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IMAGING BASED ASSESSMENT OF
SB IN BIFURCATION STENTING
DR. SOUMEN P. BEHERA
DR. PRASANT KR. SAHOO
APOLLO HOSPITALS
BHUBANESWAR
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
Why image SB in Bifurcation stenting ?
• Importance of SB
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)
• Do all SB need a stent ?
Bifurcation lesion characteristics for SB protection
• IVUS predictors of SB occlusion
IVUS predictors of SB occlusion
FURUKAWA ET AL (2005)
CAG- No significant difference between the 3 groups in the extent of
SB ostial stenosis
AS PER THE STUDY
SBs
DIFFUSE
PLAQUE
AROUND OSTIUM
GREATER RISK
OF COMPROMISE
NO PLAQUE
AROUND OSTIUM
OCCLUSION IS
UNCOMMON
(<10%)
IVUS predictors of SB occlusion
SAKAMOTO ET AL (2016)
Thickness of MV plaque on
sides of SB < 0.9 mm
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
IVUS : ‘Eye Brow sign’ in LMCA-LAD stenting
SPIKY CARINA
Indicative of
SB (LCX) OCCLUSION
After MV stenting
IVUS can tell the mechanism of SB occlusion :
Plaque shift vs Carinal shift ?
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
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
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
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
• OCT predictors of SB occlusion
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
OCT predictors of SB occlusion
TAKAGI ET AL 2021
WATANABE ET AL (2016)
Carina Tip angle <51o
Branch Point to Carina Tip
(BP-CT) length <1.75 mm
FUJINO ET AL (2014)
Calcified plaque and greater magnitude of calcium distribution
were predictors of SB compromise
KINI ET AL (2016)
 High lipid content of the proximal MV
 Lipid arc of > 90*
Y. CAO ET AL (2018)
Presence of layered plaque on either side of SB ostium on the MV
Case : Provisional stenting
48yrs M; Recent ACS
PRE OCT LAD TO LMCA
CT angle & BP-CT length
2.7mm
≥70˚
Steps of PCI
Pre & Post PCI
Pre & Post PCI
POST OCT-LMCA MALAPPOSITION
POT F/B FINAL POST OCT-LAD TO LMCA
How to do a POT to maintain SB patency
How to do a POT to maintain SB patency
Which strut to cross for better SB results ?
DISTAL STRUT
TO PREVENT FORMATION
OF METAL CARINA
A.SB RECROSSING TRHOUGH DISTAL STRUT
B. SB RECROSSING THROUGH PROXIMAL STRUT
Leaving a link across SB : Future outcomes
SUMMARY
• Imaging studies should be liberally used for SB protection
• However, it depends on the national insurance system of each
country
Bifurcation stenting is like driving a car on a road
with multiple diversions !!
THANK YOU
Questions or Comments?

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IMAGING FOR SIDE BRANCH PROTECTION IN BIFURCATION STENTING.pptx

  • 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 ?
  • 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)
  • 24.
  • 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
  • 34. PRE OCT LAD TO LMCA
  • 35. CT angle & BP-CT length 2.7mm ≥70˚
  • 37. Pre & Post PCI
  • 38. Pre & Post PCI
  • 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
  • 46.
  • 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 !!