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Technical considerations in the
Treatment of Left Main Lesions
Onassis Cardiac Surgery Center, Athens, Greece
Ioannis Iakovou, MD, PhD
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Critical issues in LM PCI
• Anatomic variability
• Techniques
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Variability of LM bifurcation
• Angle of bifurcation
• Burden of atherosclerotic lesion
• Relative involvement of the ostia of LAD or CX
• Relative relation between diameter of LM and
diameters of stemming arteries
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Left Main Measurements
Author Year Method Ramus Diameter
(mm)
Angles
(degrees)
Russell 2009 CAST 27% 4.46 68.5
Kawasaki 2009 CT
Girasis 2009 92.7
Zenia 2007 CT 4.11
Rodriguez-
Granillo2007 CT 87.8
Reig 2004 anatomy 38% 4.86 86.7
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Most Ostial Coverage
Bifurcation Stent Techniques
Less Complex Technique
More Complex Technique
Less Ostial Coverage
Provisional
T-Stent
V, Kissing
CrushCulotte
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Contemporary Stent Treatment of Coronary Bifurcations
The T Stenting Technique
Applications:
- Angulation > 75°
- SB with severe
stenosis at the ostium
location
Considerations:
- C - Accurate position of
SB stent is critical for
SB ostium coverage
Advantages:
- Simpler than Crush
- Covers proximal
lesion in the MV
Drawbacks:- Does not grant full
coverage of the SB
ostium
FKB: final kissing-balloon
SB: side branch
PV: parent vessel
Iakovou I. et al, JACC
2006;46:1446-1455.
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Contemporary Stent Treatment of Coronary Bifurcations
The Culottes Stenting Technique
Applications:- Left Main
- Large SB
- Angulation > 75°
- Restenosis in-stent
Considerations:
- C - Both advancement of
2º stent through metal
struts
Advantages:
- Optimized stent
expansion in both
branches
-Suitable for lesions
with wide angles
Drawbacks:
FKB: final kissing-balloon
SB: side branch
- Re-wiring for FKB
- High metal
concentration at the
bifurcation carina
Iakovou I. et al, JACC
2006;46:1446-1455.
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Contemporary Stent Treatment of Coronary Bifurcations
The V/Simultaneous Kissing Stents Technique
Applications:- Left Main
- Large branches
- Angulation < 90°
- Significant disease in
the proximal vessel
Considerations:
- C - Combined stent size
should “match” vessel
size proximal to the
bifurcation
Advantages:- Both branches are
never lost- No need for re-wiring
for FKB
Drawbacks:- Implantation of stents
proximal or distal to
kissing-stents
FKB: final kissing-balloon
- Covers proximal
lesions
Iakovou I. et al, JACC
2006;46:1446-1455.
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Long kissing stenting
in LMCA
a
b
c
d
e
a
b
c
d
e
Cross sectional view
Circle
Multilink Zeta
4.0/33
Multilink Penta
3.0/28
Murasato Y. ACC i2 summit 2007
Twisting of the
two stents
Simultaneous kissing stent (SKS) and V-stent
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Contemporary Stent Treatment of Coronary Bifurcations
The Crush Technique
Applications:
- All true
bifurcation, especially non-
Left Main- Angulation < 75°
Considerations:
- C - Single high pressure
balloon inflation in the
SB before FKB may be
hepful to optimize stent
expansion
Advantages:
- Immediate patency
of both branches
- Full coverage of the
SB ostium
Drawbacks:- High metal concentration
at the bifurcation
carina, less with “Mini
Crush”- Re-wiring into SB
FKB: final kissing-balloonSB: side branch
Iakovou I. et al, JACC
2006;46:1446-1455.
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Influence of Bifurcation Angle on
Outcome of Crush Technique
MA
CE
-fre
e s
urv
iva
l
Kaplan-Meier plot comparing MACE-free
Survival up to 648 days between the low-angle
group (BA<50o and high-angle group BA>50o
Dzavik et al AHJ 2006;152:762-9
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Combined Crush experience:
Milan and Rotterdam
231 pts,
241 de novo bifurcations
Hoye A, Iakovou I, et al. JACC 2006
ST=4.3%
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Final kissing balloon inflation
YES NO P value
Myocardial
infarctions
7.5%
(24/319)
29.0%
(9/31)
<0.0001
Stent thrombosis
0.9%
(3/319)
6.5%
(2/31)
0.06
CACTUS trialCoronary Bifurcation Application of the Crush
Technique Using Sirolimus-Eluting stents
Colombo et al Circ 2009
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J-Reverse: OCT substudy-Kobe
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J-Reverse: Thrombus attachment
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J-Reverse: Thrombus attachment
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One-step
kissing
post-
dilatation
No
kissing
Two-step
kissing
post-
dilatation
Two-step kissing is more effective than one-step
kissing for improving metallic side-branch ostial
area
Ormiston
58 crush
deployments
SB ostial stenosis (%) with one
step vs. two step kissing
Two steps:
Inflate at high pressure only the SB
balloon
Perform kissing inflation
Courtesy J.Ormiston
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Clinical outcomes at 12 month FU
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Impact of asymmetric expansion induced by
KBT on mid and long term resultsMurasato, EBC 2009
• KB deformation
• Position of the balloons:
long overlapping
vs
minimal overlapping
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Intimal growthSymmetrical vs. Asymmetrical expansion
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Impact of struts malapposition on flow
DiMario EBC 2012
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Vascular tissue reaction to acute malapposition in human
coronary arteries: 43 pts, 66 stents (@index & 6-13 m0s)
Incomplete stent apposition (ISA)
- Acute ISA size (estimated as ISA volume or maximum ISA distance per strut) was
an independent predictor of ISA persistence and of delayed healing at follow-up.
- The larger the acute ISA, the greater the likelihood of persistent malapposition at
follow-up and delayed healing
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OCT guidance of distal cell recrossing in
bifurcation crossing: choosing the right cell
mattersN= 52 pts
EuroIntervention.2012;8(2):205-13
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Stenting Technique (n = 139)
80 % single stent for distal lesions
n
Courtesy O Darremont
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%
n = 172/173 patients
Any Revascul.
TotalMACCE
MACCE at 1 year
O Darremont
ULM Stent Thrombosis with a provisional T stenting approach is a relatively
rare event, with a rate of 1.1% at 12-month-FU
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French left main Taxus Registry:
5-y outcomes: 1 vs. 2 stents
Mylotte et al Eurointervention 2012
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Kaplan-Meier curves for cumulative incidences of cardiac death (A) and TLR (B) among patients treated for ULMCA according to distal bifurcation stenting strategy (j-cypher)
Toyofuku, M. et al. Circulation 2009;120:1866-1874
Several techniques
3 y outcomes after SES implantation for ULM
coronary artery disease: impact of technique
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MACCE to 12 MonthsLM Distal PCI: T-stenting vs Non T-stenting
ITT populationEvent Rate ± 1.5 SE, *Fisher exact test
0 6 12
20
40
0
Months Since Allocation
Cum
ula
tive E
vent
Rate
(%
) P=0.03*
22.4%
10.4%
T-stenting (n=135) Non T-stenting (n=49)
Patients with LM, LM+1,2,3VD included
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Paclitaxel-eluting stent
(Taxus)
n=302
Sirolimus-eluting stent
(Cypher)
n=305
607 patients with unprotected left main lesionsClopidogrel 600 mg at least 2h before procedure
Aspirin 500mg i.v.
Clopidogrel 2x75 mg/day until discharge, then 75 mg indefinitely
Aspirin 200 mg/day
Intracoronary Stenting and Angiographic Results:
Drug-Eluting Stents for Unprotected Coronary Left Main Lesions
ISAR-LEFT MAIN
Mehilli J. et al. JACC 2009 53;1760-1768
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Several techniques
ISAR LM late outcome / technique
Mehilli et al JACC 2009
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Sequential SB-MV 2 Step dilatation can be used
instead of Kissing Balloon after Provisional
Stenting of Bifurcations
N.Foin EBC 2012
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Results KB vs SB-MV sequence
N.Foin EBC 2012
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Pooled data from several LM registries
Jérôme Van Rothem EBC 2012
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Should we stent toward the tightest lesion?
Jérôme Van Rothem EBC 2012
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What about the bifurcation angle?
Jérôme Van Rothem EBC 2012
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POT or not POT?
Jérôme Van Rothem EBC 2012
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Frequency of stent underexpansion
Kang et al CCI 2011
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All- Cause Mortality Stent Thrombosis
Long-Term Events after IVUS v Angio Guided DES Stenting
758 Consecutive Bifurcation Pts/7731Pts treated
420 DES (82% Cypher) v 338 BMS
473 IVUS Guided v 284 Angio Guided
82 v 92% 1 Stent Technique
SH Kim, HW Kim, .., SW Park et, CCI 2009
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Average MLA in pts incurring events
after deferred revascularization
Okabe et al. J Invas Cardiol 2008;20:635-9
Abizaid et al. J Am Coll Cardiol 1999;34:707-15
De la Torre, et al. J Am Coll Cardiol 2011; 58:351-8
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Recommendations Pertaining to Unprotected
Left Main Intervention in the ACC/AHA/SCAI
2011 Guidelines for PCI
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Open issues with LM
bifurcations• Technically demanding
• Time consuming
• Too much operator dependent
• Off the-shelf standard stents don’t fit
bifurcations
• Long term outcome?
Is dedicated bifurcation stent the answer?
Iakovou et al Interventional Cardiology 2011
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The promise of bifurcation stents
• Conformance to vessel contour without
disruption of the stent coating
• Preservation of the side branch
• Enhanced long term outcomes
• Safety
Iakovou et al Interventional Cardiology 2011
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Approach to LM Bifurcational Lesions
Is the lesion True Bifurcation?
(significant stenosis on the MB and SB)
No Yes
Stent on MB
PTCA on the SB
Is the SB suitable for stenting?
Does the disease on the SB
extends> 3 mm from the
ostium?
provisional SB
stentingelective implantation of 2
stents (MB and SB)
provisional SB stenting
Yes
Yes
No
No
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An approach for bifurcational lesions when
using 2 stents as intention to treat
no disease proximal to
the bifurcation or very
short LM
MB disease extending
proximal to the bifurcation
and SB which has origin
with about 90° angle
MB disease extending
proximal to the bifurcation
and SB which has origin with
about 60° angle
V-Stent/SKS T-Stent/Culotte Culotte/Crush
Pre Post Pre Post Pre Post
Iakovou I. et al, JACC
2006;46:1446-1455.
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Conclusions
• Stenting LM lesions remain one of the most
demanding field in PCI
• Most bifurcation lesions are relatively simple and can
be treated with 1 stent.
Results are critically dependent on technique and
appear to be improved by the use of IVUS
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• Distal cell recrossing is associated with lower
mallapposed struts.
• It seems that with the provisional approach, the
outcome is not influenced by the angle.
• Stenting towards the tightest lesion is associated with
a lower rate of double stenting.
• The use of POT and systematic (better short) FKBI
may be associated with better outcome.
Conclusions-technical considerations