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Main Session - Drug Eluting Stents Bifurcation lesions

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. Conflicts:

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Main Session - Drug Eluting Stents Bifurcation lesions

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  1. 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

  2. Conflicts: Minor stock holder in Cappella Inc. Manufacturing side branch stent

  3. 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 1 or 2 stents?

  4. Treatment of Bifurcation Lesion with two stents Can you really use one stent ? Baseline Final Result 11186/02

  5. Treatment of Bifurcation Lesion with two stents Treatment Baseline 11162/02

  6. Treatment of Bifurcation Lesion with two stents Final Result 11162/02

  7. 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 Crush

  8. 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 About the side branch: wires for recrossingand Kissing Balloon dilatation

  9. Type F Type G Type D DES in Bifurcation Lesions (Milan experience April 2002 – March 2005) Total number of patients: 368 Total number bifurcations: 389 True bifurcational lesions: 60% Bifurcations treated with Cypher stent: 54% Bifurcations treated with Taxus stent: 46%

  10. DES in Bifurcation Lesions (389 de-novo bifurcations) Lesion location 25% 6% 51% 18%

  11. DES in Bifurcation Lesions Stent technique 390 bifurcations 193 (49.6%) One stent on the MB 197 (50.4%) Stent on both branches

  12. DES in Bifurcation Lesions Stent technique (one stent vs two stents) Left main (n=98) Other locations (n=292) 32% 58% 42% 68% = One stent only = Stent on both branches

  13. DES in Bifurcation Lesions Stent technique (one stent vs two stents) True bifurcations (n=232) Other bifurcations (n=158) 63% 41% 37% 59% = One stent only = Stent on both branches

  14. DES in Bifurcation Lesion in 292 lesions Two-stent techniquesNO LMT lesions 3% 83% 7% 7%

  15. DES in Bifurcation Lesion in 292 lesions Two-stent techniquesLeft main lesions 54% 9% 27% 10%

  16. DES in Bifurcation Lesion Milan Experience Baseline Clinical Characteristics (II)

  17. DES in Bifurcation Lesion Milan Experience Clinical Follow-Up at 12 months (n=367) All patients

  18. DES in Bifurcation Lesion Milan Experience Clinical Follow-Up at 12 months NO left main (n=274)

  19. DES in Bifurcation Lesion Milan Experience Angiographic follow-up (performed in 85% of lesions) P=0.07 17.0% 10.0% 8.6% Restenosis rate (%) 6.6%

  20. Angiographic follow-up Stents on both branches One stent only P=0.03 P=0.04 23% 28% 12.0% 11% restenosis rate (%) 5.6% 7.3% 4.0% 4.6% = final kissing = No kissing

  21. DES in Bifurcation Lesion Milan Experience Stent thrombosis 0.5% 2.5% 0.5% 1.5% (%) 2T 1C 4T 1C 0% 0.5% 1 C 1C 1C

  22. Provisional SB stenting

  23. Provisional Balloon–T stenting of Bifurcation Lesions 3 2 1 Taxus 2.75/32: LAD (wire protection of Septal) Balloon: D1 Baseline

  24. 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. 6 4 5 RESULT • Taxus 2.5/24: D1 • Balloon: LAD Intermediate result

  25. Provisional Balloon–T stenting of Bifurcation Lesions (8) (7) Additional Taxus at proximal LAD (wire protection of RIM) Final result

  26. Provisional Bifurcation Crush Stentingwith IVUS control Baseline: LAD/ Diagonal

  27. Provisional Bifurcation Crush Stenting After Rotablation Rotablation prox/mid LAD burr 1.5mm

  28. Provisional Bifurcation Crush Stenting Result after LAD stent Stenting prox LAD, Cypher 3.5/33

  29. Provisional Bifurcation Crush Stenting Wiring SB Dilatation SB Result of SB Dilatation

  30. Provisional Bifurcation Crush Stenting 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

  31. Provisional Bifurcation Crush Stenting FINAL RESULT

  32. Provisional Bifurcation Crush StentingIVUS controlled (Main Branch) Post bifurcation stenting After Rotabltor at MB, before SB balloon dilatation

  33. Provisional Bifurcation Crush StentingFinal IVUS: from MB to SB diagonal

  34. Provisional Bifurcation Crush StentingFinal IVUS: from SB to MB LAD Into the diagonal

  35. Provisional Bifurcation Crush StentingFinal IVUS: from MB and from SB LAD dia LAD dia

  36. Ostial disease: Type B, Type 4

  37. V Stent-Balloon Technique For bifurcational ostial lesions (IIIB and IV) Baseline HSR 39456

  38. V Stent-Balloon Technique For bifurcational ostial lesions (IIIB and IV) Step 1 HSR 39456

  39. V Stent-Balloon Technique For bifurcational ostial lesions (IIIB and IV) Step 2 HSR 39456

  40. V Stent-Balloon Technique For bifurcational ostial lesions (IIIB and IV) Final Result HSR 39456

  41. 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 Randomized study MB vs MB and SB stentingSteigen et al ACC I2 Summit 2006

  42. CACTUS: A prospective randomized study • n = 250 patients 1- month Clinic. F/U 6- month Angio. F/U 12, 18, 24- month Clinical F/U “ Crushing” CYPHER™ SELECT n = 125 de novo TRUE bifurcation lesions of the native coronary arteries R Pre-dilatation Provisional TCYPHER™ SELECT n = 125

  43. Conclusions for bifurcations • Most bifurcations need the SB to stay open at the end of the procedure, residual stenosis appears less relevant • If optimal result on the side branch is important, in a true bifurcation 2 stents may be needed at least 50% of the time 1 stent strategy Angio F-U only if clinically needed

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