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State of the art: DES One stent only

State of the art: DES One stent only. Manuel Pan Hospital Reina Sofía Córdoba. Spain. STENT TECHNIQUES FOR BIFURCATION LESIONS. Provisional stenting T shaped stenting Inverted V technique (Kissing stenting) Inverted Y technique. Trouser-like stenting Fork stenting Culotte technique

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State of the art: DES One stent only

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  1. State of the art: DESOne stent only Manuel Pan Hospital Reina Sofía Córdoba. Spain

  2. STENT TECHNIQUES FOR BIFURCATION LESIONS • Provisional stenting • T shaped stenting • Inverted V technique • (Kissing stenting) • Inverted Y technique • Trouser-like stenting • Fork stenting • Culotte technique • Debulking + stenting • Crush … none of them has been definitively accepted. Basically, could be divided in 2 strategies: vs SIMPLE COMPLEX

  3. BARE STENT ERA: Stenting vs balloon dilation of SB (1994-2001) Pan et al. Am J Cardiol 1999; 83: 1320 Suwaidi et al. JACC 2000; 35: 929 Yamashita et al. JACC 2000; 35: 1145 38% Six-month total MACE 51%

  4. DRUG ELUTING STENT ERA: Stenting vs balloon dilation of SB (2002-05)Randomized studies Colombo A,et al. Circulation 2004;109:1244–1249. Pan M, et al. Am Heart J 2004; 148: 857-864.

  5. Treatment of bifurcation lesions with DES

  6. ESC CONGRESS Stockholm, Monday 5 September 2005 Ferrante et al.

  7. ESC CONGRESS Stockholm, Monday 5 September 2005 Ferrante et al.

  8. FAVORABLE EVOLUTION OF DISSECTED SIDE BRANCHES AFTER BALLOON DILATION Drug elution from adjacent MV stent struts???? Final immediate result Follow-up

  9. Strut position, blood flow, and drug deposition implications for single and overlapping drug-eluting stents. Balakrishnan B, et al. Circulation 2005; 111: 2958-65. …drug elution can take place in adjacent areas of the stent, even if the struts are not in contact with the vessel wall... … stents not directly apposed to the vessel wall can deliver drug to adjacent areas.

  10. RANDOMIZED COMPARISON BETWEEN Cypher & Taxus: Restenosis site. Next AHA 05 CYPHER TAXUS 1 3 4 10 3 1 1 4 1 5/53 patients (9%) 16/56 patients (29%)

  11. WHY ONE STENT ONLY ? • Comparative studies did not demonstrate a superiority of two stents over one stent and balloon dilation of the side branch. • In terms of TLR there was a tendency in favour of patients treated by one stent.

  12. THE UNPREDICTABLE FATE OF SIDE BRANCH • Everything change during the procedure. • Whatever the basic anatomy, plaque shift is common and unpredictable. • Angulation changes after SB wiring. • Uselessness of classifications. TECHNICAL ARMAMENTARIUM ACCORDING WITH THE OBTAINED PARTIAL RESULTS STEPWISE APPROACH

  13. PREDILATION OF THE SB ORIGIN BEFORE MV STENT IMPLANTATION • Facilitates the ulterior SB access. • Helps to maintain the side branch open. • May be the a definitive procedure on the SB. 1 1 2 3 Balloon MV Balloon SB 4 3 2 3 Go further: “Provisional balloon-Provisional stent” Stent MV Post Balloon

  14. PREDILATION OF THE SB ORIGIN BEFORE MV STENT IMPLANTATION:“ a definitive procedure on the SB!!!!”. BASELINE EF= 23% Super Simple Approach: - predilation of Cx - stenting of LM. No further intervention POST Stem cell infussion ICD 8 MONTHS

  15. DISTAL LESION AT LEFT MAIN (TRIFURCATION?) Stenting LM-LAD without predilation of side branches…. …no further intervention was required.

  16. TWO STENTS MANDATORY STENT LAD BALLOON Cx BASELINE STENTS IN BOTH VESSELS

  17. WHY ONE STENT ONLY ? • Why implant an stent in a coronary segment (SB) that does not need it ?. • In the CORPAL series of 205 consecutive patients with bifurcation lesions treated with DES (June 03-October 04) the SB stenting rate was 7.3%.

  18. TWO CLOSE SIDE BRANCHES 1 LAO caudal 2 4 3 2 1 RAO 3 Post Baseline Late 4

  19. WHY ONE STENT ONLY ? • An excess of metal at the carina may produce an abnormal drug distribution and damage of the vessel wall. • Long term result of patients with several layers of stent at the carina is unknown. (Crush technique was described 2 years ago).

  20. WHY ONE STENT ONLY ? STENTING LEFT MAIN BIFURCATION • Suárez de Lezo et al (Am Heart J 2004; 148: 481-5): - Major cardiac events at a 6-month: 2% (No death). • - Stent in both vessels 4/22 (18%). • Chieffo A, et al (Circulation 2005; 111:791-5): - Major cardiac events at a 6-month: 20.0% (Death 3.5%). • - Stent in both vessels 51/61 (83%)

  21. CONCLUSIONS • 1997 First comparison one vs two stents in bifurcation lesions: ...Radical stent reconstruction seems to provide no advantages over the simpler stent jail followed by ostial side branch balloon dilation. Pan M, Suárez de Lezo J, Medina A. European Heart J 1997; 18: 888. • 2005 August 16, Editorial Comment in JACC: ...the simple approach of drug-eluting stenting of the main branch with provisional stenting of the side branch remains a reasonable option with a very acceptable profile of safety and effectiveness. Williams DO, Abbott JD. JACC 2005; 46: 621-4.

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