The T-Stenting and Small Protrusion Technique for Bifurcation Lesions

The T-Stenting and Small Protrusion
Technique for Bifurcation Lesions
(TAP-Stenting)
Beijing Capital University
Beijing Anzhen Hospital
Zhou Yujie

Strategies on bifurcation lesions

DES Bifurcation Technique
Provisional side Two-stent strategy
-branch strategy
Stent implantation in the
main branch and optional
stent implantation at SB
Stent implatation at both the
main vessel and side branch
• Crush
• Provisional T-stenting
• Reverse Crush
• T stenting
• Culotte
• TAP
• SKS
• Y stenting

Nordic Bifurcation Study (n=413)
Two-stent strategy (n=206)
Stenting of the main vessel and side
413 pts with
bifurcation
lesion
Randomized
branch (MV+SB)
Provisional side-brach strategy (n=207)
Stenting of the main vessel and optional
stenting of the side branch (MV)
Primary Endpoint: Major adverse cardiac event (MACE) at 6 months

Nordic Bifurcation Study (n=413)
Primary Endpoint of MACE at 6 months (%)
p=NS
20%
10%
17.7%
12.7%
• There was no
difference in major
adverse cardiac
events at 6 months
(17.7% vs 12.7%;
p=NS)
0%
MV+SB group
MV group
Presented at ACC 2006

Nordic Bifurcation Study (n=413)
Procedure Related Myocardial Infarction (%)
15%
13%
10%
p=0.008
• Procedure related
MI was defined as a
five-fold fold elevation of
biochemical
markers
5%
0%
MV+SB group
4%
MV group
• Procedure related
MI occurred more
than three times as
often in the MV+SB
group (13% vs 4%;
p=0.008)
Presented at ACC 2006

Current opinions on PCI for bifurcation disease
Optimal treatment of bifurcation disease has yet to
be established
The two-stent strategy offer no clinical advantage
compared with the provisional side-branch strategy
Provisional side-branch strategy is the most commonly
adopted technique

Provisional side-branch strategy
Provisional T-stenting
Reverse Crush
TAP
• A sizable proportion of patients does require a stent
on SB even if the intention is to try to avoid it
• In TULIP study, a 34% rate of SB stenting has been
reported (Brunel P, et al. Catheter Cardiovasc Interv
2006;68:67-73)

The probelms of provisional T-stenting
Bench Testing of provisional T-stenting
A
B

The probelms of provisional T-stenting
It was difficult to place the side-branch
stent precisely
Deployment too distally leaves large
gaps, which may lead to
may lead to incomplete coverage
of the ostium of the SB
Deployment too proximally potentially
obstructs the main branch

The probelms of Reverse Crush
Bench Testing of Reverse Crush

Disadvantages of Reverse Crush
• Accumulation of stent struts at the ostium of SB
which could increase the risk of stent thrombosis
• The need to re-cross multiple struts with a wire and
balloon makes the procedure more laborious

Model presentation of TAP technique

TAP technique
Wire both branches
and predilate
Deploy stent in
main branch

Wire side branch and
dilate
Kissing balloon

SB stent
positioning
SB stent is
deployed with the
uninflated balloon
into the MV

The balloon of
the SB stent is
slightly retrieved
and aligned to
the MV balloon
Final kissing
balloon

In vitro TAP stenting
Perfect coverage of the
bifurcation with
minimal stent’s struts
overlap at the proximal
part of SB ostium

IVUS Image
IVUS
image of
the main
branch
showing
neocarina
about 3
mm in
length

Advantages of the TAP technique
Complete coverage of the vessel
wall including the ostium of the SB
Reduce the risk of SB ostium restenosis
Without large multiple stent layers
Reduce the risk of stent thrombosis

Differences between the Mini-
Crush and the TAP technique

Mini-Crush is not a provisional side-branch strategy!

Differences between the Reverse
Crush and the TAP technique

Reverse crushing technique
Wire both
branches and
predilate
Deploy stent in
main branch

Wire side branch and
dilate
Position stent in side
branch protruding
in MB (3-5mm),
leave a balloon in
MB

Deploy stent in
the side branch
and remove wire
and balloon
Crush the
protruding part of
SB on top of the
stent in MB

Rewire the side branch
and perform highpressure
dilatation
Kissing at medium
pressure

6F
Tips and tricks
Size of Guiding Catheter
7F
8F
0.070”
0.071’’
0.078”
0.088”
MV balloon shaft profile + SB stent shaft profile
≤5.3F
5.4F ~5.9F
≥6.0F
GC
6 F 7 F 8 F

球 囊 种 类
(≤3.5mm)
推 送 杆 外 径
Maverick 2 2.0F
Ryujin 2.5F
SeQuent 2.5F
Avita 2.55F
Sprinter 2.6F
Crosssail 2.6F
Kingou 2.6F
Aqua T3 2.7F
Powersail 2.9F
AVION
2.8F
Extensor
3.0
Voyager
2.7
Grip
2.6
CTO
2.5
6F 导 引 导 管 进 行 球 囊 对 吻 技 术
6F 导 引 导 管 的 内 径 :0.070〞
0.071)
5.4F>0.070″>5.3F
6F 导 管 完 成 对 吻 扩 张
两 球 囊 推 送 杆 外 径 之 和 应 ≤5.3F

选 用 导 引 导 管 :6F JL 3.5
球 囊 外 径 :2.9F+2.6F=5.5F
6F 导 管 内 径 :0.070 inch

Tips and tricks
The optimal visualization of the stent is important
for the precise positioning of SB stent, so stent with
higher radio-opacity (such as Cypher) is preferable
Good expansion of the MV stent and optimal
predilation of the SB ostium could facilitate the
advancement of the SB stent

Case of TAP stenting

Coronary Angiography

6F EBU 3.5
BMW
BMW
3.0×24mm
Cypher

Kissing balloon after
rewiring of SB
Deployment MV stent
with jailed guidewire
into the SB

SB stent positioning
MV balloon
SB stent
The position of the
SB stent is
adjusted to fully
cover the proximal
part of the SB
ostium (red arrow)
while an
uninflated balloon
kept into the MV

SB stent deployment
SB is deployed with
the uninflated
balloon into MV

Final kissing balloon
The balloon of the
SB stent is slightly
retrieved and
aligned to the MV
balloon
Final kissing balloon
SB stent’s balloon
+ MV balloon

Final Result

Clinical study of TAP
Burzotta F, et al.
Catheterization and Cardiovascular
Interventions 2007, 70:75–82

Angiographic characteristics
Target lesion n=61
Distal LM 26
LAD/diagonal 28
LCX/OM 5
RCA/descending posterior 2
Angulation between main and side-branch
Angle70° 26

Procedure characteristics
Approach
Transradial 24
Transfemoral 37
Guiding catheter size
6 Fr
2
7 Fr 25
8 Fr 34
Procedure time
112±52min

Clinical outcome (9 month)
MACE 4 (6.6%)
Death 1 (1.6%)
Myocardial infarction 0
TLR 3 (4.9%)
Stent thrombosis
Definited 1 (1.6%)
Suspected 1 (1.6%)
Patients without MACE 56 (91.8%)

Thank you
for your attention!