The Inverse of Can’tTransradial Bifurcation Coronary InterventionDavid E. Kandzari, MD, FACC, FSCAIChief Scientific OfficerDirector, Interventional CardiologyPiedmont Heart InstituteAtlanta, Georgiadavid.email@example.com
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
Science and Art of Transradial Coronary Intervention for BifurcationDisease — 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?
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 NESteigen 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
Inverse of Can’tDemystifying 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
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
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. TAPLouvard Y. Cather Cardiovasc Interv 2008
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.
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 noFor a planned 2 stent MB protrusion and deploy the stenttechnique, or if the (TAP technique – leave someresult is suboptimal protrusion). Option: position a(provisional): balloon in the MB to facilitate re- crossing.
T Stenting (Planned or Provisional)5 5: Perform final kissing inflation, ideally with 2 non-compliant balloons.
Sidebranch Re-Access Courtesy of Corrado Tamburino
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% 0.63Yang, Kandzari et al., JACC Interv 2009
Culotte StentingCulotte 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)
Culotte StentingCulotte 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
Culotte StentingCulotte Technique 4 5: Cross the first stent (SB) with a wire and perform kissing balloon inflation.
Culotte Technique Case ExampleCulotte Stenting: PrePre-dilatation, followedby 3.5 mm DES in LCX Courtesy of Fajadet J.
Culotte Technique Case ExampleCulotte Stenting: 3.5 mm DES in the LAD Final kiss Final result Courtesy of Fajadet J.
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
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 mmMamas MA et al, CCI 2008;72:357–364; Liang et al. CCI 2010;75:222-224
Advanced Guiding Catheter Technologies Asahi EaucathLiang et al. CCI 2010;75:222-224
Inverse of Can’tDemystifying 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
Inverse of Can’tExisting Limitations and Opportunities of TR PCI • Anatomy – Left radial – Operator experience
Inverse of Can’tExisting 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
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/OperatorBall et al. Circulation Cardiovasc Intervent 2011
Inverse of Can’tExisting 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!