IMAGING BY OCT AND IVUS FOR SIDE BRANCH PROTECTION IN BIFURCATION STENTING

1. IMAGING BASED ASSESSMENT OF
SB IN BIFURCATION STENTING
DR. SOUMEN P. BEHERA
DR. PRASANT KR. SAHOO
APOLLO HOSPITALS
BHUBANESWAR

2. Why image SB in Bifurcation stenting ?
• Importance of SB
• Do all SB need a stent ?
• IVUS predictors of SB occlusion
• OCT predictors of SB occlusion

3. Why image SB in Bifurcation stenting ?
• Importance of SB

4. SB occlusion after MB stenting : outcome ?
• It is common (4–19 %) [Cao et al, 2018]
• It increases the risk of MACE
• Clinical outcome : not well known
• Carina shift as well as plaque shift is responsible for side
branch occlusion after MV angioplasty
Vassilev and Gil et al (2012)
Yamawaki M et al (2016)
Xu J et al (2012)

5. • Do all SB need a stent ?

6. Bifurcation lesion characteristics for SB protection

7. • IVUS predictors of SB occlusion

8. IVUS predictors of SB occlusion
FURUKAWA ET AL (2005)

9. CAG- No significant difference between the 3 groups in the extent of
SB ostial stenosis

10. AS PER THE STUDY
SBs
DIFFUSE
PLAQUE
AROUND OSTIUM
GREATER RISK
OF COMPROMISE
NO PLAQUE
AROUND OSTIUM
OCCLUSION IS
UNCOMMON
(<10%)

11. IVUS predictors of SB occlusion
SAKAMOTO ET AL (2016)

12. Thickness of MV plaque on
sides of SB < 0.9 mm

13. SB diameter ratio > 1.5
SB Diameter ratio =
SB total diameter- diameter of the media-to-media of SB ostium
SB luminal diameter- diameter of intima-to-intima of SB ostium

14. IVUS : ‘Eye Brow sign’ in LMCA-LAD stenting
SPIKY CARINA
Indicative of
SB (LCX) OCCLUSION
After MV stenting

15. IVUS can tell the mechanism of SB occlusion :
Plaque shift vs Carinal shift ?

16. Tackling SB occlusion based on IVUS findings
SB plaque Shifted Carina
Large balloon,
high pressure
Relatively small balloon,
low pressure
More injury,
More dissection
Less injury,
less dissection
High chances of SB stenting Less chances of SB stenting
More late loss Less late loss

17. Why IVUS guidance for SB protection ?
• Preintervention
• Detailed anatomical information (especially longitudinal view) to plan interventional strategy
• After MV stent implantation
• Define mechanism of SB jail and to plan the SB intervention strategy
• After SB angioplasty/stenting
• Determine the cause of complication and to access the procedural success

18. Why IVUS guidance for SB protection ?
• Preintervention
• Detailed anatomical information (especially longitudinal view) to plan interventional strategy
• LOW POSITIVE PREDICTIVE VALUE TO PREDICT THE PRESENCE OF ISCHEMIA
• After MV stent implantation
• Define mechanism of SB jail and to plan the SB intervention strategy
• After SB angioplasty/stenting
• Determine the cause of complication and to access the procedural success

19. Why IVUS guidance for SB protection ?
• Preintervention
• Detailed anatomical information (especially longitudinal view) to plan interventional strategy
• LOW POSITIVE PREDICTIVE VALUE TO PREDICT THE PRESENCE OF ISCHEMIA
• After MV stent Implantation
• Define mechanism of SB jail and to plan the SB intervention strategy
• DO NOT PREDICT FUCNTIONAL SIGNIFICANCE OF JAILED SB
• After SB angioplasty/stenting
• Determine the cause of complication and to access the procedural success

20. • OCT predictors of SB occlusion

21. Advantages of OCT
• Ability to reconstruct a bifurcation in three dimensions and to
assess the SB ostium from a 3D reconstruction of the MV
pullback.
• Offers 10 times higher resolution compared to IVUS and provides
more detailed information regarding atherosclerotic plaque
composition
• No overlap or foreshortening as conventional angiogram

22. OCT predictors of SB occlusion
TAKAGI ET AL 2021

23. WATANABE ET AL (2016)

25. Carina Tip angle <51o

26. Branch Point to Carina Tip
(BP-CT) length <1.75 mm

27. FUJINO ET AL (2014)

28. Calcified plaque and greater magnitude of calcium distribution
were predictors of SB compromise

29. KINI ET AL (2016)
 High lipid content of the proximal MV
 Lipid arc of > 90*

30. Y. CAO ET AL (2018)

31. Presence of layered plaque on either side of SB ostium on the MV

32. Case : Provisional stenting

33. 48yrs M; Recent ACS

34. PRE OCT LAD TO LMCA

35. CT angle & BP-CT length
2.7mm
≥70˚

36. Steps of PCI

37. Pre & Post PCI

38. Pre & Post PCI

39. POST OCT-LMCA MALAPPOSITION

40. POT F/B FINAL POST OCT-LAD TO LMCA

41. How to do a POT to maintain SB patency

42. How to do a POT to maintain SB patency

43. Which strut to cross for better SB results ?
DISTAL STRUT
TO PREVENT FORMATION
OF METAL CARINA

44. A.SB RECROSSING TRHOUGH DISTAL STRUT
B. SB RECROSSING THROUGH PROXIMAL STRUT

45. Leaving a link across SB : Future outcomes

47. SUMMARY
• Imaging studies should be liberally used for SB protection
• However, it depends on the national insurance system of each
country

48. Bifurcation stenting is like driving a car on a road
with multiple diversions !!

49. THANK YOU

50. Questions or Comments?