Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3840_Библиотеки_им_академика_М_И_Перельмана
.pdf
90
FAVERO ET AL.
Figure 8 (
Continued
(F)
)
(G)
Advantages
This technique guarantees the complete coverage of the SB ostium while ensuring the patency
of both branches throughout the procedure. Compared to the culotte technique, there is need
to rewire only the SB and not both branches.
Drawbacks
This technique results in excess metal (triple stent layer) at the proximal MB. This requires
aggressive postdilatation at the proximal MB segment to guarantee stent apposition. Also, this
technique requires rewiring ofthe SB and recrossing it witha balloon through three stent layers,
which can be difficult, and time-consuming.
The TAP (T and Protrusion) Technique
Definition
Typically, this techniqueis used to stent the SB after a suboptimalresult in aprovisional stenting
approach. However, some haveused this approach inan EDS strategy (4).This technique differs
from all other EDS techniques in that the MB stent is deployed first followed by rewiring and
stenting of the SB, and kissing balloon inflation (11).
Step by step (Fig. 9)
1. Both the MB and the SB are wired.
2. Both the MB and the SB are predilated, if needed.
3. A stent is positioned and deployed in the MB with a jailed guidewire in the SB.
4. Kissing balloon inflation after rewiring of the SB.
5. The SB stent is positioned to fully cover the SB ostiumwith minimal protrusion into the MB,
while an uninflated balloon is kept in the MB.
6. The SB stent is deployed with the uninflated balloon in the MB.
7. After SB stent deployment, the balloon of the stent is slightly retrieved and aligned with the
MB balloon, and then final kissing balloon is performed.
Anatomic indication
technique can be used in low-to-intermediate risk bifurcations with favorable angles (avoid
This
extreme angles in either direction).
ELECTIVE DOUBLE STENTING FOR NON–LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
(G)
(A) (B) (C)
91
(D) (E) (F)
Figure 9 Angiographic images of in vitro TAP stenting. (A) Stent positioning in the MV with jailed guidewire
into the side branch (SB). (B) Deployment of MV stent. (C) Kissing balloon after rewiring of the SB. (D) SB stent
positioning: the position of the SB stent is adjusted to fully cover the proximal (or
arrow
), while an uninflated balloon is kept into the MV. (E) SB stent is deployed with the uninflated balloon into
(
the MV. (F) After SB stent deployment, the balloon of the stent is slightly retrieved and aligned to the MV balloon.
The arrow indicates the protruding side branch stent’s struts within the MV only at the distal side of the SB ostium.
(G) Final kissing balloon is performed by inflating simultaneously the SB stent’s balloon and the MV balloon.
(H) After kissing balloon, the protruding side branch stent struts are reoriented resulting in a small, single stent
struts, neocarina (
arrow).Source
: Adapted from Ref. 11.
(H)
upper
) part of the SB ostium
Advantages
This techniqueguarantees the complete coverage ofthe SB ostium without large double or triple
stent struts layers (thus differing from the culotte and the crush techniques).
Drawbacks
There are two drawbacks to this technique: (a) this technique assumes that the chances of SB
occlusion after MB stenting arezero! It also assumes that the success rate in rewiring the SB and
delivering a stent through the MB stent struts are 100%. Although these assumptions may be
true in many bifurcations, they would clearly not apply to complex bifurcation lesions (severely
angulated SBtake-off, calcifiedvessels, severelystenosed SB ostiumwith high risk of occlusion);
(b) this technique should be avoided in bifurcations with acute angles where the SB stent will
need to significantly protrude into the MB to provide complete ostium coverage.
Crush Stent Technique
Minicrush Stent Technique
Definition
The crush stent technique (12–16) consists of simultaneous advancement of the MB and the SB
stents into the vessel, followed by sequential implantation of the SB stent and the MB stent. The
SB stent is deployed first and then “crushed” by deployment of the MB stent. The minicrush
technique has largely replaced the standard crush technique to minimize the amount of metal
overlap proximal to the SB origin.
Step by step (Fig. 10)
1. Both the MB and the SB are wired.
2. Both the MB and the SB are adequately predilated.
92
FAVERO ET AL.
(A) (B) (C) (D)
(G) (H)
Figure 10 Diagram of the crush stent technique. (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 pulled back 3 mm 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. (E) The stent
is deployed in the MB. (F) The SB is rewired through the MB stent. (G) Dilatation of the SB is performed by using
noncomplaint balloon at high pressure. (H) Final kissing balloon at high pressure is performed.
MB, main branch; SB, side branch.
(E) (F)
Abbreviations
:
3. The SB stent is advanced in the SB, and the MB stent in advanced in the MB
4. The SB is pulled back
3 mm 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 should be avoided in
wide-angle bifurcation (Fig. 11).
Advantages
technique guarantees the complete coverage of the SB ostium while ensuring the patency
This
of both branches throughout the procedure. Compared to the culotte technique, there is need
to rewire only the SB and not both branches.
ELECTIVE DOUBLE STENTING FOR NON–LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
93
Drawbacks
This technique leads to the formation of three stent layers in the MB proximal to the origin of
the SB and two stent layers at the distal part of the SB ostium. This may lead to difficulty in
rewiring the SB and advancing the balloon particularly if rewiring was attempted through the
proximal aspect of the SB orifice. SB rewiring should be performed through the distal aspect of
the SB orifice.
(A)
(C)
Figure 11 Case example of the crush stent technique. (A) Baseline angiography showing a true bifurcation
lesion of the distal RCA involving the origin of large PDA and PLB. (B) Wiring and subsequent predilatation of both
branches. (C) Two stents are positioned. The stent in the PLB (SB) protrudes 3 mm into the distal RCA (proximal
MB). The stent in the RCA-PDA (MB) is placed more proximally than the stent in the PLB (SB). (D) Deployment
of the stent in the PLB (SB) (Cypher 2.5 × 13 mm). (E) After angiographic confirmation of optimal result in the
PLB (SB), the balloon and the guidewire are removed from the PLB and the stent in the distal RCA-PDA (MB) is
deployed (Cypher 2.5 × 18 mm). (F) After rewiring of the PLB, final kissing balloon with 3.5 mm balloon in the
RCA-PDA and 2.5 mm balloon in the PLB is performed. (G) Final result of the index procedure. (H) Angiographic
follow-up at nine months.
posterolateral branch; MB, main branch; SB, side branch.
Abbreviations
: RCA, right coronary artery; PDA, posterior descending artery; PLB,
(B)
(D)
(
Continued on page 94
)
94
FAVERO ET AL.
(E)
(G) (H)
Figure 11 (
Potential Failure Modes of the Crush Technique and Suggested Solutions
1. Inability to rewire the SB
a. Make sure that the wire is directed
Continued
)
towar
d the distal part, and not the
(F)
proximal part, of
the SB orifice.
b. If the primary work guidewires (BMW, Prowater, Abbott Vascular Devices) fail, try
hydrophilic wires (careful manipulation). If they also fail, then consider stiffer tapered
tip wires (Miracle wire series, Abbott Vascular Devices).
2. Inability to pass a balloon into the side branch
a. Use a
b.
compliant monorail 1.5 mm balloon.
If this balloon fails to cross, rewire the SB through a differ
ent part of the SB orifice and
reattempt balloon crossing.
c. If this also fails, then use a fixed wire balloon system.
Step Crush Technique
Definition
This is a variant of the crush technique which is used when the operator uses a 6-Fr guiding
catheter (17). In this technique, the SB stent is deployed first and then “crushed” against the
ELECTIVE DOUBLE STENTING FOR NON–LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
95
(A) (B) (C) (D)
(G) (H) (I)
Figure 12 Diagram of the step crush stent technique. MB, main branch; SB, side branch. (A) Both branches
are wired and predilated. (B) A stent is advanced in the SB and a balloon is advanced in 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.
(E) The balloon is inflated in the MB. (F) The stent is deployed in the MB. (G) The SB is rewired through the
MB stent. (H) Dilatation of the SB is performed by using noncomplaint balloon at high pressure. (I) Final kissing
balloon at high pressure is performed.
(E) (F)
vessel wallby inflation of a balloonand not by theMB stent deployment. This stepis then followed
by advancement and deployment of the MB stent.
Step by step (Fig. 12)
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 and positioned at the SB ostium, and a balloon is advanced and
positioned in the MB.
4. The SB stent is pulled back 3 mm 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. If
the angiographic result is satisfactory, the wire is removed from the SB.
7. The balloonin the MBis inflated at high pressure to crush theSB stent andis then removed.
8. The MB stent is advanced and deployed at high pressure.
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
Similar to that of the minicrush technique, but only requires a 6-Fr guide catheter (Fig. 13).
96
(A)
FAVERO ET AL.
Figure 13 Case example of the step crush
stent technique. (A) Baseline angiography
showing a true bifurcation lesion of the mid-LCx
involving the origin of a large OM branch. (B)
After wiring and predilatation of both branches,
a stent (
branch, minimally protruding into the LCx, and
a deflated balloon (
in the LCx. (C) Deployment of the stent in the
OM branch (Cypher 3 × 23 mm). (D) After
angiographic confirmation of optimal result in
the OM branch, the balloon and the guidewire
are removed from the OM branch and the
balloon is inflated in the mid-LCx (Maverick
3 × 20 mm). (E) The balloon is removed and a
stent is advanced into the mid-LCx. (F) The stent
is deployed in the mid-LCx (Cypher 3 × 28 mm).
(G) After rewiring of the OM branch, final kissing balloon with 3.0 mm balloon in the LCx and
2.5 mm balloon in the OM branch is performed.
(H) Final result.
flex artery; OM, obtuse marginal.
closed arrow
Abbreviations
) is positioned in the OM
open arrow
) is positioned
: LCx, left circum-
(B) (C) (D)
(E) (F) (G)
ELECTIVE DOUBLE STENTING FOR NON–LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
(H)
97
Figure 13 (
Continued
)
Advantages
Similar tothat ofthe minicrush technique, butcan beperformed through a 6-Fr guidingcatheter.
Drawbacks
Similar to that of the minicrush technique.
Double Kiss Step Crush Technique (Sleeve Technique)
Definition
This isa variant ofthe Step Crush techniquewith the goal
of increasing the chancesof successful
final kissing balloon inflation to further optimize the results. In this technique, the SB stent is
deployed first, then “crushed”against thevessel wallby inflationof aballoon, andthen postdilated
with kissing balloon inflation prior to deployment of the MB stent. This step is then followed
by advancement and deployment of the MB stent (18).
Step by step (Fig. 14)
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 and positioned at the SB ostium, and a balloon is advanced and
positioned in the MB.
4. The SB stent is pulled back 3 mm 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. If
the angiographic result is satisfactory, the wire is removed from the SB.
7. The balloon in the MB is inflated at high pressure to crush the SB stent.
8. The SB is rewiredat thedistal part of the SB orifice and the SB stent is postdilated, preferably
using noncomplaint balloon at high pressure.
9. First kissing balloon inflation is performed, and the SB balloon and wire are removed.
10. The MB stent is advanced and deployed at high pressure.
11. The SB is rewired again through the MB stent at the distal part of the SB orifice.
12. The SB stent is postdilated, preferably using noncomplaint balloon at high pressure.
13. 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.
98
FAVERO ET AL.
(A) (B) (C)
(D)
(G) (F) (E)
Figure 14 Diagrammatic outline of the sleeve technique. One, stenting of SB with the proximal segment of the
stent protruding into MV. A balloon is already loaded in the MV, covering the protruding stent segment (A). Two,
balloon inflation in the MV, crushing the SB stent againstthe MV wall (B). Three, rewiring of the SBthrough its own
stent strut, followed by balloon dilatation of the SB ostium (C). Four, first kissing balloon inflation of the bifurcation.
A new sleeve has been reconstructed (D). Five, stenting of the MV (E). Six, second rewiring of the SB through
the MV stent strut, followed by second balloon dilatation of the SB ostium (F). Seven, second and final kissing
balloon inflation of the bifurcation (G).
Source
: Adapted from Ref. 18.
Anatomic indication
Similar to that of the minicrush technique but only requires a 6-Fr guide catheter.
Advantages
(a) Easier to rewire the SB and pass noncompliant balloons through the stent struts for final
kissing balloon inflation; (b) leads to better stent expansion at the SB ostium.
Drawbacks
It involves an extra intermediate step of SB rewiring and dilatation.
Culotte Stent Technique
Definition
The culotte stent technique consists of sequential implantation of the SB and the MB stents as
detailed below (19).
Step by step (Fig. 15)
1. Both the MB and the SB are wired.
2. Both the MB and the SB are adequately predilated.
3. A stent is advanced to the more angulated branch (usually the SB).
4. The stent in the more angulated branch (usually the SB) is deployed at nominal pressure.
The wire in the straighter branch (MB) may be retrieved before SB stent deployment or may
be jailed at operator’s discretion.
5. The nonstented branch (MB) is rewired through the stent struts, and the wire is removed
from the stented branch (SB).
6. Dilatation of stent struts toward the nonstented branch is performed, preferably by using
noncomplaint balloon.
7. A second stent is advanced into the nonstented branch (MB) and deployed at nominal
pressure.
8. The first-stent branch (SB) is rewired through the second stent struts.
ELECTIVE DOUBLE STENTING FOR NON–LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
99
(A) (B) (C) (D)
(G) (H) (I)
Figure 15 Diagram of the culotte stent technique. (A) Both branches are wired and predilated. (B) A stent is
advanced to the more angulated branch (usually the SB). (C) The stent is deployed in the SB (the wire in the MB is
removed, as in the figure, or jailed, at operator’s discretion). (D) If the angiographic result in the SB is satisfactory,
the wire is removed from the SB and the MB is rewired through the stent. (E) Dilatation of the MB is performed
by using noncomplaint balloon at high pressure. (F) A stent is positioned in the MB. (G) The stent is deployed
in the MB. (H) The SB is rewired through the MB stent. (I) Final kissing balloon at high pressure is performed.
Abbreviations
: MB, main branch; SB, side branch.
(E) (F)
9. Final kissing balloon inflation at moderate pressureis performedby usingtwo noncomplaint
balloons of the same size as that used to deploy the stents.
Anatomic Indication
This techniquecan be used inalmost all true bifurcation lesions irrespective of bifurcation angle.
We use this technique for treatment of bifurcations in which the
MB and the SB have similar
diameter and for LMCA bifurcation (Fig. 16).
Advantages
This techniqueguarantees the completecoverage of theSB ostium withDES. The angle between
the MB and the SB does not constitute a problem using this technique.
Drawbacks
r
This technique leads to a double stentlayer at the proximalMB and at the level of the carina.
r
Open-cell stents are preferable to closed-cell stents because it permit a larger intrastrut
opening toward both branches (see section Technique Execution).
r
This technique is not advisable when there is large discrepancy between the size of the
proximal MB and the SB due to the risk of incomplete wall apposition of the SB stent in the
proximal MB segment (see section Technique Execution).
r
This technique requires rewiring of both branches through the stent struts, which can be
technically demanding and time-consuming.
Соседние файлы в папке Библиотека им академика М.И. Перельмана