Still a place for complex strategies in complex lesions?

1. Still a place for complex strategies in complex lesions? Dr Terje K. Steigen, University Hospital of Northern Norway Tromsoe, Norway

2. The MEDINA classification Medina A. et al., Rev Esp Cardiol 2006;59(2):183-4

3. In the era of DES, do we have an ideal two-stent method for bifurcations? • The answer is NO • And, we do not know which of the different two-stent methods that gives the best result on a long term basis

4. Crush Technique and IVUS • The majority of SB lesions showed stent underexpansion. • Incomplete Crush / -apposition was common. • Stent underexpansion seen by IVUS was not detected by angiography. Costa et al., J Am Coll Cardiol 2005;46:599-605

5. Crush-stenting

6. Crush-stenting Triple layers Under- Expansion? Final result Final kissing balloon

7. Culotte-stenting

8. Culotte-stenting Double layers Limitations due to stent cell diameter? Final kissing balloon Final result

9. Stent cells may be expanded up to almost 3.0 mm Picture taken by Boston Scientific. **Based on internal measurements of N =7 3.0 x 16 mm TAXUS™ Liberté™ Stents and N =7 3.0 x 18 mm Cypher Select™ Stentsconducted by Boston Scientific. Bench test results may not necessarily be indicative of clinical performance. ***The inside circle represents the diameter that a Cypher Select™ stent can be expanded to

10. T-stenting

11. T-stenting Area of incomplete stent coverage Final kissing balloon Final result

12. Distal LM/CX/Ramus. 3Cypher-stents with crushing Courtesy of Dr. Gary Mintz, TCTMD

13. 2 months later Courtesy of Dr. Gary Mintz, TCTMD

14. Higher risk of stent thrombosis? • Premature withdrawal of antiplatelet tx. • Local hypersensitivity reaction • Ostial and/or bifurcation stenting • Malapposition/incomplete apposition • Restenosis • Stent-strut penetration into necrotic core Joner et al., JACC 2006;48:193-202

15. Sidebranch-lesions are usually short 1) Gobeil et al., Am J Cardiol 2001, 2)Lefèvre et al., Am J Cardiol 2003, 3) Colombo et al. Circulation 2004

16. One-stent Technique Sufficient stent coverage of short SB-lesion Dilatation through main vessel stent +/- kissing balloon PTCA-balloon through main vessel stent Side branch balloon removed

17. Before tx. From the Nordic Bifurcation Study, Courtesy of Dr. Leif Thuesen. • Treatment: • Wiring of LAD and D1 • D1 dil. With 3,5 mm balloon • Stenting of LAD (8 mm Cypher) • Rewiring of D1 through stent • Jailed D1 wire removed • Postdil. of stent with 4 mm balloon

18. After tx. Courtesy of Dr. Leif Thuesen

19. After 8 months.

20. After 8 months.

21. The Spanish Bifurcation Study (n=91)6 Months CAG follow-up in 88%Percent binary restenosis rate % % Main vessel Side Branch Pan M, et al. AM Heart J. 2004;148:857-64

22. The Nordic Bifurcation study • The purpose of the ”Nordic PCI study group” is to conduct academic randomized clinical trials and to optimize treatment in the Nordic and Baltic countries • The first bifurcation study randomized 413 pts. to stenting of main vessel only or stenting of both main vessel and side branch • The primary endpoint was MACE, cardiac death, MI, TVR or stent thrombosis after 6 months

23. Individual endpoints after 6 months Primary endpoint, n.s.

24. CCS angina class 0-1

25. Procedural data

26. Treatment principles in the “optional stenting of side branch group”(MV) in the Nordic Bifurcation Study • Stenting of main vessel • Side branch dilatation if TIMI flow < 3 • Side branch stenting only if TIMI flow = 0 after dilatation

27. Procedural data

28. MV+SB (n=206) 29% 50% 21% Kissing balloon 74% Tx success 95%

29. The available data support the simple strategy with stenting of main branch and provisional stenting of the side branch in most situations. The data, however, does not contradict the use of a complex stenting strategy in special situations, e.g. very large side branches Conclusion

30. Thank you!