Tackling Bifurcations: What Can and
Cannot Be Done
Alaide Chieffo, MD
San Raffaele Scientific Institute,
Milan, Italy
Nothing to disclose related to this
presentation
• It is current practise in our center to
select radial access as the access of
choice even in complex cases and
bifurcati...
• Most of the bifurcation lesions are
currently treated through radial access,
both provisional or 2 stent techniques
• Ho...
What We Do through a Radial Access
1. Bifurcations with Provisional Approach
• 82 yrs, female, dyslipidemia, hypertensive,
prior smoker, PVD
• Recent history of GI bleeding
• Euroscore 15
• Presentin...
1° Case

Heart Team decision > PCI on LM/LAD
DES 3.5x30mm

Slow Flow >> hemodynamic instability
IABP was implanted, Aggrastat ic was given
A 2nd stent was implanted

Final Result
What We Do through Radial Access
2. Bifurcation with 2 stent technique
• 78 yrs, male, hypertensive
• Prior (2003) PCI with stent on LAD and
diagonal on LAD> NSTEMI on 2010
• Euroscore 5
• Posi...
PP

Pt randomized in EBC 2 trial to Culotte Strategy
Culotte Stenting Technique

DES 2.5x14mm

DES 3.0x14mm
Culotte Stenting Technique

2 Step FKBI with NCB 2.5mm on OM e 3.0mm on Cx
Culotte Stenting Technique

Final IVUS

Final Angio
• 58 yrs, male, dislipidemia, hypertensive,
positive family history for CAD
• Prior multiple PCI with DES on LAD and OM>>
...
DES 2.5x33 mm su diag and DES 3.0x38 mm su LAD (“inverted TAP”)
DEB on LAD distal
NCB postdilatation on SB

FKB
Final Angiogram
• Cross Over Radial to Femoral.. Bad
Back up
• 85 yrs, male, dislipidemia, hypertensive, prior
TIA
• Recent history of GI bleeding, baseline Hb
9.5 mg dL
• Euroscore 1...
Not optimal guiding catheter support>> cross over to femoral access
2 x2.5x12 mm BMS implanted through femoral access
Final Angiogram
Conclusions
• Most of bifurcation lesions can be
safely done through radial access
either with provisional or 2 stent
tech...
Chieffo A - Tackling bifurcations
Chieffo A - Tackling bifurcations
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Chieffo A - Tackling bifurcations

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Tackling bifurcations: What can and cannot be done

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Chieffo A - Tackling bifurcations

  1. 1. Tackling Bifurcations: What Can and Cannot Be Done Alaide Chieffo, MD San Raffaele Scientific Institute, Milan, Italy
  2. 2. Nothing to disclose related to this presentation
  3. 3. • It is current practise in our center to select radial access as the access of choice even in complex cases and bifurcations. • However there is still a 5-10% of procedures performed through femoral access.
  4. 4. • Most of the bifurcation lesions are currently treated through radial access, both provisional or 2 stent techniques • However, we still perform femoral access in case of a not optimal back up or need for simultaneous implantation of 2 stents or trifurcations
  5. 5. What We Do through a Radial Access 1. Bifurcations with Provisional Approach
  6. 6. • 82 yrs, female, dyslipidemia, hypertensive, prior smoker, PVD • Recent history of GI bleeding • Euroscore 15 • Presenting with NSTEMI • At echo in ER LVEF 25% • Preloaded with clopidrogel+ASA
  7. 7. 1° Case Heart Team decision > PCI on LM/LAD
  8. 8. DES 3.5x30mm Slow Flow >> hemodynamic instability
  9. 9. IABP was implanted, Aggrastat ic was given
  10. 10. A 2nd stent was implanted Final Result
  11. 11. What We Do through Radial Access 2. Bifurcation with 2 stent technique
  12. 12. • 78 yrs, male, hypertensive • Prior (2003) PCI with stent on LAD and diagonal on LAD> NSTEMI on 2010 • Euroscore 5 • Positive Scintigraphy in inferolateral wall and pt symptomatyc for angina CCS 2.
  13. 13. PP Pt randomized in EBC 2 trial to Culotte Strategy
  14. 14. Culotte Stenting Technique DES 2.5x14mm DES 3.0x14mm
  15. 15. Culotte Stenting Technique 2 Step FKBI with NCB 2.5mm on OM e 3.0mm on Cx
  16. 16. Culotte Stenting Technique Final IVUS Final Angio
  17. 17. • 58 yrs, male, dislipidemia, hypertensive, positive family history for CAD • Prior multiple PCI with DES on LAD and OM>> pt strongly refused CABG • Euroscore 2 • Pt asymptomatic but at 2 year fup coronary CT scan : occlusion of LAD mid
  18. 18. DES 2.5x33 mm su diag and DES 3.0x38 mm su LAD (“inverted TAP”) DEB on LAD distal
  19. 19. NCB postdilatation on SB FKB
  20. 20. Final Angiogram
  21. 21. • Cross Over Radial to Femoral.. Bad Back up
  22. 22. • 85 yrs, male, dislipidemia, hypertensive, prior TIA • Recent history of GI bleeding, baseline Hb 9.5 mg dL • Euroscore 12 • Presenting with NSTEMI
  23. 23. Not optimal guiding catheter support>> cross over to femoral access
  24. 24. 2 x2.5x12 mm BMS implanted through femoral access
  25. 25. Final Angiogram
  26. 26. Conclusions • Most of bifurcation lesions can be safely done through radial access either with provisional or 2 stent technique approach • Consider femoral approach in case of not optimal guiding catheter support or bad back up or in case of simultaneous 2 stent implantation needed (conventional minicrush or V stenting)

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