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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3585_Библиотеки_им_академика_М_И_Перельмана
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4.4 Stenting Strategy andProcedure
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4.4.5.2 Practical Culotte Stenting
Additional stenting with KBI is all that is required to accomplish culotte stenting. When performing two stenting of the
LM bifurcation, the aim is to completely eliminate SB jailing
by the rst stent. Note that to completely eliminate SB jailing, rewiring of the SB should be performed through the most
distal cell at the carina and then KBI should be repeated.
If the LM has a large diameter and if a Nobori 3.5-mm JV
stent has been implanted in the LAD, you should also implant
a Nobori 3.5-mm JV stent in the LCX. If the LCX diameter is <3.5mm, the stent should be deployed by inating
the SDB at a low pressure such as 4 to 5atm. Subsequently,
high-pressure post-dilatation should be performed with a
balloon of the optimal size. When provisional culotte stenting is performed, it is ideal to limit protrusion of the SB stent
to a distance of 6 to 8mm into the MB (LM) lumen so as
to minimize overlap between the two stents in the proximal
MB (LM). You should position the POT balloon accurately
to ensure safe and effective POT.If the POT balloon position
is too proximal, it will have little effect when inated, while
the balloon may over-dilate and damage the ostium of the
distal MB if its position is too distal.
As stated above, it is difcult to accurately position the
POT balloon at the LM bifurcation with extreme angulation
of the LAD or LCX. You do not need to worry about the
distance for which the two stents appear to overlap. The most
important objective of performing POT is to reliably achieve
dilation of at least the proximal part of the LM in order to
stabilize the stent prior to KBI.
Similar procedures apply to T stenting, except that the
kissing balloons may be inated at slightly higher pressures
after two stenting. When KBI is done in the LMT, there is
no problem with the proximal ends of the kissing balloons
protruding into the sinus of Valsalva. To prevent distal dissection, the two kissing balloons should be inated with
their distal edges slightly proximal to the distal edges of the
stents. High-pressure ination of two optimally sized kissing balloons at the LM bifurcation is likely to cause dissection. Therefore, I generally limit the maximum pressure to
about 14atm when performing KBI.If a higher pressure is
required, I try to inate balloons one quarter size smaller at
pressures escalating from 20atm.
For two stenting, it is necessary to prepare the lesion suf-
ciently to eliminate the need for post-dilatation at very high
pressures. Particularly if the LM is long, insufcient preparation will lead to luminal irregularity of the rst stent, which
may prevent advancement of a second stent through it. If the
second stent is pushed forward forcibly when it becomes
blocked, the stent often undergoes deformation and then is
very difcult to advance further.
After implantation of the rst stent, POT has to be performed in the presence of a jailed guidewire and therefore
should be done by inating the balloon at a relatively low
pressure of about 14atm. If high-pressure ination is needed
to sufciently dilate the proximal MB, high-pressure POT
may be performed before KBI after SB wiring. It is likely
that high-pressure POT will smooth out irregularities in the
rst stent. If delivering the second stent into the SB is difcult, you should withdraw it and perform high-pressure POT
along with relatively high-pressure KBI.This often facilitates delivery of the stent into the SB.
The second stent may also be blocked by the carina, but
this can be prevented if KBI is performed using a guidewire
that crosses the rst stent into the LCX in contact with the
carina. However, the second stent may sometimes be blocked
by a “hard” carina. If this obstacle cannot be overcome by
various efforts, you should remove the guidewire from the
LAD and advance it into the LCX for use as a buddy wire.
Then you should attempt to advance the second stent across
the rst stent. If this also fails, you should advance a balloon along the buddy wire across the point where the stent
is blocked while slightly and gently pulling the SDB back.
If the second stent is then advanced gently, it can often be
delivered successfully.
If this technique also fails, you should inate a balloon at
2 to 4atm in the LCX to trap the guidewire along which the
stent will be delivered. Then you should advance the stent
while pulling the guidewire back slightly. After the stent has
been advanced, you can remove the buddy wire or advance it
into the LAD.If even this procedure cannot overcome stent
blockage, it is a good idea to use a GuideLiner catheter. You
should advance this catheter gently with the tip of the balloon protruding from the tip of the catheter. To facilitate passage of the catheter past the site of blockage, you should pull
the preceding balloon back slightly. You should never apply
strong force to the catheter. If this technique also fails, trapping the guidewire at a distal point by inating a balloon at a
low pressure will facilitate steady advancement of the stent.
When upfront culotte stenting is planned, the proximal
edge of either stent is always positioned in the LMT. It is
preferable to implant the rst stent from the LMT to the
LCX and the second stent from the LM ostium to the LAD,
because this order of stenting will not induce indentations of
the parts of the stents in the LM or LAD (Fig.4.24).
Even if LAD stenting precedes LM-LCX stenting, placing the proximal edge of the stent in the LMT and covering
the LM ostium with the second sent deployed in the LCX
will avoid indentation of the stent in the LM.While inverse
indentation may occur at the LAD ostium in this situation,
the extent of indentation is usually acceptable.
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ac
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4 Stenting ofLeft Main Coronary Artery (LM) Lesions
bd
Fig. 4.24 Planned upfront culotte stenting. (a) When implanting the
rst stent in the LCX, protrusion of the proximal stent edge into the LM
lumen should be limited to a distance of about 3mm. (b) After initial
4.4.6 T Stenting
POT and KBI. (c) After implanting the second stent from the LM to the
LAD. (d) After repeat POT and KBI
that for accurately placing the proximal edge of a stent at
the LM ostium. When stenting the SB, you should advance
T stenting of the LM bifurcation may be performed if the
LCX has a take-off angle of nearly 90 degrees and particularly if there is a marked difference in diameter between the
LAD and LCX (LAD > LCX). Under these circumstances,
the struts of the stent implanted in the SB will not lose their
radial strength (Fig.4.25). You should implant the SB stent
so that its proximal edge protrudes slightly into the MB
lumen. IVUS guidance may assist with accurate positioning
of the stent. The method of stent positioning is similar to
the IVUS probe along the guidewire inserted into the LAD
and should conrm that the proximal edge of the stent is
just at the LCX ostium. Since the SB stent will never cross
over the LAD ostium, there is no need to remove the IVUS
probe when inating the SDB.If it is left in the LM/LAD,
the IVUS probe will not interfere with advancement of the
stent. Because of the large angle between the SB stent and
the IVUS catheter, it is slightly difcult to visualize the proximal part of the stent by IVUS.
4.5 LM Trifurcation Stenting
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4.5.1 Stenting with(Triple) KBI
After stenting the LAD, you should perform KBI to achieve
complete stent apposition and dilate the bifurcation to its
normal diameter, as stated previously. As with bifurcation
stenting, two-link stents should be implanted and the kissing balloons should be inated at a relatively low pressure
(8–10atm) to avoid causing dissection/injury in non-stented
segments of the SBs.
4.5.1.1 Lesion Preparation
You should follow the procedure recommended for bifurcation KBI. The individual branches should be adequately
prepared to ensure that sufcient dilation can be achieved by
low-pressure balloon ination. The objectives of triple KBI
are to reduce the risk of SB compromise by plaque shift or
carina shift and to estimate the responsiveness of the distal
LM bifurcation to low-pressure balloon angioplasty. When
the LM bifurcation can be reliably expected to show low
responsiveness, you should consider performing triple KBI
with Lacrosse NSE balloons in order to optimize preparation
of the trifurcation lesion.
Fig. 4.25 T stenting. T stenting may be performed at the LM bifurca-
tion if the SB (LCX) has a take-off angle of nearly 90 degrees and if the
LCX has a small diameter
4.5 LM Trifurcation Stenting
Sometimes an additional artery arises at the bifurcation of
the LM, forming a trifurcation. If this artery has a similar
diameter to the LCX, it may be necessary to perform triple
KBI and to implant stents in all three branches.
4.5.1.2 Stent Placement
After implanting a stent in the LAD, you should perform
POT and then triple KBI according to the following procedure (Fig.4.26): (1) insert a new guidewire into the high lateral (HL) branch via the Crusade catheter; (2) perform KBI
in the LAD and the HL branch; (3) insert a guidewire into
the LCX via the Crusade catheter advanced along the HL
guidewire; and (4) perform triple KBI.When wiring the SB,
you should always pass the guidewire through the most distal
cell at the carina.
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4 Stenting ofLeft Main Coronary Artery (LM) Lesions
Branch 3
Branch 1
Branch 2
b
d
f
a
c
e
Fig. 4.26 Stent placement at the LM trifurcation. (a) Placing a stent in
Branch 1. (b) POT. (c). Rewiring Branch 2 with the aid of the Crusade
catheter. (d) Performing KBI in Branches 1 and 2. (e) Rewiring Branch
4.5.2 Culotte Stenting attheLM Trifurcation
If lesions in the LAD and LCX are treated by culotte stenting, the HL branch will be compressed by both the LAD stent
and the LCX stent, even if the culotte stenting is completed
with triple KBI (Fig.4.27). In other words, there will be dual
carina shift toward the HL branch. If dual carina shift is considered to be approximately double that of a single carina, it
is unlikely to be negligible, and persistent compression from
dual carina shift may well increase the risk of restenosis at
this branch.
Thus, a third stent needs to be implanted in the HL
branch when treating LM trifurcation lesions because culotte
stenting cannot prevent restenosis of the branch. An interventionalist who aims to recanalize all three branches at a
trifurcation lesion should choose trifurcation stenting rather
than culotte stenting. However, LM trifurcation stenting has
3 with the aid of the Crusade catheter advanced along the Branch 2
guidewire. (f) Performing triple KBI
been reported to achieve very poor mid-term outcomes with
regard to patency of the HL branch.
The proximal HL largely overlaps the proximal LAD/LCX
on CAG.If the HL branch is stented last, its ostium may not
be covered sufciently. Also, if triple KBI is only performed
after stenting the HL branch following culotte stenting of the
LAD/LCX, the guidewire inserted into the HL branch may
bypass the culotte stents. On the other hand, if triple KBI
is added to LAD stenting and to LCX stenting, trifurcation
stenting will achieve full coverage of the three branches and
ensure that all three stents obtain sufcient radial strength.
It is best to additionally perform triple KBI after HL stenting using the balloons maintained in the LAD and LCX.The
stent in the HL branch should be positioned with its proximal
edge protruding slightly into the LM lumen from the LADLCX carina (Fig. 4.28). IVUS can be used to conrm the
position of the proximal edge of the stent.
a
4.5 LM Trifurcation Stenting
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b
c
Fig. 4.27 Culotte stenting of various trifurcation lesions. (a) HL
branch arising from the LAD ostium. (b) HL branch arising between
the LAD and the LCX. (c) HL branch arising from the LCX ostium
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a
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4 Stenting ofLeft Main Coronary Artery (LM) Lesions
c
Fig. 4.28 Placement of the third stent in the HL branch (c, d) after culotte stenting of the LAD/LCX (a, b). With the balloons maintained in the
LAD/LCX, HL stenting should be performed, followed by triple KBI
4.6 Case Study
d
Then I manipulated a guidewire via a Crusade catheter
to insert it into the SB (LCX). Angiography showed that
This section provides an example of stenting an LM bifurcation lesion at my center.
To treat a true bifurcation lesion (Fig.4.29), I introduced
a Judkins left short-tip guiding catheter (Launcher SL4) into
the LM.
I performed pre-PCI IVUS to estimate the sizes of the target vessels, as well as the characteristics and distribution of
plaques. Attenuated plaque was found in the LAD, so I delivered a Filtrap catheter to protect the distal LAD and then predilated the LAD with a 3.0 mm balloon (Fig. 4.30a). After
simultaneously inating 3.0mm and 3.5mm kissing balloons
in the LAD and LCX (Fig.4.30b), I implanted a Nobori stent
(3.5 × 24mm) from the LM to the LAD and expanded it at a
relatively low pressure (Fig.4.30c). Subsequently, I performed
POT by inating a 5.0mm balloon in the LM (Fig.4.30d).
the wire had failed to cross the stent through the most distal
cell at the carina (Fig.4.31a), so I performed SB rewiring
(Fig.4.31b).
After simultaneously inating 3.0mm and 3.5mm kissing balloons in the LAD and LCX (Fig. 4.32), there was
residual stenosis in the LCX.Therefore, I decided to switch
to culotte stenting and implanted a Nobori 3.5-mm JV stent
from the LM to the LCX with expansion at a relatively low
pressure (Fig.4.33a). I then performed POT by inating a
5.0mm balloon in the LM (Fig.4.33b).
Next, wiring of the SB (LAD) was done via the Crusade
catheter, and I conrmed by angiography that the wire
crossed the stent through the most distal cell at the carina
(Fig.4.34a). After KBI (Fig.4.34b), the bifurcation lesion
was successfully recanalized (Fig.4.34c).
ab
ab
4.6 Case Study
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Fig. 4.29 True LM bifurcation lesion
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Fig. 4.30 KBI plus stenting of an LM bifurcation lesion. (a) POBA of
the LAD was done using a 3.0-mm balloon. (b) KBI was performed
with 3.0-mm and 3.5-mm balloons in the LAD and LCX, respectively.
LAD : POBA (3.0×20 mm) KBI :
LAD 3.0 mm×LCX 3.5 mm
8 atm
(c) A Nobori 3.5-mm stent was deployed in the LAD at a relatively low
pressure. (d) POT was performed by inating a 5.0-mm balloon in the
LM
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Fig. 4.30 (continued)
4 Stenting ofLeft Main Coronary Artery (LM) Lesions
LAD : Nobori 3.5×24 mm
8 atm
LM : 5.0×10 mm
a
Fig. 4.31 SB (LCX) rewiring via a Crusade catheter. SB (LCX) rewir-
ing was done under angiographic guidance. (a) The guidewire inserted
into the SB has not crossed the stent through the cell nearest to the
carina. (b) The SB guidewire now crosses the stent through the most
distal cell at the carina
4.6 Case Study
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b
Fig. 4.31 (continued)
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KBI :
LAD 3.0 mm×LCX 3.5mm
10 atm
Fig. 4.32 Simultaneous balloon ination in the LAD and LCX.A 3.0-mm balloon in the LAD and a 3.5-mm balloon in the LCX were inated
alternately at high pressure and then were inated simultaneously (KBI)
LCX : POBA (3.5×20 mm)
14 atm
LAD : POBA (3.0×20 mm)
14 atm
KBI :
LAD 3.0 mm×LCX 3.5 mm
10 atm
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4 Stenting ofLeft Main Coronary Artery (LM) Lesions
LCX : Nobori 3.5×24 mm
10 atm
Fig. 4.33 Culotte stenting. After implanting a Nobori 3.5-mm stent in the LCX (a), POT was performed by inating a 5.0-mm balloon in the
LM (b)
LM : 5.0×10 mm
14 atm
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