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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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170
LATIB ET AL.
p = 0.046). The relevance of this angiographic finding is unclear and may be explained by the
lack of two-step FKI in the crush group.
T- and Modified T-Techniques
The T-technique is most frequently utilized to crossover from provisional stenting to stenting
the SB and is most suited to bifurcations where the angle between the branches is close to
90 degrees. This technique is less
laborious than the crush or culotte technique. Unlike the
V-technique, it can be used for the coverage of lesions located proximal to the bifurcation. In
our view, the T-technique is associated with the risk to leave a small gap between the stent
implanted in the MB and the one implanted in the SB. This gap may be a factor contributing
(A) (B)
(C)
Figure 14 This patient underwent crossover stenting with a 3.5 × 38 mm Taxus paclitaxel-eluting stent (Boston
Scientific, Natick, MA) from the LMCA toward the LCX for a long lesion extending from the ostium to the midsegment of the LCX (A–C). A provisional approach was taken toward the LAD, which after FKI at the distal LMCA
had a linear dissection proximally extending to its ostium (D). A 3.0 × 24 mm Taxus stent was then inserted from
the LMCA to the LAD utilizing the culotte technique (E). High-pressure dilatation was performed toward to the LAD
(F) followed by FKI with 3.5 ×12 mm and 3.0 ×12 mm noncompliant balloons at 14 atm (G). IVUS was performed
to verify optimal stent deployment. Although, the angiographic result was good (H), IVUS demonstrated that the
stent was well expanded in the LMCA and LAD, but there was suboptimal expansion of the stent at the ostium of
the LCX (I). The stent CSA was 5.95 mm
a 3.5 mm postdilatation balloon (see AVIO criteria in Table1). We then performed high-pressure dilatation with a
3.5 × 12 mm noncompliant balloon at 26 atm toward the LCX and repeated the FKI. Final angiography confirmed
an excellent result (J). Repeat IVUS at the ostium of the LCX now demonstrated a marked improvement of the
minimal CSA to 9.94 mm
case illustrates the importance of performing high-pressure dilatation toward both branches before FKI when
perfor
ming the culotte technique.
2
(K). At angiographic follow-up, the good final result was maintained (L and M). This
2
, which is well below the 8 mm2that we accept as an optimal result for
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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(D)
171
(E) (F) (G)
Figure 14 (
Continued
)
to an uneven distribution of the drug, hence leading to ostial restenosis at the SB. This may
have been a possible cause for the restenosis we noticed at the ostium of the SB when two
stents were implanted in the Sirolimus bifurcation study (29). Currently, we rarely perform
the classical T-technique in our practice, and in our opinion there are two reasons to perform
the T-technique:
(i) to place a stent at the ostium of a SB after placement of a stent in the MB
because theresult atthe SB ostium wasunsatisfactory (provisionalSB stenting). In thissituation,
we have replaced the classical T-technique with the TAP. (ii
)
To perform stenting at the ostium
of the SB when there is isolated SB ostial stenosis (e.g., T-balloon stenting).
Classical T-Technique Description (Figs. 16 and 17)
(a) Position a stent first at the ostium of the SB, being careful to avoid stent protrusion into the
MB while trying to minimize any possible gap.
(b) Deploy the stent and remove the balloon from the SB (keep the wire in the SB).
(c) Advance and deploy the MB stent.
(d) Rewire SB and then remove the jailed wire.
(e) SB balloon dilatation and FKI.
Continued on page 172
(
)
172
LATIB ET AL.
(H)
(J)
(I)
(K)
Figure 14
(Continued
(L) (M)
)
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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(A) (B)
173
Figure 15 This is a patient who previously had a left mammary implantation on the LAD with graft failure who
underwent culotte stenting on this unprotected LMCA stenosis (A and B). Following wiring of both branches and
predilatation of the LCX, a 3.5 × 16 mm Taxus stent paclitaxel-eluting stents (Boston Scientific, Natick, MA) was
deployed on the LCX (C). The LAD was then rewired and dilatation of the struts toward this vessel was performed
without difficulties (Panel D). At that point a second Taxus stent was advanced towards the LAD during which
the vessel abruptly closed and the patient had hemodynamic collapse (E). A Zeta stent (Guidant Corporation,
Santa Clara, CA) was successfully advanced into the LAD reestablishing flow in this vessel (F). In addition,
balloon counterpulsation was initiated. Following stabilization, the procedure was completed with implantation of
a3.5× 16 mm Taxus stent from the LMCA toward the LAD (G). The stent was then crossed and dilated toward
the LCX (H) and FKI was performed (I). The final result was excellent (G and I). This case illustrates one of
the disadvantages of the culotte technique in comparison to the crush and V-techniques, both of which ensure
patency of both branches without removing the wire. In this case, we were fortunate that the LAD occluded only
after the LCX stent was recrossed and we thus had access to the LAD.
(C) (D)
(
Continued on page 174
)
174
LATIB ET AL.
(E)
(F)
(G) (H) (I)
Figure 15
(Continued
(J) (K)
)
ELECTIVE DOUBLE STENTING FOR LEFT MAIN CORONARY ARTERY BIFURCATION LESIONS
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175
T-stenting
1. Wire both branches
and predilate if
(A)
Figure 16 A schematic representation of the T-stenting technique.
needed.
2. Stent the MB leaving
a wire in the SB.
The stent in the MB
can be deployed at
high pressure.
T-stenting
(C)
(B)
Assuming that the result is suboptimal
5. Perform final kissing inflation
following advancement of a
balloon in the MB. If needed
use a new balloon for the SB.
T-stenting
3. Rewire the SB passing
through the struts of the
MB stent, remove the
jailed wire and dilate
toward SB.
4. Advance stent into the
SB with no or minimal
protrusion into the MB
and deploy the stent.
The above description of T-stenting describes the situation in which the operator decides
to stent the SB first. However,
in majority of cases, the T-stenting technique is performed after
MB and provisional SB stenting for a suboptimal result of flow-limiting dissection (Fig. 16).
Modified T-Technique
Modified T-stenting is avariation performed by simultaneously positioning stents atthe SB and
MB when the angle between the branches is close to 90 degrees. The SB stent is deployed first,
and then after wire and balloon removal from the SB, the MB stent is deployed. The procedure
is completed with FKI.
T-Stenting and Small Protrusion (TAP)
The TAP is a simplified form of the reverse crush technique, which combines some features
of the T- and crush technique (30). Unlike the classical T-technique, the TAP ensures complete
coverage of the SB ostium while the absence of crushing facilitates recrossing into the SB. The
TAP has become our technique of choice when having to implant a second stent in the SB for a
suboptimal result after the provisional approach.
Technique description
(a) A second stent is advanced in the SB in a way to minimally protrude (1 or 2 mm) into the
MB where a stent has been already implanted.
(b) A balloon is advanced in the MB.
(c) SB stent is deployed as usual (12 atm or more), and the MB balloon is simultaneously
inflated at 12 atm or more.
(d) Both balloons are deflated and removed.
The technique is quite similar to the V-stenting technique with the only difference that
one of the components of the system is a balloon, which is inflated inside a stent previously
deployed in theMB. Despite some concerns about stent protrusion in the MB, in our experience
we have been able to perform IVUS in both branches and, when needed, to advance additional
stents distally in the MB and the SB.
176
LATIB ET AL.
(A) (B)
(C) (D)
Figure 17 This patient presented with multivessel disease involving a distal LMCA trifurcation, proximal LAD,
and mid-LCX (A–C). An IABP was electively inserted, an 8-Fr EBU guide catheter utilized, and the mid-LCX
was stented first (D)witha2.5× 12 mm Endeavor Resolute zotarolimus-eluting stent (Medtronic, Minneapolis,
MN). Guidewires were placed in the LCX, RI, LAD, and the first two septal branches were also protected with
guidewires. Our strategy for the LMCA trifurcation was to stent the LMCA toward the LAD with an initial provisional
strategy to the LCX and RI. The LAD was predilated (E) and a 3.5 × 30 mm Endeavor Resolute stent implanted
from the LMCA to LAD (F). The LCX and RI were rewired by recrossing the LAD stent struts; and the triple kissing
inflation performed (G) on the distal LMCA trifurcation (LAD: 3.5 mm;LCX: 2.5 mm; RI: 2.0 mm). The angiographic
result toward the LMCA was good, but the result on LCX and RI appeared angiographically suboptimal (H). We
assessed the severity of LCX and RI lesions by IVUS and fractional flow reserve (FFR); both the lesions were
functionally significant with an FFR of 0.73 in the RI and 0.77 in LCX (I;
T-stenting of the RI and LCX (Endeavor Resolute 2.5 × 30 mm in both) was performed. A 4.0-mm noncompliant
balloon was placed in LMCA-LAD and used initially as a marker to guide accurate placement of the stents at the
ostia of the LCX and RI (J). The stents and balloon were inflated simultaneously (K). The final angiographic result
was excellent (L–O).
seealsocolorinsert
). Thus simultaneous
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(E) (F)
177
(G)
(H)
Figure 17 (
Final Kissing Inflation (FKI) After Double Stenting
Continued
)
(Continued on pages 178 and 179
)
A special mention needs to be made of the importance of FKI when implanting two stents in
LMCA bifur
cations. FKI has been repeatedly demonstrated to reduce late loss and restenosis,
especially at the SB, and has now become standard in the performance of all double stenting
techniques (17,20,31,32). FKI is not only important to correct stent distortion and expansion
(23,33) but is especially important in fully expanding the stent in the distal LMCA where the
diameter is usually much larger than the diameters of the LAD and LCX. The effective balloon
diameter in the distal LMCA(which we calculate as the MB balloondiameter plus 1/3 of the SB
balloon diameter) from the two balloons used for FKIis essential to fullyexpand the stent(s). As
previously mentioned, our experience of bifurcation stenting utilizing two stents has taught us
how important it is to perform the FKI in two steps: high-pressure inflation in the SB following
wire recrossing and then FKI (17,20,34). This has now also been proven in a bench model
(Fig. 12) (25). In performing FKI, it is critical to choose postdilatation balloons of appropriate
size; thatis, the kissingballoons should bethe same sizeor larger thanthe deploying balloonsto
preventstent distortion(23). Whenperforming FKI,we inflatebothballoons simultaneouslyand
slowly which makes “melon seeding” less likely. We also deflate the balloons simultaneously
to avoid distortion.
178
LATIB ET AL.
(I)
(J)
(K)
Figure 17
(Continued
)
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(L) (M)
179
(N) (O)
Figure 17
(Continued
)
The Challenge of Difficult Access to the SB
Access to the SB is one of the greatest challenges in bifurcation PCI. Difficult access to the SB
can occur either at the start of the procedure or after MB stenting in recrossing the stent struts
into the SB with a guidewire or advancing a balloon through the stent struts.
At the Beginning of the Procedure
After having attempted different types of wires with all sorts of curves and all personal tricks
the operator may fail to advance a wire into the SB. At this point, few options are available:
to abort the procedure because the riskof losing the SB will be too high considering the size and
distribution
of the branch (typically an angulated circumflex artery),
atherectomy on the MB with the intent to remove the plaque which prevents entry towards
(i)
(ii) to perform directional
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