. C. A. I. Director of Peripheral Interventions Division of Cardiology Scripps Clinic and Research Foundation La Jolla, CA 1

Curtiss Stinis, MD Consulting: Abbott Vascular Medtronic, Inc. Honoraria: Cook Group Incorporated

Easy…. . Not so Easy!

Background u Bifurcation lesions have historically been associated with lower procedural success rates and higher complication and restenosis rates u Various 2 -stent techniques have been devised to ensure full coverage of the side-branch ostium in an attempt to improve acute and long-term outcomes u Thus far, no single 2 -stent technique has been truly proven to be superior u Useful for the operator to know several techniques since there are certain advantages and disadvantages to each

Why Do Bifurcation Lesions Pose Such a Challenge? u When treating the main vessel, shift of plaque or thrombus can lead to sidebranch occlusion, particularly if: u. The ostium of the sidebranch itself is diseased u. The sidebranch is of small diameter u. Thrombus from ACS is present u Clinical consequences of loss of the sidebranch are dependant on vessel size and amount of myocardium

Bifurcation Intervention: The Problem of Plaque Shift (“Snow Plow”) Main Branch Side Branch 6

Bifurcation Lesion: Definition u “A parent vessel with a side branch more than 2 mm, with a lesion involving at least one vessel receiving PCI” – Antonio Colombo, MD

Commonly Used Bifurcation Techniques u. Provisional Stent Technique u u. Crush and Mini-Crush Techniques u. Simultaneous Kissing Stent Technique (SKS) u. TAP Technique u. Culotte Technique

Provisional Stent Technique: The ‘simplest’ way to treat a bifurcation lesion Main Branch u Wire both vessels u Pre-dilate as needed u Stent main branch u Rewire and Side Branch 10 balloon side branch (+/- kissing balloon inflation)

Provisional Stent Technique Advantages: ● Simple ● Less Metal ● Easier to treat restenosis ● Less thrombosis? ● Less restenosis? Disadvantages: ● Residual stenosis at sidebranch ● If sidebranch stent needed may be harder to insert through stent

Commonly Used Bifurcation Techniques u. Provisional Stent Technique u. Crush and Mini-Crush Techniques u. Simultaneous Kissing Stent Technique (SKS) u. TAP Technique u. Culotte Technique

The Crush Technique Main Branch u Wire both vessels u Pre-dilate as needed u Position stents u Deploy side branch stent, remove balloon/wire u Deploy main branch stent- ‘crushes’ side branch stent u Rewire side branch and Side Branch 13 perform kissing balloon inflation

The Crush Technique

2 layers of stent separate side branch from the main branch…. can be difficult to re-wire!

The Evolution of the ‘Crush’ Technique: Post-Crush Kissing Balloon Inflation After Kissing Balloon Inflation Before Kissing Balloon Inflation

Kissing Balloons: Before and After

Classic Crush Technique Mini Crush Technique Also Reverse Crush Technique

Crush and Mini-Crush Stent Technique Advantages: ● Assures ostium coverage ● Prevents loss of side branch ● Can be used if side branch and main branch are different sizes Disadvantages: ● Complex ● Time consuming ● Difficult to rewire ● Sometimes cant perform final kiss ● Difficult to treat restenosis

Commonly Used Bifurcation Techniques u. Provisional Stent Technique u. Crush and Mini-Crush Techniques u. Simultaneous Kissing Stent Technique (SKS) u. TAP Technique u. Culotte Technique

The Simultaneous Kissing Stent (SKS) Technique Main Branch u Wire both vessels u Pre-dilate as needed u Position stents u Deploy stents simultaneously u Perform kissing balloon post-dilatation Side Branch 21

Simultaneous Kissing Stent Technique Advantages: Disadvantages: ● Simple ● Can be difficult to ● Maintain wire access to both rewire branches at all times ● Longer carinas can ● Minimal ischemic time cause trouble later ● Requires larger vessels of similar size ● Can be challenging to treat restenosis

Commonly Used Bifurcation Techniques u. Provisional Stent Technique u. Crush and Mini-Crush Techniques u. Simultaneous Kissing Stent Technique (SKS) u. TAP Technique u. Culotte Technique

The TAP Technique T stent And Protrusion Main Branch u Wire both vessels u Pre-dilate as needed u Position and deploy main branch stent u Rewire side branch and balloon dilate u Position side branch stent so proximal edge protrudes slightly into main branch, ‘backstop’ balloon in main branch Side Branch 24 u Deploy side branch stent first, then inflate main branch balloon to kiss

TAP Technique Advantages: ● Relatively simple ● Assures ostium coverage ● Less metal at side branch ostium compared to crush Disadvantages: ● Excessive stent protrusion cause main branch access problems later ● May be harder to treat restenosis

Commonly Used Bifurcation Techniques u. Provisional Stent Technique u. Crush and Mini-Crush Techniques u. Simultaneous Kissing Stent Technique (SKS) u. TAP Technique u. Culotte Technique

The Culotte Technique Main Branch u Wire both vessels u Pre-dilate as needed u Position and deploy stent in most angulated branch u Remove first wire, wire second branch and balloon dilate u Position second branch stent so proximal portion equal with previous stent edge and deploy Side Branch 27 u Rewire initially stented branch and perform kissing post-dilitation

Culotte Technique Advantages: ● Complete coverage ● Good radial strength Disadvantages: ● Complex ● Time consuming ● Can be challenging to treat restenosis ● Too much metal/drug in main branch?

In Conclusion… u Various 2 -stent techniques have been devised to treat complex bifurcation disease u Each has unique advantages and disadvantages u Having experience with a multitude of techniques can help to ensure clinical success in a variety of anatomical situations

Thank You!