technical considerations in the treatment of left main...

Technical considerations in the

Treatment of Left Main Lesions

Onassis Cardiac Surgery Center, Athens, Greece

Ioannis Iakovou, MD, PhD

Critical issues in LM PCI

• Anatomic variability

• Techniques

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

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

Most Ostial Coverage

Bifurcation Stent Techniques

Less Complex Technique

More Complex Technique

Less Ostial Coverage

Provisional

T-Stent

V, Kissing

CrushCulotte

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.


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:


SB: side branch

- Re-wiring for FKB

- High metal

concentration at the

bifurcation carina


2006;46:1446-1455.


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


- Covers proximal

lesions


2006;46:1446-1455.

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


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


2006;46:1446-1455.

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

Combined Crush experience:

Milan and Rotterdam

231 pts,

241 de novo bifurcations

Hoye A, Iakovou I, et al. JACC 2006

ST=4.3%

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

J-Reverse: OCT substudy-Kobe

J-Reverse: Thrombus attachment

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

Clinical outcomes at 12 month FU

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

Intimal growthSymmetrical vs. Asymmetrical expansion

Impact of struts malapposition on flow

DiMario EBC 2012

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

OCT guidance of distal cell recrossing in

bifurcation crossing: choosing the right cell

mattersN= 52 pts

EuroIntervention.2012;8(2):205-13

Stenting Technique (n = 139)

80 % single stent for distal lesions

n

Courtesy O Darremont

%

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

French left main Taxus Registry:

5-y outcomes: 1 vs. 2 stents

Mylotte et al Eurointervention 2012

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

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

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

Several techniques

ISAR LM late outcome / technique

Mehilli et al JACC 2009

Sequential SB-MV 2 Step dilatation can be used

instead of Kissing Balloon after Provisional

Stenting of Bifurcations

N.Foin EBC 2012

Results KB vs SB-MV sequence

N.Foin EBC 2012

Pooled data from several LM registries

Jérôme Van Rothem EBC 2012

Should we stent toward the tightest lesion?


What about the bifurcation angle?


POT or not POT?


Frequency of stent underexpansion

Kang et al CCI 2011

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

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

Recommendations Pertaining to Unprotected

Left Main Intervention in the ACC/AHA/SCAI

2011 Guidelines for PCI

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

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

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

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


2006;46:1446-1455.

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

• 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

Thank you!

Email: [email protected]

technical considerations in the treatment of left main...

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