Yuejin Yang MD, PhD, FACC, FESC Cardiovascular Institute and Fu-Wai Hospital, CAMS & PUMC

1. TRI for Challenge LM Cases with Trifurcated, Angulated and Calcified Lesions: Strategies and Techniques Yuejin Yang MD, PhD, FACC, FESC Cardiovascular Institute and Fu-Wai Hospital, CAMS & PUMC 2014 Northeast Cardiovascular Forum (NCF), Shengyang, 2014-4-25-27

2. The Advantages of TRI • Free mobile post procedure ： • Un-painful and acceptable for patients • no risk of death induced by DVT+PE！ • Less puncture site complications • no big hematoma and • less risk of hemorrhagic death！ • Much less care work needed • Save human resources • No occlude device and short hos. stay: • cost less

3. Numbers of PCI in Each Year @ Fu Wai 2011: PCI case No: 10649, Radial 90.8%（9673/10649) TRI from <1% in 1998 to >90% in 2011 with the very low mortality rate of just 0.05% in elective PCI

4. New Techniques Currently Used for Complex Lesions For CTO: final stronghold antigrade approach retrograde approach For LM: high risk one-stent techniques two-stent For bifurcation: complicated One stent technique Two stent technique DK crush Culottes SKS Provisional T TAP

5. New Techniques for Complex Lesions in TRI Practice For CTO: anti-grade approach retro-grade approach？ For LM: one-stent technique two-stent techniques For bifurcation: one-stent technique two-stent techniques step DK crush step DK inverse crush step culotte step kissing stent Provisional T TAP

6. Clinical Evidence: Support of LM PCI Clinical trial indicative of safty and efficacy DES vs BMS DES vs CABG Randomized clinical tial DES vs CABG PES （Taxus） : SYNTAX SES（ Sirolimus） : PRECOMBAT Guidelines: IIb indication

7. LM PCI Strategic Determinations • PCI vs CABG risk evaluation & selection • PCI itself strategies • One-stent • Two-stent • Crush or step crush • Cullotte • T or provisional T • Kissing or step kissing • Principal: safety first !!!

9. LM PCI by TRA: Technical Considerations Experienced operators in both TRI & LM lesion Pre-determined strategy Cardiac surgery stand-by and support Emergency measures during procedure : device and drug Pre-IABP (not stand-by): routine use for high risk patients Routine IVUS check after procedure Post-procedural monitoring (CCU)

10. TRI fo Challenge LM Cases ? • With complex lesions of • Trifurcation • Angulations • Calcification • Challenges and risks • At even higher risk • More complicated • Technical demand and challenging • Technical feasible ?

11. Anatomy of LM Trifurcation • Distal LM + • Two plus • Two: Ostium of LAD and LCX • Plus: involving the ostium of: • Ramus • Dia. In Pro. LAD • OM in Pro. LCX • The combination of above three

12. The Principles and Strategies in TRI of LM Trifurcation • No side branch acute closure • No three-stent strategy • Avoid of three-balloon kissing • Two-stent strategy reasonable and even optimal • Routine branch protection with wire • Pre-dilatation of the branch if needed • Post-ballooning and kissing if needed

13. LM Calcification and Angulations • Calcification involving: • Distal LM • Prox LAD • Prox LCX • Angulations between: • LM and LAD or LCX • Nearly 90 degrees or more

14. Case-1: TRI for LM Trifurcation • Mr. Li Shimin, Male, 77yrs • Transferred to FuWai Hospital from Provincial Hospital • IABP support & 3 Pilot wires • Two-stent reverse crush strategy in Feb. 8, 2012 with wire protection while without pre-dilatation of ramus • Excel 3.5mm*14mm & 4.0mm*18mm stents deployed

15. Baseline CAA: LM Trifurcation with Left Dominance

16. Balloon Pre-dilatation with Wiring Side Branch Protection

17. Stenting of LAD and Balloon Crushing

18. Stent Crushing from LCX

19. Rewiring & Re-ballooning 1.25mm ballooning & then 3.5mm High Pressure Ballooning

20. Sequential High Pressure Ballooning & Final Kissing

21. Final Results

22. Case-2 TRI for LM Trifurcation • Mr. Zhao Yushu, Male, 66yrs • File No: 395732 • Done on Mar. 7, 2012 • Two-stent reverse crush technique with wires protecting and balloon pre-dilatation the branches • Branch balloon post-dilatation and final kissing

23. Baseline CAA LM Trifurcation equivalent (two OMs in Pro. LCX)

24. Three Wires Protection and Balloon Pre-dilatation Pre-dilatation of Trifurcation

25. LAD Stenting with Balloon Crushing Resolute 3.0mm*15mm

26. LM-LCX Stent Crushing of LAD Stent LM-LCX: Resolute 3.5 by 24 mm

27. Rewiring & Re-ballooning 1.25mm ballooning & then 3.0mm high pressure ballooning

28. Sequential High Pressure Post-dilatation and Final Kissing

29. Rewiring & Re-ballooning the OM2 With 1.5mm & 2.5mm ballooning

30. Final Kissing of LM Bifurcation Again Final kissing again with 3.0mm & 3.5mm Quantum Maverick

31. Final Results

32. Case 3. LM Trifurcation Lesion • Mrs. Xue X L, 64 yrs • Unique No: 902447 • LM trifurcation lesion involving the ostium of LAD, ramus and LCX • Step crush technique with LM-LAD and ramus and just ballooning in LCX was performed on April 16, 2014 • Final results acceptable

33. Baseline CAA: LM Trifurcation Lesion

34. 3 Wires for Protection Each of Vessels

35. Ramus Ballooning and Stenting

36. Ballooning LCX

37. LAD & LCX Stenting

38. LAD Balloon & stent Crushing

39. Rewiring & Reballooning

40. Sequential HP Ballooning

41. Final Balloon Kissing with Low Pressure

42. Final Results

43. LM Bifurcation with Angulations of LCX or LAD • Challenges and risks • LAD or LCX ostium wiring problems • Unsuccessful • At the risk of acute closure of leading to • AMI • Cardiogenic shock • CV collapse even death

46. Case-4:Euro PCR 2012 Live Transmission case to Main Arena from Fuwai Hospital • Mr. Cong Xin Fang, 50yrs old • Baseline: CAG: LM Bifurcation lesion • Previous PCI: 2 times • SYNTAX score: 22 • Euro score: 2 • Real technical challenge even tough case • Wiring problems solved at 20 min of the procedure: • Plot 50 to 150 • “J” curve to “s” curve reshaped tip • Time: 55mins

47. Baseline CAA: LM Bifurcation lesion without visible entry channel at the LCX orifice

48. Wiring with Pilot 50 to LAD easily,but very difficulty into LCX

49. 20mins later, Wiring with Pilot 150 and the “S” shaped type tip into LCX gradually and successfully

50. Final Results (1)