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CENTRO
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29th ANNUAL SCIENTIFIC SESSIONS – SCA&I
CHICAGO, IL – MAY 10-14, 2006
Main Session - Drug Eluting Stents
Bifurcation lesions
Antonio Colombo
Centro Cuore Columbus Milan, Italy
S. Raffaele Hospital Milan, Italy
Columbia University, NY, USA
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Conflicts:
Minor stock holder in Cappella Inc.
Manufacturing side branch stent
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1 or 2 stents?
A) If the side branch is significantly diseased at
its ostium or nearby, it is sufficiently large to
be stented, safety and duration of PCI are an
issue: 2 stents
B) In all other conditions 1 stents and then
evaluate
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Treatment of Bifurcation Lesion with two stents
Can you really use one stent ?
Baseline
Final Result
11186/02
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Treatment of Bifurcation Lesion with two stents
Treatment
Baseline
11162/02
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Treatment of Bifurcation Lesion with two stents
Final Result
11162/02
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Crush
• Standard Crush: 7F, two stents in position together, side branch inflated
first, main branch stent crushes side branch
• Reverse Crush, used when provisional stenting requires another stent in
the side branch: 6F, main branch stent deployed first, side branch stent
is crushed against the main vessel stent with a balloon
• Inverted Crush, makes recrossing easier and improves side branch
coverage: 7F similar to Standard Crush but the side branch stent is
positioned more proximally than the main branch stent, the side
branch stent will crush the main branch stent.
• Step Crush, as standard Crush but can be done with 6F.Advance and
deploy stent in side branch
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•
•
•
•
•
•
About the side branch: wires for recrossing
and Kissing Balloon dilatation
Dilate the main vessel stent at high pressure
The original Universal Balance wire
Prowater/ Rinato (Asahi Intech wire)
Intermediate wire
Pilot 50 or 150 wire
Always perform high pressure inflation in the side
branch before doing kissing
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DES in Bifurcation Lesions
(Milan experience April 2002 – March 2005)
368
Total number bifurcations: 389
Total number of patients:
Type D
True bifurcational lesions:
Type F
Type G
60%
Bifurcations treated with Cypher stent:
Bifurcations treated with Taxus stent:
54%
46%
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DES in Bifurcation Lesions
(389 de-novo bifurcations)
Lesion location
LMT
(n=97)
25%
6%
18%
51%
LAD-diag
(n=199)
LCX-OM
(n=71)
RCA
(n=22)
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DES in Bifurcation Lesions
Stent technique
390 bifurcations
193 (49.6%)
One stent
on the MB
197 (50.4%)
Stent on
both branches
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DES in Bifurcation Lesions
Stent technique (one stent vs two stents)
Left main
(n=98)
32%
68%
= One stent only
Other locations
(n=292)
58%
42%
= Stent on both branches
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DES in Bifurcation Lesions
Stent technique (one stent vs two stents)
True bifurcations
(n=232)
41%
59%
= One stent only
Other bifurcations
(n=158)
63%
37%
= Stent on both branches
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DES in Bifurcation Lesion in 292 lesions
Two-stent techniques
NO LMT lesions
3%
7%
7%
83%
Crush
T-stent
V-stent
Culotte
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DES in Bifurcation Lesion in 292 lesions
Two-stent techniques
Left main lesions
9%
54%
Crush
T-stent
27%
10%
V-stent
Culotte
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DES in Bifurcation Lesion
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Milan Experience
Baseline Clinical Characteristics (II)
Group 1S
Group 2S
(n = 155 patients)
(n = 119 patients)
37 (24%)
24 (21%)
0.5
26.80±18.1
37.69±23.4
0.001
54±9
53±9
0.2
10 (7%)
10 (9%)
0.5
Prior MI, %
68 (54%)
41 (43%)
0.8
Unstable angina, %
49 (43%)
40 (35%)
0.7
GP 2b/3a inhibitors, %
17 (11%)
27 (23%)
0.009
Diabetes mellitus, %
SYNTAX score
LVEF, %
Prior CABG, %
P Value
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DES in Bifurcation Lesion
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Milan Experience
Clinical Follow-Up at 12 months
(n=367) All patients
Group 1S
Group 2S
(n = 185 patients)
(n = 183 patients)
Death
3 (1.7%)
5 (2.7%)
0.5
MI
(after hospital discharge)
1 (0.6%)
4 (2.2%)
0.2
TLR
18 (5.0%)
40 (11.0%)
0.002
TVR
25 (6.9%)
52 (14.4%)
0.001
Cumulative MACE
28 (7.6%)
55 (15.0%)
0.001
P Value
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DES in Bifurcation Lesion
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Milan Experience
Clinical Follow-Up at 12 months
NO left main (n=274)
SES
PES
P Value
(n = 156 patients)
(n = 118 patients)
Death
2 (1.3%)
1 (0.9%)
0.7
MI
(after hospital discharge)
4 (2.6%)
0
0.08
TLR
25 (16%)
14 (12%)
0.3
TVR
33 (21%)
18 (16%)
0.2
Cumulative MACE
35 (22%)
19 (16%)
0.2
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DES in Bifurcation Lesion
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Milan Experience
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Angiographic follow-up
(performed in 85% of lesions)
P=0.07
20
Restenosis
rate (%)
17.0%
15
10
8.6%
10.0%
6.6%
No kissing
(24%)
5
0
Main branch
Final kissing
(76%)
Side branch
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Angiographic follow-up
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restenosis rate (%)
One stent only
20
P=0.03
12.0%
5.6%
4.0%
5
4.6%
15
10
P=0.04
23%
20
15
10
Stents on both branches
28%
11%
7.3%
5
0
0
Main branch
Side branch
= final kissing
Main branch
Side branch
= No kissing
DES in Bifurcation Lesion
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Milan Experience
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Stent thrombosis
3
(%)
0.5% 2.5%
2
1
0
0.5% 1.5%
0% 0.5%
1C
1C
acute
4T
1C
sub-acute
2T
1C
1C
confirmed
and late
one stent only
both branches stent
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Provisional SB stenting
Provisional Balloon – T stenting
of Bifurcation Lesions
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3
2
1
Baseline
Taxus 2.75/32: LAD
(wire protection of Septal)
Balloon: D1
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Provisional Balloon – T stenting
of Bifurcation Lesions
3 STEPS:
-stent at 15-18atm.
KISS
-stent balloon down to
8 atm.
-main branch balloon
up to 20 atm.
4
6
5
Intermediate result
• Taxus 2.5/24: D1
• Balloon: LAD
RESULT
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Provisional Balloon – T stenting
of Bifurcation Lesions
(8)
(7)
Additional Taxus at proximal LAD
(wire protection of RIM)
Final result
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Provisional Bifurcation Crush Stenting with
IVUS control
Baseline: LAD/ Diagonal
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Provisional Bifurcation Crush Stenting
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Rotablation prox/mid LAD burr 1.5mm
After Rotablation
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Provisional Bifurcation Crush Stenting
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Stenting prox LAD, Cypher 3.5/33
Result after LAD stent
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Provisional Bifurcation Crush Stenting
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Wiring SB
Dilatation SB
Result of SB Dilatation
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Provisional Bifurcation Crush Stenting
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3 STEPS:
-stent at 15-18atm.
KISS
-stent balloon down to 8 atm.
-main branch balloon up to 20 atm.
Cypher stenting at side branch ostium: 2.5/18mm
MB: Quantum Maverick 3.5 mm
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Provisional Bifurcation Crush Stenting
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FINAL RESULT
Provisional Bifurcation Crush Stenting IVUS
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controlled (Main Branch)
After Rotabltor at MB,
before SB balloon dilatation
Post bifurcation stenting
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Provisional Bifurcation Crush Stenting Final
IVUS: from MB to SB
diagonal
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Provisional Bifurcation Crush Stenting Final
IVUS: from SB to MB
LAD
Into the
diagonal
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Provisional Bifurcation Crush Stenting Final
IVUS: from MB and from SB
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LAD
dia
dia
LAD
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Ostial disease: Type B, Type 4
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V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Baseline
HSR 39456
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V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Step 1
HSR 39456
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V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Step 2
HSR 39456
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V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Final Result
HSR 39456
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Randomized study MB vs MB and SB stenting
Steigen et al ACC I2 Summit 2006
MB stenting 207 pts randomized vs MB+SB stenting 209
• Procedural and fluoro time, contrast use and biomarkers >
when 2 stents where implanted
• 6 months MACE rates < 5% in 1 or 2 stents strategy with no
difference
No report about angio FU,
We do not know how many bifurcations where “True”
bifurcations: the lesion length in the SB was 6 mm vs 16
mm in the MB
CACTUS:
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
A prospective randomized study
n = 250 patients
“ Crushing”
CYPHER™ SELECT
n = 125
de novo TRUE
bifurcation
lesions of the
native coronary
arteries
R
Pre-dilatation
Provisional T
CYPHER™ SELECT
n = 125
1- month
Clinic.
F/U
6month
Angio.
F/U
12, 18, 24- month
Clinical F/U
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Conclusions for bifurcations
• Most bifurcations need the SB to stay open at the
end of the procedure, residual stenosis appears
less relevant
1 stent strategy
Angio F-U only if clinically needed
• If optimal result on the side branch is important,
in a true bifurcation 2 stents may be needed at
least 50% of the time