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
160
LATIB ET AL.
(E) (F)
(G) (H)
(I) (J)
Figure 8
(Continued
)
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
(A) (B)
161
(C)
Figure 9 This patient underwent LMCA and multivessel stenting(LAD andLCX) withelective IABPhemodynamic
support (A–C). In view of the short left main trunk, we elected to perform V-stenting with two 3.0 ×16 mm Taxus
paclitaxel-eluting stents (Boston Scientific, Natick, MA). Both stents were positioned in the LMCA with their
proximal markers overlapping (D); the LAD stent was inflated first (E); then both stents were inflated together
(F); and FKI inflation was performed with a 3.5 × 12 mm (LAD) and 3.0 × 12 mm (LCX) noncompliant balloons
(G). We then proceeded to treat the LCX and obtuse marginal (OM) bifurcation. We used a
catheter (Boston Scientific, Natick, MA) in order to place another wire into the OM (before stent implantation and
for FKI) without crisscrossing the V-stenting struts in the LMCA; a 3.0 × 16 mm Taxus stent was placed on
after
the proximal LCX (H); the OM was rewired and FKI was performed (I). The multifunctional probing catheter was
again used to place another wire in the LAD in order to protect the first diagonal branch. Two 3.0 × 32 mm Taxus
stents were placed on the mid to proximal LAD, and FKI was performed on the LAD/diagonal bifurcation (J–L).
The final result was excellent (M and N).
Continued on pages 162 and 163
(
multifunction probing
)
162
LATIB ET AL.
(D)
(E)
(F) (G)
(H) (I)
(J) (K) (L)
Figure 9
(Continued
)
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
(M) (N)
163
Figure 9
(Continued
)
The Crush Technique (the SB Stent Crushed by the MB Stent)
The main advantage of the crush technique is that immediate patency of both branches is
assured, and therefore it should be applied in conditions of
instability or when the anatomy
appears complex (Fig. 10) (20). This objective is notably important when the SB is functionally
relevant or difficult to be wired. In addition, this technique provides excellent coverage of the
ostium of the SB. The main disadvantage is that in order to perform FKI, there is the need
to recross multiple struts with a wire and a balloon. The crush technique has evolved and is
nowadays performed with less stent protrusion into the MB (i.e., minicrush) and mandatory
two-step FKI (21,22).
Technique Description—Requires a 7- or 8-Fr Guiding Catheter (Fig. 11)
(a) Both branches are wired and fully dilated.
(b) SB stent positioned in the SB and then MB stent is advanced.
(c) SB stent ispulled backinto the MB about 1 to 2mm andis verified in at least two projections.
(d) SB stent is deployed at least at 12 atm. The balloon is deflated and removed from the
guiding catheter. An angiogram is taken to verify that the SB has an appropriate lumen,
normal flow, and that no distal dissection or residual lesions are present. If an additional
stent is needed in the SB, this is the time to implant it. Following this check, the wire is
removed from the SB and the stent in the MB is fully deployed at high pressure, usually
above 12 atm. An angiogram is taken following removal of the balloon from the MB. When
we use this technique, we keep only a single indeflator on the table that is connected to the
SB stent. This will prevent inadvertent deployment of the MB stent first, thereby crushing
the undeployed SB stent.
(e) Rewire SB. It is important to perform a two-step FKI. First, we suggest a dilatation of the
stent toward the SB with a balloon appropriately sized to the diameter of this branch and
inflated at high pressure (16 atm or more), then FKI with a second balloon in the MB with
an inflation pressure about
8 to 14 atm in both balloons.
Step Crush
When thereis the need to perform a two-stent technique asintention-to-treat and a 6-Fr guiding
catheter as the only available approach (radial approach), the “step crush” or “the modified
balloon crush” techniques can be used. The final result is basically similar to that obtained with
the standardcrush technique, withthe only difference that eachstent is advanced and deployed
separately. Another modification of the step crush is when reverse crush stenting needs to be
performed as a crossover from provisional SB stenting. The need for a 6-Fr guiding catheter is
the only reason to utilize this technique.
164
LATIB ET AL.
Technique description
(a) Both branches are wired and fully dilated.
(b) Stent isadvanced in the SB protruding a few millimetersinto the MB. A balloonis advanced
in the MB over the bifurcation.
(c) Stent in SB is deployed, the balloon removed, an angiogram is performed, and if the result
is adequate the wire is also removed.
(d) MB balloon is then inflated (to crush the protruding SB stent) and removed.
(e) A second stent is advanced in the MB and deployed (usually at 12 atm or more).
(f) The next steps are similar to those of the classical crush technique and involve recrossing
into the SB, SB stent dilatation, and two-step final kissing balloon inflation.
Specific issues
An importantchange in the classical crush technique isthat we now try tolimit the areaof crush
stenting and multiple layering of stent struts by performing a minicrush. The minicrush may
be associated with more complete endothelialization (and theoretically less stent thrombosis)
(A) (B)
(C)
Figure 10 This patient with a history of previous CABG and occluded bypass grafts (two vein grafts and left
internal mammary artery) presented to us with an acute coronary syndrome. Baseline coronary angiography (A–
C) demonstrated a severe stenosis of the distal LMCA bifurcation involving both the LAD and LCX; a subtotally
occluded anddiffusely diseased LAD; and severestenosis of the first diagonal branch (D1). An IABP was electively
inserted; wires were placed in the LAD, LCX, OM, D1; and the LAD, D1, LCX and LMCA were predilated. A 2.75 ×
32 mm Taxus paclitaxel-eluting stent (Boston Scientific, Natick, MA) was placed on the mid-LAD. We then performed crush stenting of the LMCA with a Taxus 3.5 ×32 mm stent toward the LCX (D) and Taxus 3.5 × 32 mm
stent toward the LAD (E). Two-step FKI was performed with two 3.5 × 15 mm noncompliant balloons, first only
dilating the LCX ostium at high pressure (F) followed by conventional FKI (G). Although the angiographic result
appeared good (G), IVUS demonstrated marked malapposition of the stent in the distal LMCA (H and I;
We thus performed further postdilatation with noncompliant balloons: 4.0 × 15 mm at 18 atm toward LAD, 3.5 ×
12 mm at 18 atm toward LCX, and 4.5 ×20 mm at 18 atm on the LMCA. Repeat angiography and IVUS confirmed
good stent apposition (K–M). We then treated the LAD-D1 bifurcation by implanting a Taxus 2.5 × 16 mm stent
with the reverse crush technique. The final angiographic result was excellent (N and O), which was maintained at
angiographic follow-up performed seven months later (P and Q).
arrows
).
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
(D) (E)
(F) (G)
(I)
165
(H)
Figure 10 (
Continued
)
(J)
Continued on page 166
(
)
166
(K)
LATIB ET AL.
(L)
(M)
Figure 10
(N) (O)
(P) (Q)
(Continued
)
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
167
Crush stenting
1. Wire both branches
and predilate if needed
(A)
2. Advance the two stents.
MB stent positioned proximally.
The SB stent will protrude only
minimally into MB.
Crush stenting
5. Rewire the SB and perform
high pressure dilatation
(C)
6. Perform final kissing balloon
inflation
Figure 11 A schematic representation of the crush technique.
Crush stenting
3. Deploy the SB stent
(B)
4. Check for optimal result in the
SB and then remove balloon
and wire from SB.
Deploy the MB stent
and easier recrossing of thecrushed stent. Ormiston et al have reported bench testing with three
different stent platforms(BX Velocity, Cordis,A Johnson & Johnson Company, Miami Lakes, FL;
Express II, BostonScientific, Natick, MA; andDriver, Medtronic,Minneapolis, MN) utilizingthe
crush technique (23,24). The authors stressed the importance of FKI and concluded that appropriate SB and MB postdilatation is needed to fully expand the stent at the SB ostium, to widen
gaps between stent struts overlying the SB (facilitating subsequent access), and to minimize
stent distortion. The importance of FKI with the crush technique has also been confirmed in a
clinical study that demonstrated significant reductions in restenosis (11.1% vs. 37.9%) and late
loss (0.32 mm vs.0.52mm) of the SB in the group treated withfinal kissing balloon (17).It is very
important to perform the so-called “two-stepkissing inflation,” which consistsof high-pressure
balloon inflation in the SB before performing the true FKI at medium pressures. Ormiston
et al. have recently demonstrated through imaging of bench deployments that
(i) recrossing the
crushed stent for kissing postdilation, the most difficult part of the procedure, is technically
easier with minicrush than with classical crush; (ii) traditional one-step kissing postdilation
leaves considerable residual metallic stenosis that may not be visible on angiography and may
predispose tothrombosis because ofeddy currents, stasis,altered shear stress, and foreignbody
presence; (iii) SB ostial coverage and residual stenosis by metal struts is significantly reduced
by a two-step kissing inflation (Fig. 12) (25). Finally, the bifurcation angle may be an important
factor to be considered when performing the crush technique. When the angle between the MB
and the SB is closed to 90 degrees, it is possible to minimize the gap even without crushing
the SB stent and utilizing the modified T-technique. Furthermore, a bifurcation
Angle B ≥50
◦
between thetwo branches hasbeen suggested as an independent predictorof MACE aftercrush
stenting (26).
The Culotte Technique
The
culotte
technique
uses twostents and leads to full coverage ofthe bifurcation atthe expense
of an excess of metal covering the proximal end (27). The culotte technique will give the
168
(A) (B) (C)
LATIB ET AL.
Figure 12 This figure demonstrates a bench model of a bifurcation treated with the crush stenting as seen
from the SB directly after stenting and after normal FKI. Two-step FKI results in improved opening of and less
obstruction by stent struts at the SB ostium.
Source
: Photo courtesy of Dr. John Ormiston.
best immediate angiographic result and theoretically it may guarantee a more homogeneous
distribution of the struts and of the drug at the site of the
bifurcation. It is for this reason that
we prefer using this technique to treat restenosis of the LMCA bifurcation that occurs after Tor crush stenting. Important caveats about this approach are that with some closed cells stents
such as
the Cypher (Cordis Corp, Johnson & Johnson, Warren, NJ) stent, the opening of the
struts toward the branches may only reach a maximum diameter of 3 mm. For this reason, the
culotte
technique shouldbe only used with stentsthat have a design (opencells stents) allowing
full opening of the struts toward both branches or when the expected size of the SB is ≤3 mm.
This technique is suitable for all angles of bifurcations and provides near-perfect coverage of
the carina and SB ostium. However, like the crush technique, it leads to a high concentration
of metal with a double-stent layer at the carina and in the proximal part of the bifurcation. The
long-term impact of this double dose of drugwith DES onre-endothelialization isunknown. The
main disadvantage of this technique is its complexity in that rewiring both branches through
the stent struts can be difficult and time-consuming. The only anatomic limitation to the culotte
technique is when there is a large mismatch in diameter between the distal LMCA and LCX.
Technique Description—Can Be Performed with a 6-Fr Guiding Catheter (Fig. 13)
(a) Both branches are wired and predilated.
(b) A stent is deployed across the most angulated branch, usually the SB.
(c) The nonstented branch is rewired through the stent struts and dilated.
(d) A second stent is advanced and expanded into the nonstented branch, usually the MB.
(e) Finally, kissing balloon inflation is performed. When performing the kissing inflation,
we prefer using noncompliant balloons and dilating each limb of the culotte (i.e., at the
ostium ofthe LCX and LAD) at highpressure (≥16atm) individually beforesimultaneously
inflating both balloons at 8 to 12 atm (Fig. 14).
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
169
Culotte stenting
1. Wire both branches
and predilate if
(A)
Figure 13 A schematic representation of the culotte technique.
needed.
2. Leave the wire in the
more straight branch
(MB) and deploy a stent in
the more angulated
branch (SB).
Culotte stenting
(C)
(B)
5. Recross the second
stent’s (MB) struts
into the first stent
(SB) with a wire and
perform kissing
balloon inflation.
Culotte stenting
3. Rewire the unstented branch
and dilate the stent struts to
unjail the branch (MB).
4. Place a second stent into
the unstented branch (MB)
and expand the stent
leaving some proximal
overlap.
Specific Issues
Although theculotte techniquemay betechnically more challengingthan othertechniques, there
are a number of factors that can facilitate its successful performance. When rewiring the other
branch after stent placement, we always first place the guidewire distal into the stented branch
to be sure that we have not passed under the stent struts before re-crossing into the branch. In
performing the culotte technique, we recommend stenting the branch with the sharpest angle
first, which is usually the LCX. This has the advantage that recrossing stent struts into the less
angulated branch will be easier as will passing the second stent through stent struts into a
less angulated branch. However, this conventional practice has recently been challenged by the
Nordic PCI Study Group. In the Nordic Stent Technique Study, a randomized comparison of
culotte and crush stenting of coronary bifurcations, the authors recommended
MB
first to avoid acute closure of the MB (28). This approach guarantees patency of the MB,
which
in this case is the LAD, and may avoid one of the potential problems of performing the
stenting of the
culotte technique where we always need to remove the wire from one of the two branches and
where patency of this branch is not guaranteed (Fig. 15). In the Nordic Stent Technique Study,
culotte stenting was associated with similar rates of procedural success as crush stenting and
higher rates of protocol-mandated FKI (92% vs. 85%; p =0.03) (28). The authors speculated that
rewiring and balloon insertion through stent struts are more difficult in the crush technique,
where three layers of stent have to be crossed versus only one layer in the culotte technique.
Even though in our experience we have not had greater difficulty in recrossing stent struts with
the crush versus culotte techniques, it is reassuring that in the Nordic Study the authors did not
have difficulty in recrossing stent struts into the more angulated branch. Only 10% of the 424
bifurcation lesions included in this study involved the LMCA, thus limiting the generalizability
of the results to this subgroup. However, this is the first study to randomly compare the two
double stent techniques that result in complete coverage of the SB ostium. At six months, there
were no significant differences in MACE rates between the groups (crush 4.3% vs. culotte 3.7%;
p = 0.87). Procedure and fluoroscopy times and contrast volumes were similar in the two
groups. Angiographically, there was a trend toward less in-segment restenosis (6.6% vs. 12.1%;
p =0.10) and
significantly reduced in-stent restenosis following culottestenting (4.5% vs.10.5%;
Соседние файлы в папке Библиотека им академика М.И. Перельмана