Đang tải... (xem toàn văn)
PCI for birfurcation lesions tài liệu, giáo án, bài giảng , luận văn, luận án, đồ án, bài tập lớn về tất cả các lĩnh vực...
Suresh G Vijan., MD., MRCP., FACC., FESC., FEISI Interventional Cardiologist Lilavati and Fortis Hospitals Mumbai., INDIA SYNTAX Bifurcation Substudy Bifurcation / Trifurcation Subset A B Prebranch (12.9%) D C Parent Vessel Only (9.6%) Postbranch E Bifurcation Ostial (39.3%) (8.0%) (13.9%) F Prebranch& Ostial (7.5%) G (8.9%) True bifurcations (D,F,G): 55.7% Postbranch&ostial *Medina Classification not available at study design Bifurcation Stent Techniques More Complex Technique Crush Culotte Kissing Less Ostial Coverage T-Stent Provisional LessComplex Technique Siegburg More Ostial Coverage Classical T stenting Classical T stenting • Indications – Bifurcation lesions with an angle between MB and SB of ~ 90 degrees • Advantages – The technique is easy, fast and not technically demanding • Drawbacks – When trying to position the SB stent exactly at the ostium without minimal protrusion into the MB the stent often misses the ostium (gap) – This technique has been largely replaced by the Modified T stenting technique Classic T-Stenting Problems Hope Elective Reality Provisional Gap Gap Variants of T-Stenting Elective Provisional Classic-T Gap Gap Variant-T Modified-T TAP Elective Modified T-Stenting Elective Modified T-Stenting Lesion Preparation V stenting A 1: Wire both branches and predilate if needed 2: Position two parallel stents covering both branches and extending into the MB - V: minimal protrusion into MB - SKS: double barrel into the MB V stenting B 3: Deploy one stent 4: Deploy the second stent Some operators deploy the two stents simultaneously V stenting Perform high pressure single stentpostdilatation and medium pressure kissing inflation with short and noncompliant balloons V Stenting Ostial LAD and LCX Disease Baseline Sequential Deployment FKI V Stenting V Stenting Courtesy of YoshinobuMurasato, MD Optimal performance of stent techniques important in reducing event rates Style or substance? Conclusions Shallow angle Crush preferred > 50* Culotte preferred =90* T stenting SKS? Ease of use Clinical trials Operator experience NCC 2010 Size of the ostium changes with the angle of bifurcation 90° 45° Courtesy P Mortier et al In a perfect world, all stent struts should be in contact with the arterial tissue • Why? – – – – To reduce the risk of stent thrombosis To facilitate subsequent stent insertion in the side branch To reduce the disturbance of the blood flow To optimize drug delivery • If the stent cells are too small, this is not possible! Mortier, EBC 2008 Siegburg NCC 2010 Dedicated Bifurcation Stents Siegburg Summary • Largely, evidence is lacking as to the superiority of one EDS technique versus others • The decision as to what technique to use should be driven by bifurcation morphology and operator experience • Although conclusive evidence is lacking, FKI should be attempted in all patients • IVUS can help optimize the results and should be used more liberally Summary • Variants of the traditional double stenting techniques have impacted ease of performance and bifurcation stent geometry Its impact on clinical outcome is yet to be proven • At the end, final results optimization rather than technique variant is the most likely factor to impact clinical outcome During provisional stenting, stent cells are distorted by PTCA Courtesy El-Jack et al ... stent 4: Check for optimal result in the SB and then remove balloon and wire from SB Deploy the MB stent Crush stenting 5: Rewire the SB and perform high pressure dilatation 6: Perform final kissing... (MB) struts into the 1st stent (SB) with a wire and perform kissing balloon inflation Culottestenting • Indication – True bifurcation lesions particularly when the MB and the SB have the same... Technique The (Mini) Crush Technique Pre dilate MB Pre dilate SB After DES placement in distal lesions (SB & MV) The (Mini) Crush Technique Sequential Stent Deployment Distal Lcxstent deployment