Insight of Various Bifurcation Stenting Techniques ... - summitMD.com
Insight of Various Bifurcation Stenting Techniques ... - summitMD.com
Insight of Various Bifurcation Stenting Techniques ... - summitMD.com
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Left Main & <strong>Bifurcation</strong> 2008<br />
<strong>Insight</strong> <strong>of</strong> <strong>Various</strong> <strong>Bifurcation</strong><br />
<strong>Stenting</strong> <strong>Techniques</strong> from<br />
Bench Testing<br />
Yutaka Hikichi, M.D.<br />
Saga University School <strong>of</strong> Medicine<br />
Saga, Japan<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Treatment <strong>of</strong> <strong>Bifurcation</strong> Lesion with two stents<br />
Do you really need just one stent ?<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Do you really need just one stent ?<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Three-dimensional images generate<br />
by Computer Tomography<br />
•Crush stenting<br />
•Modified T-stenting T<br />
•Provisional T-stenitng T<br />
•Culottes stenting<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
This is the Crush stenting<br />
Side branch stent<br />
implantation<br />
18atm 60sec<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Main Vessel stent<br />
implantation.<br />
SB stent is<br />
crushed by MV<br />
stent.<br />
18atm 60sec<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
KBT<br />
To get better<br />
opening <strong>of</strong> SB<br />
ostium.<br />
18atm 60sec<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Final image<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 1<br />
3×3mm<br />
post KBT<br />
3 layer<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Modle1: Good result <strong>of</strong> the Crush<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 2<br />
4×3mm<br />
post KBT<br />
3 layers<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
post KBT<br />
Model 2<br />
4×3mm<br />
Side branch strut<br />
Jailed side branch<br />
post KBT<br />
Main branch strut<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Which wire is the best choice?<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Which choice is the best? Liberte<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
An in<strong>com</strong>plete treatment<br />
results in a malformed crush<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Conclusion1: Crush stenting<br />
• 3 layers <strong>of</strong> strut remain in the<br />
main vessel.<br />
• Even after LBT, the results are not<br />
constant.<br />
• This technique has a high risk <strong>of</strong><br />
in<strong>com</strong>plete apposition on the side<br />
branch ostium.<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Modified T-stenting<br />
(Mini Crush stenting)<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 3<br />
Step 1<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 3<br />
Step 2<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 3<br />
Step 3<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 3<br />
Final<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 3<br />
In<strong>com</strong>plete coverage<br />
<strong>of</strong> the ostium<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 4<br />
Step 1<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 4<br />
Step 2<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 4<br />
Step 3<br />
KBT...<br />
Guide Wire<br />
crossing through<br />
the two struts.<br />
But the Balloon<br />
dose not pass<br />
through.<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 4<br />
Final<br />
Without KBT<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Model 4<br />
2 layers without KBT<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Jailed side branch<br />
like a Crush stenting<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Conclusion2:modified T-stenting<br />
• When the angle between the both<br />
branches are approximately 90<br />
degrees, the procedure is apt to be<br />
more successful.<br />
• But if the angle is less than 90<br />
degrees, the stent <strong>of</strong> side branch is<br />
apt to be crushed or made a gap with<br />
main branch stent.<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Provisional T-stentingT<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Provisional T-stentT<br />
Liberte Ø 4.0mm × Cypher Ø 3.5mm<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
XIENCE Ø 4.0mm × Cypher Ø 3.0mm<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Culottes stenting<br />
(Y-stenting)<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Full expanded stent strut<br />
makes napkin-ring lesion<br />
Remaining strut in<br />
the vessel lumen<br />
Causes <strong>of</strong> the<br />
malapposition<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Cypher : 3.0×3.0mm<br />
3.0mm ×45°<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Cypher : 3.0×3.0mm<br />
3.0mm ×45°<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
TAXUS Liberte: 4.0×4.0mm ×45°<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Conclusion3: Culottes stenting<br />
• Culottes stenting requires more<br />
<strong>com</strong>plicated and sensitive technique.<br />
• Over size expansion be<strong>com</strong>es the cause<br />
that in<strong>com</strong>plete apposition in each side.<br />
• So that, we should not try this technique<br />
for the treatment <strong>of</strong> bigger coronary<br />
artery that exceed the size <strong>of</strong> stent.<br />
• Each platform has a different limit in size.<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Next step…<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
The new three dimensional model<br />
LMT: Culottes<br />
LAD-D1: Crush<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
The new three dimensional model<br />
LMT: Culottes<br />
LAD-D1: Crush<br />
Saga Univ. Med. Cardiovascular
Left Main & <strong>Bifurcation</strong> 2008<br />
Final Conclusion<br />
• The true problem bifurcation lesion still<br />
remains one <strong>of</strong> the most challenging<br />
lesion subsets for PCI.<br />
• All DES are not the same.<br />
• It is important that we fully understand<br />
its capacities and limit when using these<br />
stents.<br />
• It is important things that we practice<br />
these examinations on a model before<br />
using in vivo for real.<br />
Saga Univ. Med. Cardiovascular