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1、PCI Strategies for Complex PCI Strategies for Complex Coronary Coronary Bifurcation lesionsBifurcation lesions 首都医科大学附属北京安贞医院首都医科大学附属北京安贞医院 周玉杰周玉杰 聂斌聂斌 Beijing Anzhen Hospital One or two stents?Nordic Bifurcation Study (n=413)413 pts with bifurcation lesion Stenting of the main vessel and side branc
2、h (MV+SB)Stenting of the main vessel and optional stenting of the side branch (MV)n=206n=207RandomizedPrimary Endpoint: Major adverse cardiac event (MACE) at 6 monthsPrimary Endpoint: Major adverse cardiac event (MACE) at 6 monthsPrimary Endpoint: Major adverse cardiac event (MACE) at 6 monthsPrimar
3、y Endpoint of MACE at 6 months (%)Primary Endpoint of MACE at 6 months (%)p=NSp=NSPresented at ACC 2006Presented at ACC 2006 There was no There was no difference in major difference in major adverse cardiac adverse cardiac events at 6 months events at 6 months (17.7% vs 12.7%; (17.7% vs 12.7%; p=NS)
4、p=NS)Nordic Bifurcation Study (n=413) Procedure related Procedure related MI was defined as a MI was defined as a five-fold elevation of five-fold elevation of biochemical biochemical markersmarkers Procedure related Procedure related MI occurred more MI occurred more than three times as than three
5、times as often in the MV+SB often in the MV+SB group (13% vs 4%; group (13% vs 4%; p=0.008)p=0.008)Procedure Related Myocardial Infarction (%)Procedure Related Myocardial Infarction (%)p=0.008p=0.008Presented at ACC 2006Presented at ACC 2006Nordic Bifurcation Study (n=413) One Stent StrategyProvisio
6、nal T StentingProvisional T StentProvision-T stent technique53 pts, SB2mmMACE 9.4% at 14+/-3 monthsTLR 3.8%, MV restensosis 3.2%, SB 12.9% at 6 monthsVigna C, et al. J Invasive Cardiol. 2007 Mar;19(3):92-7. p The SB has a narrowing at its ostiump The MB has severe stenosis with a large plaqueburden
7、and the SB originates with an angle of 45p The ostium of the SB deteriorates after pre-dilatation of the MBA wire is needed in the following circumstances:Provisional T StentFKB is Very Important for Provisional T StentProvisional T StentTwo Stents Techniquesl lT stentl lCulotte l lSKS l lV stentl l
8、Provisional Tl lModified T stentl lY stentBMS EraDES Era Crush Reverse Crush Balloon Crush DK Crush Mini-Crush Inverted CrushT stent TechniqueCulotte TechniqueClinical Outcomespp In BMS era, the incidence of TLR was 24% at 6 months (Chevalier. Am J (Chevalier. Am J CardiolCardiol 1998;82:943) 1998;8
9、2:943)pp In DES era, the incidence of MACE was 5.3% and TLR was 15.4% (Hoye, et al. (Hoye, et al. IntInt J J CardiovascCardiovasc interveninterven 2005;7:36) 2005;7:36)Culotte vs T stent in DES era 80 patients with bifurcation lesions Culotte technique 45 cases T stent 35 casesThe procedural success
10、 rate 100% TLR: 8.9% P = 0.014 ;9monthsMACE 13.3% P=0.051Kaplan S, et al. Am Heart J. 2007 Aug;154(2):336-43 The procedural success rate 100% TLR: 27.3% 9monthsMACE 27.3%SKS TechniqueClinical Outcome200 patients with bifurcation lesions SKS technique Cypher stentsThe clinical success rate is 97%The
11、incidence of TLR: 4% 9+/- 2 monthsSharma SK. Catheterization and Cardiovascular Interventions 2005;65:10Clinical Outcome36 patients with bifurcation lesions SKS technique SES stents 26.7+/-8.6 monthThe procedure success rate is 100%No MACE, MB restenosis13%, SB 10%The incidence of TLR: 14%,Kim YH, e
12、t al. Catheter Cardiovasc Interv. 2007 Nov 15;70(6):840-6 Y Stent TechniqueCrush TechniqueClinical OutcomesppThe survival rate free of TLR was 90.3%, incidence The survival rate free of TLR was 90.3%, incidence of of restenosisrestenosis at MB was 9.1%, at MB was 9.1%, restenosisrestenosis at SB was
13、 at SB was 25.3% 25.3% ( (HoyeHoye A . J Am A . J Am CollColl CardiolCardiol 2006;47:1949-1958 ) 2006;47:1949-1958 )pp Incidence of TLR at 6 month follow-up is 11.3% ( (Moussa I Moussa I Am J Am J CardiolCardiol 2006 2006；9797：131713171321)1321)Colombo et al. PCR 2004Final Kissing is very important
14、!Step 1: Wire both branches and predilate bothStep 2: Both stents in place.Side-branch stent positioned more proximalInverted Crush Wire both branches and predilateDeploy stent in main branchReverse crushing techniqueWire side branch and dilatePosition stent in side branch protruding in MB (slight),
15、 leave a balloon in MBDeploy stent in the side branch and remove wire and balloonCrush the protruding part of SB on top of the stent in MBBalloon CrushDK Crush ( Sleeve Technique)mini-crush45 pts, 52lesionsProcedural success 100%No in-hospital MACETLR 12.2%, MV restensosis 12.2%, SB 2% at 8 monthsGa
16、lassi AR, et al. Catheter Cardiovasc Interv. 2007 1;69(7):976-83 TAP techniqueWire both branches and predilateDeploy stent in main branchWire side branch and dilateKissing balloonSB stent positioningSB stent is deployed with theuninflated balloon into the MVThe balloon of the SB stent is slightly re
17、trieved and aligned to the MV balloonFinal kissing balloonIn vitro TAP stentingPerfect coverage of the bifurcation withminimal stents struts overlap at the proximal part of SB ostium0.070”0.0710.078”6F7F 5.3F 5.4F 5.9FTips and tricks Size of Guiding Catheter MV balloon shaft profile + SB stent shaft
18、 profile 8F6.0F0.088” 6 F 7 F 8 FGC 球囊种类球囊种类球囊种类球囊种类（ 3.5mm)3.5mm)推送杆外径推送杆外径推送杆外径推送杆外径Maverick 2Maverick 22.0F2.0FRyujinRyujin2.5F2.5FSeQuentSeQuent2.5F2.5FAvitaAvita2.55F2.55FSprinterSprinter2.6F2.6FCrosssailCrosssail2.6F2.6FKingouKingou2.6F2.6FAqua T3Aqua T32.7F2.7FPowersailPowersail2.9F2.9FAVIONA
19、VIONExtensorExtensorVoyagerVoyagerGripGripCTOCTO2.8F2.8F3.03.02.72.72.62.62.52.55.4F0.0705.3F6F导管完成对吻扩张导管完成对吻扩张6F导引导管的内径：导引导管的内径：0.0700.071)两球囊推送杆两球囊推送杆外径之和外径之和应应5.3F6F导引导管进行球囊对吻技术导引导管进行球囊对吻技术球囊外径：球囊外径：球囊外径：球囊外径：2.9F+2.6F=5.5F2.9F+2.6F=5.5F 6F 6F导管内径：导管内径：导管内径：导管内径：0.070 inch0.070 inch5.4F5.4F选用选用导引
20、导管：导引导管：6F JL 3.5Case of TAP stentingCoronary Angiography6F EBU 3.5BMW BMW 3.024mm CypherDeployment MV stent with jailed guidewire into the SBKissing balloon after rewiring of SBSB stent positioningSB stentMV balloonThe position of the SB stent is adjusted to fully cover the proximal part of the SB
21、ostium (red arrow) while an uninflated balloon kept into the MV SB is deployed with the uninflated balloon into MVSB stent deploymentFinal kissing balloonThe balloon of the SB stent is slightly retrieved and aligned to the MV balloonFinal kissing balloon SB stents balloon MV balloonFinal ResultClini
22、cal study of TAP Burzotta F, et al. Catheterization and Cardiovascular Interventions 2007, 70:7582Angiographic characteristicsTarget lesion n=61n=61 DistalDistal LMLM2626 LAD/diagonalLAD/diagonal2828 LCX/OMLCX/OM5 5 RCA/descending posteriorRCA/descending posterior2 2AngulationAngulation between main
23、 and side-branch between main and side-branch AngleAngle70703636 AngleAngle70702626 Approach TransradialTransradial 2424 TransfemoralTransfemoral 3737Guiding catheter sizeGuiding catheter size 6 Fr 6 Fr 2 2 7 Fr7 Fr2525 8 Fr8 Fr3434Procedure timeProcedure time 11252min11252minProcedure characteristi
24、csClinical outcome (9 month)MACEMACE 4 (6.6%)4 (6.6%) DeathDeath 1 (1.6%)1 (1.6%) Myocardial infarctionMyocardial infarction0 0 TLRTLR 3 (4.9%)3 (4.9%)StentStent thrombosis thrombosis DefinitedDefinited 1 (1.6%)1 (1.6%) SuspectedSuspected 1 (1.6%)1 (1.6%)Patients without MACEPatients without MACE 56
25、 (91.8%)56 (91.8%) Strategies for LMCA lesionsStent implantation in the side branch?NoYes6F Guiding Catheter Treatment StrategyBalloon/DK/Reverse crushProvisional T stent/CulotteStandard crush/SKSModified T stent6F Guiding Catheter7F Guiding CatheterSelect the size of GC 116 pts with LMCA bifurcatio
26、n lesions Cross-over (n=67) Complex strategy (n=49) SKS (n=24) Crush (n=25)Kim YH, et al. Am J Cardiol. 2006 ;97(11):1597-601 Compared to the complex stenting approach, the simple approach (stenting cross-over) was technically easier and appeared to be more effective in improving long-term outcomes for lesions with normal or diminutive LCXConclusionThankThank you you for yourfor your attention attention
