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
100
FAVERO ET AL.
V-Stent and Kissing Stent Techniques
Definition
The V and simultaneous kissing stent (SKS) techniques consist of implantation of the MB and
the SB stents simultaneously (20,21). When the twostents protrude minimally into the proximal
MB creating a new carina, the technique is called V-stent technique [Fig. 17(A)] (20), whereas
when the two stents protrude more deeply into the proximal MB, then that technique is called
SKS technique [Fig. 17 (B)] (21).
(A)
(C)
Figure 16 Case example of the culotte technique. (A and B) Baseline angiography showing a true bifurcation
lesion involving the LAD and a large diagonal branch. (C) Wiring and predilatation of both branches. (D) The stent
in the diagonal branch (SB) is deployed (Cypher 3 ×23 mm). A jailed choice PT guidewire is left in the LAD (MB).
(E) The guidewire of the diagonal branch (SB) is removed and the LAD (MB) is rewired through the stent struts.
After dilatation of the stent struts, the stent is advanced and deployed in the LAD (MB) (Cypher 3 × 18 mm).
(F) The diagonal branch (SB) is rewired, and kissing balloon inflation is performed with two 3.0 mm balloons
(G and H). Final result.
Abbreviations
: LAD, left anterior descending; MB, main branch; SB, side branch.
(B)
(D)
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/
(E) (F)
101
(G) (H)
Figure 16 (
(A) (B)
Continued
)
Figure 17 (A) Positioning of stents in the V-stent technique.
(B) Positioning of stents in the kissing stent technique.
102
(A) (B) (C) (D) (E)
Figure 18 Diagram of the V-stent technique. (A) Both branches are wired and predilated. (B) The stents are
simultaneously advanced in the MB andin the SB; both stentsprotrude into the MB. (C) The stentsare deployedby
inflating both balloons simultaneously (In case the proximal MB diameter is relatively small and a risk of proximal
MB damage by simultaneous inflation of the two stents do exist, the operator may consider to deploy the single
stent individually.) (D) Final kissing balloon at high pressure is performed. (E) Final result.
main branch; SB, side branch.
FAVERO ET AL.
Abbreviations
:MB,
Step by step (Fig. 18)
1. Both the MB and the SB are wired.
2. Both the MB and the SB are adequately predilated.
3. The stents of the MB and the SB are advancedand positioned at the lesion site. In V-stenting
the stents are positioned such that they minimally protrude into the proximal MB, while
in SKS the stents protrude deeply into the proximal MB. It is advisable to check stent
positioning
in at least two projections.
4. The stents are deployed by inflating both balloons simultaneously, or sequentially, up to at
least
12 atm.Simultaneous stentdeployment should be avoided ifthe proximalMB diameter
is relatively small.
5. Postdilate the stents using simultaneousinflation of two noncomplaint balloons of the same
size as that used to deploy the stents. We recommend postdilatation at high pressure but, if
the proximal MB diameter is relatively small, moderate or low pressure should be used.
Anatomic Indication
V-Stenting
A (0,1,1) bifurcation with large proximal MB and a <90-degree angle between both branches.
We reserve this technique to patients with very short LMCA free from disease and critical disease of
both LAD and LCx ostia (Fig. 19).
SKS Technique
The
authors of this chapter do not use this technique and believe that proximal stent overlap
should always be kept to a minimum.
Advantages
Access to both branches during the procedure is always preserved with no need for rewiring
any of the branches. The technique is relatively easy and fast.
Drawbacks
This technique,particularly the SKS, leads tothe creation ofa metallic neocarina in theproximal
MB with stent malapposition (Fig. 20). Theoretically, this technique raises several concerns:
1. The risk of proximal dissection after stent deployment, which would require converting the
procedure to a crush technique.
2. The stent lumen area in the double barrel is often suboptimal and asymmetric.
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/
103
3. If reintervention becomes necessary at follow-up rewiring, the stented vessels may be complicated by wire passage behind stent struts.
4. If restenosis occur inthe neocarina or at theproximal stent edge, itwould require converting
to the crush technique for treatment.
ELECTIVE DOUBLE STENTING: TECHNIQUE EXECUTION
Patient Preparation
EDS is a complex coronary intervention that requires optimal antithrombotic pretreatment.
Although the RCTs (1–4) did not demonstrate an increased risk of stent thrombosis after EDS
(A)
(C)
Figure 19 Case example of the V-stent technique. (A and B) Baseline angiography, showing a true bifurcation
lesion involving the distal LMCA, the ostial LAD, and the ostial LCx. The proximal LCx is occluded. (C to E)
After wiring the LAD and recanalization of the proximal LCx, two stents are advanced simultaneously and correct
positioning was checked using three different projections. (F) Deployment of the two stentby simultaneousinflation
(Cypher 3.5 × 18 mm in the LAD, Cypher 3.0 × 18 mm in the LCx). (G and H) Final result after kissing balloon.
(I) Angiographic follow-up at eight months.
descending; LCx, circumflex coronary artery; MB, main branch; SB, side branch.
Abbreviations
: LMCA, left main coronary artery; LAD, left anterior
(B)
(D)
(
Continued on page 104
)
(E)
(F)
(G)
(I)
Figure 19 (
Continued
(H)
)
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/
Figure 20 V-stent and kissing stent techniques. Cross-sectional view
of the neocarina in the proximal MB. The arrows indicate the zones of
the proximal MB in which malapposition may occur.
105
up to one-year follow-up, they did show higher postprocedure cardiac enzyme elevation.
Furthermore, real world registries indicate that bifurcation intervention, irrespective of the
technique, increases the risk of stent thrombosis
(22–24). Therefore, optimal antiplatelet and
antithrombotic therapies are mandated to minimize procedural complications and reduce stent
thrombosis.
Guide Catheter Selection
When an operator decides to perform elective DS, a
7
or 8-Fr
guide catheter (GC) is preferable.
The utilization of an 8-Fr GC have several advantages: first, it reduces the friction among the
multiple catheters that are simultaneously introduced into the vessel assuring easy manipulation; second, it allows adequate visualization that is particularly important for simultaneous
stent positioning; and third, it provides optimal support for stent delivery particularly through
tortuous and calcified vessels. If the operator chooses not to use an 8-Fr GC, the procedure can
certainly be performed with a 6-Fr GC, but technique choices will be more limited (i.e., step
crush or culotte techniques) and procedure execution potentially more challenging.
Wire Introduction
Although wiring the MB and the SB is considered a simple step and is often taken for granted,
this is not always the case. Bifurcations with wide angulation and/or severe calcifications
can present a challenge.
One potential option that can be used in selected cases after failure
to wire the SB is to perform low-pressure balloon dilatation of the MB using an undersized
balloon which may modify the plaque geometry at the bifurcation site allowing access to the
Needless to say, if the operator fails to wire the SB (and if it is alarge SB), then theprocedure
SB.
should beaborted rather than hope that theSB will remain patent after stenting theMB. Another
potential problem when using two or more guidewires is
wire crisscrossing, which may lead to
difficulty (or inability) to advance balloons and/or stents into the vessel.
minimize the chances of this problem is to wire the branch with the
where prolonged wire manipulation and rotation is expected. Then the second wire aimed for
the easier access vessel should be advanced with minimal rotation while keeping both wires
separate on the table.
Lesion Preparation
Lesion predilatation (in the MB and SB)followed by intracoronary
nitroglycerin administration
should beperformed in all patientsundergoing EDS. This would allow(a) more accurate assessment of vessel diameter (particularly the SB) to optimize stent sizing;(b) facilitate advancement
of stents into the bifurcation and optimize visualization during positioning;(c) identify difficult
to dilate bifurcation lesions prior to stent implantation to avoid suboptimal stent expansion.
Alternative techniques can then be used to properly prepare the lesion prior to stent deployment. Devices such as rotational atherectomy in severely calcified lesions, the cutting balloon
A simple rule
that can
more difficult access first,
106
FAVERO ET AL.
or the angiosculpt balloon in fibrotic lesions are valuable in lesion preparation before stenting
(Fig. 21)(25,26). One
potential disadvantageof aggressive balloon predilatationprior to EDSare
dissections; however, this represent a challenge only with the culotte technique where there is a
need to rewire one of the branches to position a second stent. Therefore, when only the culotte
technique is planned, gentle predilatation should be performed on the branch that needs to be
rewired (the less angulated branch).
Stent Implantation
EDS,
when indicated, must be carried out with DES. Numerous studies have demonstrated the
superiority of DES over historical results obtained with BMS in coronary bifurcation lesions
(1–4,27,28). The DES most extensively studied in RCTs of EDS is the sirolimus-eluting stent,
but
comparative data among the various DES in bifurcation lesions are limited and do not indicate
significant differences in outcome (29).
(A)
(C) (D)
Figure 21 Case example of the step crush stent technique in a severely calcified true bifurcation lesion involving
the LAD and a large diagonal branch. (A) Baseline angiography. (B) Lesion dilatation with noncompliant balloon at
high pressure failed to dilate the stenosis. (C and D) Rotational atherectomy was first performed toward the diagonal branch and subsequently toward the LAD. Note that during rotablation the second guidewire was removed.
(B)
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/
(E) (F)
107
Figure 21 (
balloon was positioned in the LAD (MB). (F) The balloon and the wire are removed from the diagonal branch and
the balloon is inflated in the LAD to crush the SB stent. (G and H) Positioning and deployment of the stent in the
LAD (Cypher 3 × 23 mm). (I) Rewiring of the diagonal branch and dilatation at high pressure. (L) Induction of
long dissection in the diagonal branch, distal to the first stent, requiring stent implantation (Cypher 2.5 × 28 mm).
(M) Final kissing balloon inflation with 3.5 mm balloon in the LAD and 2.5 mm balloon in the diagonal branch.
(N and O) Final result. (P) Angiographic follow-up at eight months.
LCx, circumflex coronary artery; MB, main branch; SB, side branch.
Continued
(G)
)(E) The stent is deployed in the diagonal branch (SB) (Cypher 2.5 ×13 mm). A deflated
Abbreviations
(H)
: LAD, left anterior descending;
(
Continued on page 108
)
(I) (L)
(M) (N)
Figure 21 (
Continued
(O) (P)
)
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/
Figure 22 The culotte technique is not advisable when there is large discrepancy in vessel size between the proximal MB and the SB, because the
proximal segment of the SB stent will not attain good apposition to the vessel
wall of the proximal MB.
109
Stent sizing is of particular importance to optimize lumen dimensions and to avoid stent
malapposition inall EDS techniques.In particular, carefulattention should bepaid to vesselsize
discrepancy between theSB and the MB whenthe culotte techniqueis being consideredbecause
this can lead to lack of apposition of the SB stent in the proximal portion of the MB (Fig. 22).
Intravascular ultrasound (IVUS) can inform decision making and assist the operator in
choosing the optimal stent size and postdilatation balloon for both the SB and the MB.
Stent type (open vs. closed cell design) is also of particular importance, especially when
using the culotte technique. The intrastrut space in closed-cell stents is limited to <3 mm,
whereas it is >3 mm in open-cell stents (30).
The Jailed Wire Technique
Most ofthe EDS techniques (T-stent,modified T-stent,crush stent, V-stent) donot require jailing
a SB wire.
Only culotte stenting may require a jailed wire technique at operator’s discretion (see
above). Most operators use nonhydrophilic wires as jailed wires: the rational of this preference
is that jailing hydrophilic guidewires may lead to coatingpeeling upon retrivalof the guidewire
(31).
In our practice, we routinely jail a hydrophilic guidewire (Choice PT, Boston Scientific)
because it is
much more easier to retrieve than nonhydrophilic guidewires after implanting the
MB stent at nominal pressure. Using this technique, we never observed peeling or fracture of
the guidewire.
In either case there are several tips that need to be followed to avoid complications due to
the jailedwire technique: (a) this techniqueshould not be usedwhen the “jailing stent(s)”covers
a long segment proximal to the SB (the longer the stent, the higher the friction with the jailed
wire); (b) prior to deployment of the jailing stent (typically the MB stent), the SB wire should be
pulled backand positioned
only fewcentimeters
away from the SB ostium(no need tojail a long
segment of the wire); (c) the jailing stent (typically the MB stent) should be deployed at nominal
or intermediate pressure; (d) the jailed wire should not be removed until recrossing the SB with
a second wire; (e) prior to removal of the jailed wire, the guide catheter should be pulled back
into the aorta and be held with one hand while the jailed wire is removed. The reason for this
maneuver is to avoid guide catheter “deep throating” into the coronary artery when the jailed
wire is forcefully removed (an almost predictable event); (f) if attempts to remove the jailed
wire fail using the above technique, one should load a monorail low profile 1.5 mm balloon (or
smaller) over the jailed wire and embed this balloon behind the jailing stent (the MB stent) and
reattempt wire removal.
Rewiring the SB Across the MB Stent Struts
All the EDS techniques, except for the V-stent and kissing stent techniques, require recrossing
into the SB. Using the culotte technique, a double stent layer need to be recrossed, whereas
using the modified T-stent (or minicrush)
technique, three stent layers need to be recrossed.
Соседние файлы в папке Библиотека им академика М.И. Перельмана