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CTO Bifurcation Techniques Guide
- 1. www.icps.fr Thierry Lefèvre, Massy, France CTO and Bifurcation
- 2. www.icps.fr X XXX X X XX 0
- 3. www.icps.fr Bifurcations in CTOs are frequent
- 4. www.icps.fr 1726 CTO-Patients (1st attempt) 575 bifurcations (33.3%) 1152 non bifurcations (66.7%) 442 SB close to CTO (38.4%) 349 distal/inside CTO (60.7%) At least 1 proximal (39.3%) 170 No visible stump (38.4%) 170 No visible stump (53.3%) ICPS CTO PCI database (2004-2013)
- 5. www.icps.fr Bifurcation lesions and CTOs Ojeda, International Journal of Cardiology 230 (2017) 432–438
- 6. www.icps.fr Loss of relevant side branches are not rare
- 7. www.icps.fr The clinical impact is not benign
- 8. www.icps.fr Immediate and clinical outcomes on follow-up Bifurcation lesions and CTOs Ojeda, International Journal of Cardiology 230 (2017) 432–438
- 9. www.icps.fr MACE-free survival in case of failure to treat the bifurcation Bifurcation lesions and CTOs Ojeda, International Journal of Cardiology 230 (2017) 432–438
- 10. www.icps.fr Simple bifurcation rules does apply to CTOs with bifurcation lesions
- 11. www.icps.fr Hachamovitch. Circulation. 2003;107:2900-2906 Log hazard ratio for Revasc vs Medical Rx as a function of % myocardium ischemic based on final Cox proportional hazards model. Model, P= 0.0001; interaction, P= 0.0305. Notion of Side branch relevance
- 12. www.icps.fr Notion of Side branch relevance The branch that you do not want too loose ! The branch that you do not want to leave untreated ! May be small SB protection > 10% of the myocardial mass (Long branch > 73 mm) Only one diagonal branch 14Th EBC Consensus Banning et al. Eurointervention 2019
- 13. www.icps.fr Physiological Relevance of Diagonal Branch in LAD Bifurcation Lesions Koo, J Am Coll Cardiol Intv 2012;5:1126 –32 A Diagonal Branch Scoring System (SNuH Score)
- 15. www.icps.fr Like for all bifurcation lesions, think provisional Relevant side branch protection Main branch stenting Optimal POT Evaluation of side branch relevance Keep it open POT/Kiss/POT > POT/Side/POT SB stenting if necessary (T, TAP, Culotte) Priority MB Carina in the center
- 16. www.icps.fr But remain open to 2 stents techniques Sometimes it is preferable to stent the side branch first in order to secure the access to the most difficult branch Then many techniques are possible: Systematic T technique Reverse provisional Culotte Reverse T or TAP DK Crush
- 17. www.icps.fr Become confident with difficult SB access techniques
- 18. www.icps.fr Multivariate predictors of bifurcation technical success Bifurcation lesions and CTOs Ojeda, International Journal of Cardiology 230 (2017) 432–438
- 19. www.icps.fr Reshape the wire tip Move to a softer wire: Fielder FC, Pilot 50, Sion POT Long U shape reverse wire IVUS guided SB access Wiring success Retrograde approach Difficult SB access before stenting in CTOs Pull-back technique Dual lumen microcath Supercross 120°
- 20. www.icps.fr Bifurcation at the level of proximal cap 25-40% of CTO cases
- 21. www.icps.fr
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- 25. www.icps.fr
- 26. www.icps.fr
- 27. www.icps.fr Bifurcation at the distal cap About 50% of CTO cases
- 28. www.icps.fr
- 29. www.icps.fr
- 31. www.icps.fr Unable to wire the PL Branch
- 32. www.icps.fr
- 33. www.icps.fr Stent 3.0 x 38
- 34. www.icps.fr POT 3.5 and Kiss (3.0 and 2.75 NC)
- 35. www.icps.fr Bifurcation in the CTO segment ✓ 20-25% of cases ✓ Protect the SB(s) as soon as you can, when they are relevant ✓ Respect the fractal law during predilatation ✓ Size the stent according to the distal reference ✓ Do POT proximal to each relevant SB ✓ Be carefull not the jail the wire with sevreal long stents
- 36. www.icps.fr Conclusion ✓ Bifurcations are a frequent problem when treating CTOs ✓ Loosing a relevant SB impact the outcome ✓ The risk of loosing a relevant SB is high when using an ADR approach ✓ POT, dual lumen microcath, long U shape reverse wire technique, IVUS guided penetration and retrograde approach are very useful in this setting
- 37. www.icps.fr Conclusion When the SB is relevant, bifurcation lesions should be treated like all bifurcation lesions: ▪ Wire the SB as soon as you can ▪ Be careful not too jail the SB wire with several long stents ▪ Provisional does not mean that you will use only 1 stent or stent first the MB ▪ Respect the fractal low ▪ Know escalation techniques for difficult SB access
- 38. www.icps.fr Conclusion When the SB is relevant, bifurcation lesions should be treated like all bifurcation lesions: ▪ Wire the SB as soon as you can ▪ Be careful not too jail the SB wire with several long stents ▪ Provisional does not mean that you will use only 1 stent or stent first the MB ▪ Respect the fractal low ▪ Know escalation techniques for difficult SB access