The Inverse of Can't: Transradial Bifurcation Coronary Intervention

1. The Inverse of Can’t
Transradial Bifurcation Coronary Intervention
David E. Kandzari, MD, FACC, FSCAI
Chief Scientific Officer
Director, Interventional Cardiology
Piedmont Heart Institute
Atlanta, Georgia
david.kandzari@piedmont.org

2. Disclosure
Within the past 12 months, I or my spouse/partner have had a
financial interest/arrangement or affiliation with the organization(s)
listed below
Affiliation/Financial Relationship Company
Grant/Research Support Abbott Vascular, Cordis Corporation,
Medtronic CardioVascular
Consulting Fees/Honoraria Abbott Vascular, Cordis Corporation,
Medtronic CardioVascular, Micell
Technologies, Terumo Medical
Major Stock Shareholder/Equity None
Royalty Income None
Ownership/Founder None
Intellectual Property Rights None
Other Financial Benefit None

3. Science and Art of Transradial Coronary Intervention for Bifurcation
Disease
— What are existing barriers– or opportunities– to
advancement of TR bifurcation PCI?
— Can and how is complex PCI be performed by a
transradial approach?
— How does evidence inform existing limitations and
challenges of bifurcation TR PCI?

4. Frequency of Crossover to 2 Stents in Bifurcation PCI
40.0% C ros s ov er from 1 s tent to 2 s tents Ang iog raphic S B res tenos is
35.0%
31.0%
30.0%
25.0%
19.2% 18.8%
20.0% TVF due to SB
14.7% restenosis 2.8%
15.0% (no angio f-up)
9.4%
10.0% NA
4.3%
5.0% 2.8%
0.0%
NO R D IC BBK C AC T US B B C O NE
Steigen TK et al. Circulation. 2006;114:1955-1961 Ferenc M et al. Eur Heart J 2008; 29:
2859–2867 Colombo A et al. Circulation. 2009;119:71–78 Hildick-Smith D et al.
Circulation. 2010;121:1235-1243

5. Inverse of Can’t
Demystifying Complex TR PCI
Performed with 6 Fr Guide Cannot Be Performed
Provisional Single Stent Crush and Mini-Crush
T- and modified T V-stent
T and Protrusion (TAP) Simultaneous Kissing Stents (SKS)
Step crush
Culotte
Reverse Crush

6. Device Compatibility Considerations
1. RX notch diameter
2. Distal shaft diameter*
3. Mid balloon crimped diameter and nominal size*
4. Compliant vs non-compliant balloon
5. Shaft coating
*Assumes PTCA catheter only, without stent

7. Equipment Limitations for 6 Fr (0.071” ID) Guiding Catheters
Rx Notch Distal Shaft
Sprinter Legend 0.036 0.034
Apex 0.036 0.031
Trek 0.033 0.030
NC Trek 0.035 0.031
Xience V/Promus 0.045 0.041

8. Equipment Limitations for 6 Fr (0.071” ID) Guiding Catheters
Rx Notch Distal Shaft
Sprinter Legend 0.036 0.034
Apex 0.036 0.031
Trek 0.033 0.030
NC Trek 0.035 0.031
Xience V/Promus 0.045 0.041

9. Equipment Limitations for 6 Fr (0.071” ID) Guiding Catheters
Rx Notch Distal Shaft
Sprinter Legend 0.036 0.034
Apex 0.036 0.031
Trek 0.033 0.030
NC Trek 0.035 0.031
Xience V/Promus 0.045 0.032

10. Equipment Limitations for 6 Fr (0.071” ID) Guiding Catheters
Rx Notch Distal Shaft Mid Balloon Size
Sprinter Legend 0.036 0.034
Apex 0.036 0.031
1. The math doesn’t add up
3.0: 0.032
2. Deliver stent first, then balloon
Trek 0.033 0.030 3.5:
4.0:
3. Caution for stressing system (eg, nondeflate, fracture etc.)
3.0: 0.034
NC Trek 0.035 0.031 3.5:
4.0:
Xience V/Promus 0.045 0.032 0.041*
*Crimp profile

11. Provisional or Bail-Out Stent Technique
Options when a 2nd stent is required
• General rule: Avoid bail-out stenting. If you
suspect you will need 2 stents, start with a
planned 2-stent strategy.
But if you need a bail-out stent:
• T-provisional: When you are confident to
obtain perfect positioning of the SB stent
(i.e. a near 90 angle)
• Culotte or Internal crush: When both
branches are of near equal size and the
angle is narrow
1. Elective T-stenting
2. Internal (reverse) crush) • TAP or Internal crush: When SB is smaller
3. Culotte than MB and the angle is narrow
4. TAP
Louvard Y. Cather Cardiovasc Interv 2008

12. T Stenting (Planned or Provisional)
1
1: Wire both branches and
pre-dilate if needed
2
2: Stent the MB leaving a wire
in the SB.
The stent in the MB can be
deployed at high pressure.

13. T Stenting (Planned or Provisional)
3
3: Rewire the SB passing
through the struts of the MB
stent, remove the jailed wire
and dilate toward the SB
4
4: Advance stent into the SB with no
For a planned 2 stent MB protrusion and deploy the stent
technique, or if the (TAP technique – leave some
result is suboptimal protrusion). Option: position a
(provisional): balloon in the MB to facilitate re-
crossing.

14. T Stenting (Planned or Provisional)
5
5: Perform final kissing inflation, ideally
with 2 non-compliant balloons.

20. Sidebranch Re-Access
Courtesy of Corrado Tamburino

24. Transradial vs Transfemoral Left Main PCI
Procedural and Clinical Complications
Transradial Transfemoral
P value
N=353 N=468
Procedural and In-Hospital Outcomes
Procedural success (%) 97% 96% 0.57
MACE 4.0% 3.2% 0.57
TIMI Major Bleeding 0.6% 2.8% 0.02
Hospital stay (days) 8.5±5.9 9.9±5.9 0.001
Late Clinical Outcomes (Mean 17 mos)
Cardiac Death 1.4% 1.7% 0.74
Non-fatal MI 4.0% 2.6% 0.26
LM specific TLR 5.7% 5.8% 0.95
MACE 10.2% 9.2% 0.63
Yang, Kandzari et al., JACC Interv 2009

31. Culotte Stenting
Culotte Technique
1
1: Wire both branches and
pre-dilate if needed
2
2: Remove or leave the wire in the
more straight branch (MB) and
deploy a stent in the more
angulated branch (SB)

32. Culotte Stenting
Culotte Technique
3 3: Remove the wire from the
stented branch and cross with
a wire and balloon into the
unstented branch (MB)
and dilate.
4
4: Place a second stent into the
unstented branch (MB) and
expand the stent leaving some
proximal overlap

33. Culotte Stenting
Culotte Technique
4
5: Cross the first stent (SB)
with a wire and perform
kissing balloon inflation.

34. Culotte Technique Case Example
Culotte Stenting:
Pre
Pre-dilatation, followed
by 3.5 mm DES in LCX
Courtesy of Fajadet J.

35. Culotte Technique Case Example
Culotte Stenting:
3.5 mm DES
in the LAD
Final kiss
Final result
Courtesy of Fajadet J.

38. • CTO crossing with
Fielder XT wire
• Predilate with 2.5 mm
balloon

39. • 3.0 X 30 mm DES

40. • LCx
⎯Predilate with 2.5X15
⎯2.5X18 DES
⎯Post-dilate with 2.75X15
• Ramus
⎯Direct stent with 3.0X15
DES
⎯2.5X15 PTCA backstop

41. • Ramus
⎯Direct stent with 3.0X15
DES
⎯3.0X15 PTCA backstop

42. • Ramus
⎯ Direct stent with 3.0X15
DES
⎯ 2.5X15 balloon backstop

43. • LAD/LM
⎯ 3.5X28 DES

44. • LAD/LM
⎯ 3.5X28 DES

45. • LCx/Ramus/LM
⎯ Kissing non-compliant
balloon post-dilation

46. • LAD/LM/Ramus
⎯ Kissing non-compliant
balloon post-dilation

47. • Final IVUS all three
segments

48. Final Result

49. Guide Catheter Size for TR PCI:
Smaller, Bigger…Better?
Accessability
3, 4 and 5 Fr Guiding Catheters
Mizuno et al. CCI 2010;75:985-988
Takeshita et al. CCI 2010;75:735-739
Mizuno et al. CCI 2010;75:985-988
Hamon et al. CCI 2002:55;340-343
7 Fr and 8 Fr Guiding Catheters
Gioia G, et al. CCI 2000;51:234 –238
Wu SS, et al. J Invasive Cardiol 2000;12:605–609
Complications
Procedural Failu

50. Advanced Guiding Catheter Technologies
Asahi Eaucath
7.5 Fr Sheathless Hydrophilic Guiding Catheter
Smaller outer diameter < 6Fr sheath, Inner diameter > 7 Fr guide
Catheter external diameter: 2.49mm (5.5 Fr)
6F Sheath external diameter: 2.62 mm
Mamas MA et al, CCI 2008;72:357–364; Liang et al. CCI 2010;75:222-224

51. Advanced Guiding Catheter Technologies
Asahi Eaucath
Liang et al. CCI 2010;75:222-224

52. Inverse of Can’t
Demystifying Complex TR PCI
• Can’t Achieve good guiding catheter support
• Can’t Perform complex PCI with 6 Fr guides
• Can’t Engage and perform bypass PCI
• Can’t Stent complex bifurcation disease
• Can’t Perform complex CTO PCI
• Can’t Perform ULM PCI

53. Inverse of Can’t
Existing Limitations and Opportunities of TR PCI
• Anatomy
– Left radial
– Operator experience

54. Inverse of Can’t
Existing Limitations and Opportunities of TR PCI
• Anatomy
• Equipment
– TR-specific guiding catheters
– Guideliner
– 6 Fr Guiding Catheter*
• 2 simultaneous stents or 3 simultaneous balloons
• Certain brand PTCA balloons with stent
• IVUS and support catheter (eg, Finecross, Tornus)
• Balloon and 2.6 Fr Tornus
• Rotational atherectomy burr >1.75 mm
*Note: Increasing sheath/guide size consistently an independent risk factor for vascular and
bleeding complications

55. Is There a Learning Curve to Transradial Catheterization?
1.0 28 Operators, 1,672 TR PCIs
Odds Ratio of Procedural Failure
— Odds of procedural failure decreased 32% for every
0.75 50 cases
— Contrast volume, fluoroscopy time highest among
low volume operators
0.50
— Minimum 50 cases required to achieve outcomes
similar to high volume operators
0.25
0
0 50 100 150 200 250 300
PCI Volume/Operator
Ball et al. Circulation Cardiovasc Intervent 2011

56. Inverse of Can’t
Existing Limitations and Opportunities of TR PCI
• Anatomy
• Equipment
• Experience
Complex PCI is achievable by TR vascular access without
compromising procedural success or late outcomes
As with all PCI procedures, operator experience will be the greatest
determinant of procedural outcome as patient and lesion
complexity increases!