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Bifurcation stenting

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Bifurcation stenting

Bifurcation stenting

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  • 1. BIFURCATION STENTING Coronary artery disease Subha RathaYatra 2014
  • 2. BASIS  The approach to bifurcation lesions is based on the angiographic configuration of the lesion(s) in the main branch and the side branch  Significant disease (>50% stenosis) in the ostium of the side branch increases the likelihood of side-branch closure as well as the restenosis rate after PCI
  • 3. ONE STENTVSTWO STENT STRATEGY  Default approach is one-stent technique ± provisional angioplasty/stent to side branch  Use two-stent technique if side branch is significant and has high-risk features for closure
  • 4. RISK  The risk of side-branch closure with an ostial narrowing approaches 15%  PCI across an uninvolved side branch carries a less than 1% risk of occlusion
  • 5. CLASSIFICATION
  • 6. MEDINA CLASSIFICATION
  • 7. GUIDE CATHETER  7 F or 8 F guiding catheter should be selected if the operator anticipates using two stents  A 6 F guiding catheter can accommodate only two monorail balloon  8 F guiding catheter can accommodate two stent systems as well as other large- diameter PCI devices such as the Rotablator or the Flextome Cutting Balloon  The maximum Rotablator burr that can be used with a 6 F guiding catheter is 1.5 mm  It may be prudent to “upsize” guiding catheters when approaching any bifurcation lesion so that all options remain available if trouble occurs during the procedure
  • 8. GUIDEWIRE  To protect the side branch, two guidewires are placed, one in the side branch and one in the main vessel  The order of inflation is relatively unimportant  Wire markers or using two different wire types is helpful to reduce confusion during balloon inflations and wire repositioning  When using a two-guidewire system, the guidewires may become entangled after multiple wire manipulations  . Efforts should be made to avoid guidewire entanglement, which will prevent advancement of the balloon and may result in failure to recross the stenosis.
  • 9. BALLOON  Standard balloon use  Different balloon sizes may be required for each branch  Sequential balloon inflations or simultaneous “kissing” balloon inflations can be performed with elimination of plaque shifting being the advantage of the latter  It is important to make sure that the main vessel can accommodate both balloon diameters when performing kissing balloon inflations (proximal vessel should be at least two thirds of the combined balloon diameters)  After stent placement in the main branch and the side branch, simultaneous kissing balloon inflations are critical to restore the circular and fully expanded stent to each lumen  Failure to perform final kissing balloon inflation will likely lead to restenosis
  • 10. SEQUENTIAL BRANCH INFLATIONS  Dilate the main vessel first, the side branch second, and finish dilation in the main branch  A sequential main-side-main branch inflation strategy provides a safe and straightforward approach  Sequential inflations may result in suboptimal main vessel dilation and plaque shifting , requiring repeated dilatations  An unprotected major vessel dissection will require reinstrumentation and jeopardize further attempts to open the side branch  Serial inflations, first in one branch then in the other, as opposed to simultaneous balloon inflations in both branches, may limit the need for extra manoeuvres.
  • 11. T STENTING-2 STENTS  The side branch off ostium ,therefore no crush
  • 12. V STENT-2 STENTS
  • 13. Y STENTS-3 STENTS
  • 14. DOUBLE BARREL(V STENTVARIANT)
  • 15. CULLOTTE TECHNIQUE  Angle <70 degree  Bend branch stenting first
  • 16. CRUSHTECH  Side branch stenting protrudes into and get crushed after main stent expansion
  • 17. ONLY FOR EXPERTS  Crush  Culottes  Angle is < 70 degree  Excellent coverage in excellent hand
  • 18. CRUSH  Wire both vessels  Predilate both  Two stents are then advanced and positioned into each vessel of the bifurcation with the proximal end of the side-branch stent in the main vessel  The side-branch stent is deployed first  The main-branch stent is then deployed  The side branch then needs to be rewired and balloon dilated  Final kissing balloon inflation is then performed to complete the procedure
  • 19. JAIL FOR ONLY UNPARDONABLE MISTAKE  Physiologic Guidance for Bifurcation or Jailed Side-Branch Stenting is decided by IVUS and FFR
  • 20. IVUS  To overcome visual elusion of best result
  • 21. FFR  By using FFR, the “jailed” side branches with an FFR >0.75 have a very low clinical event rate without further balloon or stent therapy to the side branch  Performing FFR of ostial side-branch lesions that appear to be <70% from angiography can prove that most of these lesions are not physiologically significant
  • 22. KEEP IT SIMPLE STUPID: KISS  Wire both main branch and side branch if side-branch loss is important.  Consider treating side branch first (i.e., balloon dilatation, rotational atherectomy, or cutting balloon).  Dilate and stent main branch; reassess side branch (can use FFR to determine hemodynamic significance).  Provisional PTCA + stent side branch. If stenting side branch, stent with pullback technique.  Choice of two-stent technique depends on size of proximal vessel, an assessment of the importance and risk of side- branch closure, and operator expertise and preference.  Use two wires if side branch loss is important.  Dilate smaller branch first or use Rotablator or cutting balloon.  Dilate and stent main branch; reassess side branch.  Redilate side branch.  Stent side branch through main stent only when absolutely necessary; use FFR to assess physiologic significance of side branch.  If a two-stent technique is used, final kissing balloon inflation is necessary to optimize outcomes
  • 23. SUBHA RATHAYATRA -2014