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Bifurcation Stenting: Provisional
Strategy
Y. Louvard, ICPS, Massy, Quincy,
France
Busan, Korea, december 8-9, 2011
Bifurcation branching laws
D1
D2
D3
Finet’s law
D1 = 0.67(D2 + D3)
D1
D2
D3
Murray’s law
D1
3*= D2
3* + D3
3*
* 2.3
Structure-function scaling laws of vascular trees
Kassab, EBC 2009
Myocardial
mass
/ Diameter / Length
/ Flow
Mathematical model of coronary arterial tree
From G. Kassab
Provisional SB stenting
LAD2,LAD3,Dg2 0,1,0
M Main prox. first
A Main Accross side first
D Distal first
S Side branch first
Extended V
Skirt
PM stenting
MB stenting across SB
MB stenting + kissing
MB stenting + SB balloon
Elective T stenting
Internal crush
Culotte TAP
DM stenting
Provisional SKS
V stenting
SKS
Trouser legs and seat
SB ostial stenting
SB minicrush
SB crush
Syst. T Stenting
Minicrush Crush
After balloon
2 stents
3 stents
1st stent
Skirt + DM
Skirt + SB
Y. Louvard, CCI 2008 Feb 1;71(2):175-83.
Double Vs Single Stenting for Coronary Bifurcation Lesions
Kastritsis Circ Cardiovasc Intervent. 2009;2:00-00
True coronary bifurcation lesions: meta-analysis and
review of litterature
Athappan, J Cardiovasc Med 11:103–110 Q 2010
Postprocedural MLD of the side branch
Follow-up MLD of the side branch
True coronary bifurcation lesions: meta-analysis and
review of litterature
Athappan, J Cardiovasc Med 11:103–110 Q 2010
Significant Post Stenting SB Stenosis:QCA vs FFR
(jailed side branch lesions, n=94)
Bon-Kwon Koo et al JACC 2005; 46: 633-7
100 90 80 70 60 50 40
1.0
.9
.8
.7
.6
.5
Functionally
significant
stenosis
r = - 0.464
p < 0.001
Percent Stenosis (%)
Fra
cti
on
al F
low
Re
se
rve
38 % of
lesions
Proximal crossing Distal crossing
Nobori 3.5 x 24 at 12 ATM
Proximal vessel 4.5 mm, distal 3.5 mm
Nobori 3.5 x 24 at 12 ATM
Proximal vessel 4.5 mm, distal 3.5 mm
After POT technique using NC balloon 4.5 x 10
Nobori 3.5 x 24 at 12 ATM
Proximal vessel 4.5 mm, distal 3.5 mm
Final result after kissing
Gwon Circ J 2010 Sept 28
Independent Risk Factors for MACE and TLR
COBIS Registry
Medina 1,0,1 - 0,1,1 – 1,1,1
True Bifurcation Subgroup
FKBD
(n=92)
No-FKBD
(n=80)
p
8m SB ≥50% DS (%) 7.6 20.0 0.024
Nordic-Baltic Bifurcation Study III (6 m)
Non compliant high pressure balloons for
kissing
Kinoshita, EBC 2009
Jailed diagonal branch: LAD1,LAD1,Dg1 0,0,1
After balloon
2 stents
3 stents
1st stent
Inv. MB stenting across SB
MB to SB stenting + kissing
MB to SB stenting + DM balloon
Inv. Elective
T stenting
Inv. Internal crush
Inv. Culotte
Inv. TAP
DM ostial stenting
DM minicrush
DM crush
Inv. Syst.
T Stenting
Inv. Minicrush
Inv. Crush
Inv. Provisional
SKS
M Main prox. first
A Main Accross Main first
D Double
S DM branch first
Y. Louvard, CCI 2008 Feb 1;71(2):175-83.
Medina Classification
1,1,1 1,1,0 1,0,1 0,1,1
1,0,0 0,1,0 0,0,1
0, 1
0, 1
0, 1
MB (Proximal)
MB (Distal)
SB
Live Raleigh Durham
Double stenting
LAD1,LAD2,Dg1 1,1,1
Live Raleigh Durham
Double stenting
LAD1,LAD2,Dg1 1,1,1
From Peter Mortier
D1
D2 D3
D1= (D2 + D3) 2/3
Stent diameter
= DM diameter
*
*
POT
*
Stent diameter
= PM diameter
Conclusions
• The provisional SB stenting strategy is the gold standard
- For 1,1,0; 0,1,0; 1,0,1; 0,0,1
- For 1,1,1; 0,1,1 and short SB stenosis
- 3 segments with different diameters: POT
• For long SB stenosis, difficult SB access ?:
- why not systematic SB stenting after MB stenting ?
- Culotte / DK crush ?
- systematic final Kissing
Conclusions
• The provisional SB stenting strategy is the gold standard
- For 1,1,0; 0,1,0; 1,0,1; 0,0,1
- For 1,1,1; 0,1,1 and short SB stenosis
- 3 segments with different diameters: POT
• For long SB stenosis, difficult SB access ?:
- why not systematic SB stenting after MB stenting ?
- Culotte / DK crush ?
- systematic final Kissing