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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3840_Библиотеки_им_академика_М_И_Перельмана
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80
LIM AND KOO
(A)
STRESS
REST
(B)
Figure 10 (
angiogram, left circumflex ostium and the ostia of three diagonal branches seem to have significant stenosis. FFR
was 0.82 forLCx ostiumand 0.94for 1st diagonal, 0.77 for the2nd diagonal,and 0.82for the 3rd diagonal branches.
(B) A radioisotope scan after stenting shows no reversible perfusion defect at the territories of LCx and diagonal
branches.
See color insert
)(A) A casewith multiple jailed branches after leftmain to LAD crossover stenting. By
STRESS
REST
a stent into the LAD that an operator electing to place a provisional stent in the LCx despite
knowing that the lesion was associated with a negative FFR. The case in Figure 10 illustrates
that nuclear perfusion scans may not be sensitive enough to define ischemia in sidebranches
that were found to be physiologically significant by FFR. The case in Figure 11 demonstrates
that a physiologically negative FFR in a jailed ostial LCx lesion remains durable, even after 9
months of follow-up.
PHYSIOLOGIC GUIDANCE OF PROVISIONAL STENTING IN CORONARY BIFURCATION LESIONS
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81
Figure 11 (
FFR was 0.87 at a jailed circumflex artery (
was only a minimal functional late loss of 0.02 in this nontreated jailed circumflex artery.
See color insert
) Functional outcome of a nontreated jailed circumflex artery. Just after stenting,
left
). Nine months after stenting, FFR at LCx is still 0.85 (
right
). There
SUMMARY
The treatment of bifurcation lesions is complex in that it not only involves two vessels, but
multiple decision-making points are encountered during the procedure that have significant
implications. Angiography, unfortunately, remains a poor tool to guide decision making in
lesions involving the ostia of a vessel or the ostium of a “jailed” side branch. Intravascular
ultrasound has a significant role in helping the operator in the treatment of bifurcation disease,
but FFR provides real-time ability to determine ischemic significance of these lesions. More
importantly, FFR guidance as a strategy has been shown to be something that can be performed
frequently in bifurcation lesions and provide good clinical results.
TAKE HOME MESSAGES
1. FFR provides operators with an ability to determine the physiologic significance of any
coronary stenosis, and this information can be incorporated into decision making when
treating bifurcation lesions.
2. Performing FFR to interrogate ostial side-branch lesions that appear to be significant from
angiography may prove that some of these lesions are not physiologically significant.
3. Assessing angiographic abnormalities in side branchesthat are “jailed”by main vessel stents
have been proven to be a useful strategy to determine the physiologic significance of these
abnormalities.
4. “Jailed” side branches that are found to have an FFR >0.75 have been shown to have a very
low clinical event rate without further balloon or stent therapy to the side branch.
REFERENCES
1. Steigen TK, Maeng M, Wiseth R, et al. Randomized study on simple versus complex stenting of
coronary artery bifurcation lesions: the Nordic Bifurcation Study. Circulation 2006; 114:1955–1961.
2. Bech GJW, De Bruyne B, Pijls NHJ, et al. Fractional flow reserve to determine the appropriateness of
angioplasty in moderate coronary stenosis: a randomized trial. Circulation 2001; 103:2928–2934.
82
LIM AND KOO
3. Bech GJW, Pijls NHJ, De Bruyne B, et al. Usefulness of fractional flow reserve to predict clinical
outcome after balloon angioplasty. Circulation 1999; 99:883–888.
4. Rieber J, Schiele TM, Koenig A, et al. Long-term safety of therapy stratification in patients with
intermediate coronary lesions based on intracoronary pressure measurements. Am J Cardiol 2002;
90:1160–1164.
5. Tonino PAL, De Bruyne B, Pijls NHJ, et al. Fractional flow reserve versus angiography for guiding
percutaneous coronary intervention. N Eng J Med 2009; 360:213–224.
6. Furukawa E, Hibi K, Kosuge M, et al. Intravascular ultrasound predictors of side branch occlusion in
bifurcation lesions after percutaneous coronary intervention. Circ J 2005; 69:325–330.
7. Abizaid AS, Mintz GS, Mehran R, et al. Long-termfollow-up afterpercutaneous transluminal coronary
angioplasty was not performed based on intravascular ultrasound findings: importance of lumen
dimensions. Circulation 1999; 100:256–261.
8. Ziaee A, Parham WA, Herrmann SC, et al. Lack of relationship between imaging and physiology in
ostial coronary artery narrowings. Am J Cardiol 2004; 93:1404–1407.
9. Koo BK, Kang HJ, Young TJ, et al. Physiologic evaluation of jailed side branch lesions using fractional
flow reserve. J Am Coll Cardiol 2005; 46:633–637.
10. Koo BK, Park KW, Kang HJ, et al. Physiological evaluationof the provisional side-branch intervention
strategy for bifurcation lesions using fractional flow reserve. Eur Heart J 2008; 29:726–732.
5
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Elective Double Stenting for Non–Left Main
Coronary Artery Bifurcation Lesions:
Patient Selection and Technique
Luca Favero, Andrea Pacchioni, and Bernhard Reimers
Department of Cardiology, Mirano Hospital, Mirano, Italy
INTRODUCTION
The randomized controlled trials (RCTs) comparing provisional stenting to elective double
stenting (EDS) technique in patients with coronary bifurcation lesions (1–4) cannot be generalized to all patients with bifurcation coronary artery disease. In these trials, operators chose
to randomize patients who are candidates for both techniques (see Chap. 1). This means that
patients with complex coronary bifurcation anatomy (significant atherosclerosis of a large side
branch and/or severely angulated side branch origin) were not well represented in these trials.
Therefore,although provisionalstenting canbe successfullyused inthe majorityof patientswith
bifurcation lesions, there are approximately 20% to 30% of patients where the EDS technique
may be a safer approach (i.e., lower risk of procedural side branch compromise). The decision
as to when to utilize the EDS technique depends on patient’s clinical risk profile, bifurcation
anatomy, and operator experience.
INDICATIONS FOR ELECTIVE DOUBLE STENTING
Patient Selection
The use of drug-eluting stents (DES) should be considered the default strategy for EDS techniques. Patients treated with a EDS strategy should undergo at least 12 months of dual antiplatelet therapy (5). Hence,EDS should be avoided in patients who are noncompliant with their
medical regimen and who are at high risk for bleeding.
Bifurcation Lesion Anatomy
The decision to perform EDS technique depends primarily on bifurcation lesion morphology
(Fig. 1).
(a) The presence of a true bifurcation lesion, defined as a bifurcation in which both the main
(b) The SB lesion is severe and/or long (Fig. 3): Side branches
(c) The SB should supply a large amount of myocardium and it should be appropriate for
(d) A wide anglebetween the MB and the SBthat wouldbe anticipated to increase the difficulty
EDS. Specifically, the presence of features (a, b, and c) or (a, c, and d) combined are probably
The most important bifurcation morphologic features that favor an EDS technique are
branch (MB) and the side branch (SB) are significantly narrowed (≥50 diameter stenosis)
(Medina classification 1:1:1, 1:0:1, and 0:1:1) (Fig. 2) (6).
with longer lesions, compared
to those with shorter lesions, have a significantly higher risk of occlusion after stenting (7).
It is noteworthy to remind the reader that the SB lesion length in all the RCTs comparing
provisional to
trials.
stenting (diameter > 2.25–2.5 mm) (Fig. 4).
in recrossing into the SB after stenting the MB (Fig. 5).
Of course, the combination of several of these features is what determines the need for
EDS was∼5
reflecting thelower scale ofbifurcation complexity inthese
mm,
84
FAVERO ET AL.
True Bifurcation ?
YES
Side branch ostium ≥ 2.25 mm ?
YES
Is the side branch disease
beyond 5 mm from ostium ?
YES
No
No
No
Provisional
stenting
Provisional
stenting
Provisional
stenting
Elective double stenting
Figure 1 Proposed flow chart for elective double stenting.
1,1,1 1,1,0 1,0,1 0,1,1 1,0,0 0,1,0
MV
(Distal)
,,
MV
SB
(Proximal)
0,0,1
0,1
0,1
0,1
(A)
(B)
Figure 2 (A) Medina classification of bifurcation lesions.
lesions according to the Medina classification.
Source
: Adapted from Ref. 6. (B) True bifurcation
ELECTIVE DOUBLE STENTING FOR NON–LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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85
(A)
Figure 3 (A) Baseline angiography of a true bifurcation lesion involving the LAD and a large diagonal branch
(Medina 0:1:1). The SB lesion is severe and extends beyond 5 mm from the SB ostium. (B) Final result after step
crush stenting with DES.
Abbreviations
: LAD, left anterior descending; SB, side branch; DES, drug-eluting stents.
(B)
the strongest predictors for the need for EDS technique. Finally, EDS should not be performed
thrombotic
in
bifurcation lesions.
ELECTIVE DOUBLE STENTING: TECHNIQUE DESCRIPTION
When adecision has beenmade to employ EDS,several questions needto be answered: (1) How
to choose among the various techniques? (2) How to optimally perform the procedure? and
(3) Is there an evidence-base for decision making? Over the last decade, several EDS techniques
have been proposed and some of these techniques have undergone various modifications in an
(A) (B)
Figure 4 (A) Case example of true bifurcation lesion with large SB that is appropriate for EDS. (B) Caseexample
of true bifurcation lesion with small SB that is not appropriate for EDS technique.
86
FAVERO ET AL.
(A)
(B)
Figure 5 Case examples of true bifurcation lesion with narrow (A) and wide (B) angle between the MB and the
SB.
Abbreviations
: MB, main branch; SB, side branch.
attempt to make them more “user friendly” and to optimize outcomes. Although each of these
techniques has its “devotees” as well as its theoretical rational, strong evidence as to the superiority of one technique over others is lacking. Nonetheless, some techniques have been more
rigorously studied (T-technique, crush technique, culotte technique) compared to others (Vstenting, kissing stent technique). The value of any given technique should be judged based on
r
ease of performance,
r
bifurcation stent geometry (coverage, deformation), and
r
clinical outcome.
In the absence of unequivocal evidence as to the superiority of one technique over others,
the decision as to which technique to use should be driven by bifurcation anatomy, operator
experience, and the relevant contemporary evidence-base. At the end, it may well be that
optimization of final results, rather than which technique is used, is what determines clinical
outcome.
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87
(A) (B) (C) (D)
(G)
Figure 6 Diagram of the T-stent technique. (A) Both branches are wired and predilated. (B) A stent is advanced
in the SB, avoiding any stent protrusion into the MB. (C) The stent is deployed in the SB. (D) If the angiographic
result in the SB is satisfactory, the wire is removed from the SB and a stent is positioned in the MB. (E) The stent
is deployed in the MB. (F) The SB is rewired through the MB stent. (G) Final kissing balloon at high pressure is
performed.
Abbreviations
: MB, main branch; SB, side branch.
(E) (F)
T-Stenting Technique
Classical T-Stent Technique
Definition
This technique consists of implantation of a stent in the SB followed by implantation of a stent
in the MB. The SB stent does not protrude into the MB. With this technique, there is no overlap
between the MB and the SB stent struts (8).
Step by step (Fig. 6)
1. Both the MB and the SB are wired.
2. Both the MB and the SB are adequately predilated.
3. The SBstent is advanced and positionedat the SB ostium, beingcareful toavoid stent protrusion
into the MB.
4. The SB stent is deployed at nominal pressure.
5. The balloon isremoved fromthe SBand acontrol angiogram is performed.If distaldissection
or residual disease is present, a second stent is advanced and deployed in the SB. If the
angiographic result is satisfactory, the wire is removed from the SB.
6. The stent is advanced and deployed in the MB at high pressure.
7. The SB is rewired through the MB stent layers.
8. Dilatation of the SB is performed, preferably using noncomplaint balloon at high pressure.
9. Final kissing balloon at high pressure is performed by using two noncomplaint balloons of
the same size as that used to deploy the stents.
Anatomic indication
Bifurcation lesions with ∼90 degrees angle between the MB and the SB.
88
(A) (B) (C) (D) (E) (F)
Figure 7 Diagram of the modified-T stent technique. MB, main branch; SB, side branch. (A) Both branches are
wired and predilated. (B) The stents are advanced in the MB and in the SB; the stent in the SB is slightly pulled
back into the MB, just to ensure SB ostium coverage, avoiding marked protrusion into the MB. (C) The stent is
deployed in the SB. (D) If the angiographic result in the SB is satisfactory, the wire is removed from the SB and the
stent is deployed in the MB. (E) The SB is rewired through the MB stent. (F) Final kissing balloon at high pressure
is performed.
FAVERO ET AL.
Advantages
This technique is easy and not technically demanding.
Drawbacks
An angle between the MB and the SB of ∼90 degrees is quite uncommon in non–left main
coronary bifurcations. Moreover, even when the angle is ∼90 degrees, an attempt to position
the SB stent exactly at the SB ostium without protrusion into the MB is often associated with
missing the ostium. The risk of this occurrence is even higher if the angle is <90 degrees. An
unstented segment at the SB ostium may increase the risk of restenosis at this site (1). For this
reason, this technique has been largely replaced by the modified T-stenting technique.
Modified T-Stent Technique
Definition
This technique differs from the classical T-stent technique in that both the SB and the MB stents
are positioned simultaneously and the SB stent is deployed with minimal protrusion into the MB.
This techniqueguarantees the coverageof the SB ostium and issynonymous with the
minicrush
technique (9,10).
Step by
step (Fig. 7)
1. Both the MB and the SB are wired.
2. Both the MB and the SB are adequately predilated.
3. The SB stent is advanced in the SB, and the MB stent in advanced in the MB.
4. The SB is slightly pulled back into the MB to ensure SB ostium coverage with avoidance of
marked protrusion into the MB.
5. The SB stent is deployed at nominal pressure.
6. The balloon is removed from the SB and a control angiogram is performed. If distal dissection or residual disease is present in the SB, a second stent is advanced and deployed in
the SB. If the angiographic result is satisfactory, the wire is removed from the SB.
7. The MB stent is deployed at high pressure.
8. The balloon is removed from the MB and a control angiogram is performed.
9. The SB is rewired through the MB stent at the distal part of the SB orifice.
10. The SB stent is postdilated, preferably using noncomplaint balloon at high pressure.
11. Final kissing balloon inflation at moderate pressure is performed by using two noncomplaint balloons of the same size as that used to deploy the stents.
Anatomic indication
This technique can be used in almost all true bifurcation lesions but
to 90 degrees (Fig. 8).
close
is preferable if the angle is
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(A) (B)
89
(C)
(D)
(E)
Figure 8 Case example of the modified T-stent technique (synonymous with the minicrush technique). (A and
B) Baseline angiography showing a true bifurcation lesion of a large OM branch of a dominant LCx in the caudal
RAO and in the cranial RAO view, respectively. Chronic total occlusion of the LAD is also present. (C) After
predilatation of both branches and positioning of two stents, the stent of the SB,
(
closed arrow
SB, the balloon and the guidewire are removed from the SB and the stent is deployed in the MB (Cypher 2.5 ×28
mm). (E) After rewiring of the SB, kissing balloon with 3.0-mm noncompliant balloon in the MB and with 2.5-mm
noncompliant balloon in the SB branch is performed. (F and G) Final result in the caudal RAO and in the cranial
RAO view, respectively.
side branch; RAO, right anterior oblique.
), is deployed (Cypher 2.5 × 13 mm). (D) After angiographic confirmation of optimal result in the
Abbreviations
: LCx, left circumflex artery; OM, obtuse marginal; MB, main branch; SB,
minimally protruding into the MB
(
Continued on page 90
)
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