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Shunt Stenting Technique for Bifurcation Lesions: An Australian Perspective

This article discusses the Shunt Stenting Technique for bifurcation lesions, providing a step-by-step guide and sharing the results of a clinical trial. The technique aims to protect the main vessel while ensuring complete coverage with DES and facilitating final kissing inflation.

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Shunt Stenting Technique for Bifurcation Lesions: An Australian Perspective

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  1. Bifurcations – An Australian Perspective

  2. Background - Bifurcations • Accounts for 15-20% PCI case-load - challenging procedures • Optimal strategy remains controversial in era of DES • Lack of stent coverage at bifurcation predictive of restenosis however multiple stent layers unfavourable • Final simultaneous kissing inflation important with two stent technique

  3. Background Goal was to devise a technique that was: • Simple and reliable • Always protects main vessel • Does not compromise main vessel with stent overlap • Applicable to DES permitting complete coverage • Facilitates final kissing inflation

  4. Shunt - Basic Premise Two stent technique • A Modified T stent Technique – SB stent deployed first. ALWAYS high pressure final kiss after MV stent implantation • Optimal SB stent positioning achieved by deploying stent purposefully into MV and then MOVING (“shunting”) stentdownstream by balloon inflation in main vessel

  5. Shunt Technique (1) Wire both SB & MV

  6. Shunt Technique (2) Predilate both vessels

  7. Shunt Technique (3) Initially deploy stent at low pressure (6 atm) - note stent projects into MV to ensure ostial coverage Position SB stent projecting back into MV with MV protected by uninflated NC balloon

  8. Shunt Technique (4) Several cycles performed Inflate MV balloon to push SB stent down into optimal position. This tends to conform back end of stent. Note balloon left in SB stent to restore stent symmetry. Several sequential inflations performed, then stent locked by high pressure inflation.

  9. Shunt Technique (5) Once SB stent is positioned and locked by high pressure inflation, the MV stent is taken down into position. The SB wire is often initially left as a buddy wire in case a corner of SB stent catches MV stent. This wire is removed and MV then stented at high pressure. SB then rewired and final high pressure kiss at bifurcation (NC balloons).

  10. Shunt Technique (6): Post Kiss Maintenance of stent geometry with bifurcation coverage – avoid of multiple stent layers Catheter Cardiovasc Interv 2004;63:474-81

  11. Shunt Results with Medtronic Stents Shunt performed by Medtronic engineers in bench model - confirming side branch stent maintains normal geometry with good ostial coverage

  12. Shunt Stenting – IVUSOptimal Stent coverage at SB ostium MV distal SB proximal MV proximal Catheter Cardiovasc Interv 2004;63:474-81

  13. REWIRE Trial - #1

  14. REWIRE Trial - #1

  15. REWIRE Trial - #1

  16. REWIRE Trial - #1

  17. REWIRE Trial - #1 6mths

  18. From October 2002 - August 2006, a total of 254 de novo bifurcation lesions in 239 patients were treated by the technique of Shunt stenting using DES at the Prince of Wales Hospital Patients were enrolled in a non-randomised prospective registry evaluating the safety and efficacy of Shunt stenting as a novel approach to bifurcation disease Study Design I - REGISTRY

  19. Clinical follow-up at 30days, 6 and 12 months after PCI End-points – Death, MI and revascularization Angiography as dictated clinically Clopidogrel and Aspirin – combination > 6 mths Side branch > 2.0mm No anatomical exclusions (calcium, tortuosity, thrombus, LMS all acceptable) No pre-specified angle between main and side-branch Study Design II

  20. Baseline Clinical Characteristics Patients/lesions 239/254 Age (yrs) 67 (37-87) Gender (male %) 83 Hypertension (%) 73 Current/exsmoker (%) 31 LVEF (%) 46±5 Diabetes (%) 26 Hyperlipidaemia (%) 82 CABG (%) 15 PCI (%) 23

  21. Indication for Intervention NSTEMI/UAP 65% STEMI 3% SAP 32% NSTEMI/UAP SAP STEMI

  22. Bifurcations Lesions Treated Medina Classification % lesions 1,1,1 39 1,0,1 32 0,1,1 17 1,1,0 7 1,0,0 3 0,1,0 1 0,0,1 1 88%

  23. Baseline Lesion Characteristics - Location LAD/diagonal 63% Circumflex/marginal 21% LMS bifurcation 8% RCA bifurcation 7% Sub-branch 1% Lesions (n=254) LAD/diagonal Circumflex/marginal LMS RCA Sub-branch

  24. Baseline Lesion Characteristics - QCA Main Vessel Side-branch Reference vessel size (mm) 2.9±0.6 2.1±0.4 Minimal luminal diameter (mm) 0.8±0.5 0.7±0.3 Diameter stenosis (%) 72±16 65±13 Lesion length (mm) 19±8 10±7

  25. Procedural Details • Stent Utilization - • SES 81% • PES 12% • ZES 7% • Stents/lesion 2-5 (mean 2.8) • GP IIb/IIIa use – 73%

  26. Procedural Results (1) – Main vessel Stent delivery 100% Angiographic success 100% Post procedural residual stenosis proximal 5±2% distal 10±8% Dissections needing stents (n=16) 6% Initial proximal stent “catch”† (n=19) 7% † all cases solved by further and more aggressive shunt dilatations

  27. Procedural Results (2) – Side-branch • Stent delivery 100% • Angiographic success 100% • Post procedural residual stenosis (%) 13±9 • Dissections needing stents (n=13) 5% • No final simultaneous “kissing” inflation (n=11) 4% • unable to re-cross with wire in 2 cases • unable to re-cross with balloon in 9 cases • “Undershunting” (n=6) 2% • “Overshunt” with poor ostial coverage (n=14) 6%

  28. Results - Inhospital Outcomes Procedural success (both vessels) 100% Death 1 (0.4%) MI 3 (1.2%) TVR 2 (0.8%) MACE 4(1.6%) Acute stent thrombosis 1 (0.4%) Periprocedural TnI rise 42(17%) Non-fatal stroke 1 (0.4%)* *CVA at 48hrs after PCI

  29. Results – Follow-up at 12 months (1) 237/239 pts Death 4 (1.6%) Myocardial Infarction 8 (3%) Target Vessel Revascularization 13 (5.1%) PCI 11 CABG2 Accumulative MACE 21 (8.3%)

  30. Results – Follow-up at 12 months (2) 237/239 pts Cardiac death 3 (1.2%) Subacute stent thrombosis 2 (0.8%) Late stent thrombosis 1 (0.4%) Clinical Restenosis 15 (5.9%) MB 2 SB 11 Both 2 TLR 11 (4.3%) Freedom from MACE 91.7%

  31. Location of Restenosis • 1.2% in-stent restenosis in the • main-vessel • 4.7% in-stent restenosis in the • side branch (all ostial) – • “overshunt” or no final kiss 7/12 • Both (2) subacute stent • thromboses occurred at SB origin • - no final kiss and both • “undershunted” (ie crush) 12 2 1 Angiography n=86 lesions at 56 mths

  32. Summary I Technique of Shunt stenting with DES for bifurcation lesions is associated with excellent (100%) procedural success – no cases of failure to deliver stents no side branch loss low in-hospital MACE (1.6%)

  33. Summary II Shunt stenting for bifurcation disease with DES was associated with a low rate of; - late clinical events (MACE 8.3%) - clinically driven revascularization (TVR 5.1%, TLR 4.3%)) - subacute/late stent thrombosis (1.2%) - “clinical” restenosis in “parent vessel” (1.2%) - “clinical” restenosis in either vessel (5.9%) Patient population with high proportion of diabetics (26%) and the majority with true bifurcation disease

  34. Conclusions • Shunt stenting with DES is a safe and highly effective method for the treatment of complex bifurcation lesions • Strict attention to technical aspects of “Shunting” may improve clinical outcomes with this approach- Failure to perform final simultaneous balloon inflation and “over-shunting” was associated with increased risk of SB restenosis “Undershunt” (or crush) was associated with SB subacute stent thrombosis • Await the results of the Randomised Re-Wire Trial

  35. Thankyou

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