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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

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