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250

LATIB ET AL.

38. Agostoni P, Verheye S. Novel self-expanding stent system for enhanced provisional bifurcation stenting: Examination byStentBoost andintravascular ultrasound.Catheter Cardiovasc Interv2009; 73:481–

487.

39. Johnson TW, Kay IP, Ormiston JA. A novel paclitaxel-eluting dedicated bifurcation stent:a case report from the ﬁrst human use Taxus Petal trial. Catheter Cardiovasc Interv 2009; 73:637–640.

40. Agostoni P, Verheye S. Bifurcation stenting with a dedicated biolimus-eluting stent: X-ray visual enhancement of the ﬁnal angiographic result with “stentboost subtract.” Catheter Cardiovasc Interv 2007; 70:233–236.

Index

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3-D model

of classical crush stenting, 199 of crush stenting, 199 of LCX, 201 of left main coronary bifurcation, 194

6-Fr guiding catheter, 139, 163, 168, 170–171, 181 7-Fr guiding catheter, 139, 163, 167 8-Fr guiding catheter, 105, 156–157, 163, 181

Abbott Pathﬁnder

, 218–219 Abbott Vascular Devices, 110, 181, 214 Achievable optimal result (AOR), 188–189 American College of Cardiology/American Heart

Association (ACC/AHA/SCAI) guidelines, 117, 118, 149

AMIGO (Atherectomy before Multi-Link Improves

Lumen Gain and Clinical Outcomes) trial, 183–184

Angiographic Versus IVUS Optimization (AVIO),

188

Antares SAS

, 233–235 Antiplatelet therapy, 145 Antithrombotic therapy, 180–181 Aspirin, 145, 180 AST Petal AST SLK-View

, 229

, 224–225 Atherosclerotic plaque, 52, 56, 57, 59 AXXENT trial, 247 Axxess Plus

, 212, 244–247

Clopidogrel, 145, 180–181 Coronary artery bifurcation interventions, 1

evidence-base, review of

informed decision, making, 3–7, 8, 9 provisional stenting (PS) vs. elective double

stenting (EDS), 2–3

retrospective studies, 2

RCTs, generalizability of, 7, 9

Coronary artery bifurcation lesions, 14

cardiac motion on, 19 classiﬁcation of, 19

SB compromise, frequency and severity of,

22–28 deﬁnition, 14–16 ex vivo characterization of, 16–18 imaging

intravascular ultrasound (IVUS), 38–39, 40, 41,

42, 43

multislice computed tomography (MSCT), 44 quantitative coronary angiography (QCA),

29–38, 39

virtual histology (VH) and optical coherence

tomography (OCT), 40–41, 43, 44 intersection between anatomy and physiology,

18–19, 20 left main coronary artery bifurcation, 44–45

Coronary artery bypass graft (CABG) surgery, 116,

117, 118, 121, 125, 126, 130, 131 vs. DES, 120–121 durability of, 126

Bare metal stents (BMS), 134, 140, 119, 193 Bench testing

of coronary bifurcation stenting techniques

clinical practice, 207–209 importance of, 193 methods, 193–195 observations gained from, 195–208

Balloon jailing, 180

Bifurcation angle, 26–28, 167, 196, 208

Biguard

, 212, 244

BiPAX trial, 224

vs. medical therapy, evidence for, 117 vs. PCI, 118, 121–122, 123, 124, 128

Coronary bifurcation stenting techniques, bench

testing of, 193 clinical practice, 207–209 importance of, 193 methods, 193–195 observations gained from, 195

crush stenting, 197–201 culotte stenting, 202, 203 double stenting techniques, 196–197 modiﬁed T-stenting, 201–202

Cardiac motion, on coronary artery bifurcation

lesions, 19 Carina shift, 22 CASS (Coronary Artery Surgery Study), 117 Charge Coupled Device (CCD) camera, 195 Classical T-stenting technique, 87–88

“MV to SB” stenting technique, 206–207, 208 provisional stenting technique, 195–196 simultaneous kissing stenting (SKS), 202–204 T-stenting and protrusion (TAP), 204–205 V-stenting technique, 204

Cross-sectional area (CSA), 188

252

Index

Crush stent technique, 91–98, 163, 188, 197–201

7- or 8-Fr guiding catheter, 163 double kiss step crush technique, 97–98 minicrush stent technique, 91–94 step crush techniques, 94–97, 163–164, 167

Culotte technique, 98–99, 109, 167, 202, 203

6-Fr guiding catheter, 168, 170–171

speciﬁc issues, 169–170 Cutting balloon, 58, 183, 184–185 Cypher stent, 168

culotte technique, 167–170 distribution of disease, 150–152 ﬁnal kissing inﬂation (FKI), 175, 177–179 guide selection, 181 hemodynamic support, 181 lesion preparation, 182–185, 186–187 modiﬁed T-techniques, 175 patient preparation, 180–181 patient selection for, 150–155 side branch (LCX) lesion, 154, 155 side branch (SB), access to, 179–180

Debulking coronary atherectomy (DCA), 140 Debulking, role of, 140, 182–185 Dedicated bifurcation stent systems, 211

categories, 212

characteristics, 211–212

description and development, 214, 215–217

Antares SAS AST SLK-View Axxess Plus Biguard Invatec Twin-Rail medtronic bifurcation Y-stent Multilink Frontier Nile CroCo Pathﬁnder Petal Sideguard Stentys Tryton Y-med Sidekick

, 229–233

, 240–244

, 233–235

, 224–225

, 244–247

, 244

, 222–224

, 214, 218–219

, 235–240

, 225–229

, 219–221

, 214, 218–219

, 214, 218

need for, 211

regulatory challenges, 247

technical challenges, 212–213 Delirium, 125 Delta Pax DESIRE trial, 219 Devax

, 222, 224

, 247 “Digital caliper” tool, 26 Directional atherectomy, 58, 183–185 DIVERGE (Drug-Eluting Stent Intervention for

Treating Side Branches Effectively) Study, 246

stent choice, 185 stent deployment optimization, 185, 188–189 T-techniques, 170–175 technical planning, 181–189 V-stent and simultaneous kissing stent (SKS)

techniques, 156–163

for non–left main coronary artery bifurcation

lesions, 83, 85 bifurcation lesion anatomy, 83–85 classical T-stenting technique, 87–88 crush stent technique, 91–98 culotte stent technique, 98–99 guide catheter selection, 105 jailed wire technique, 109 lesion preparation, 105–106, 107, 108 MB stent struts, 109–110 modiﬁed T-stent technique, 88–90 optimal EDS technique, 113–114 patient preparation, 103, 105 patient selection, 83 stent deployment optimization, 110–113 stent implantation, 106, 109 T And Protrusion (TAP), 90–91 V-stent and kissing stent techniques, 100–103,

104, 105 wire introduction, 105

vs. provisional stenting (PS), 2–3

Elective stenting (ES) vs. provisional stenting (PS),

Evidence-based medicine, 3 Ex vivo characterization, of coronary artery

bifurcation lesions, 16–18

Double balloon SDS, 212, 222 Double kiss step crush technique, 97–98 Double stenting techniques, 196–197 Drug-eluting stents (DES), 59, 83, 106, 119, 120, 134,

140, 193 vs. BMS, 119–120 vs. CABG, 120–121

FAME, 67, 68, 71 FFR-guided provisional stenting, 69–70 Final kissing balloon inﬂation (FKI), 56, 59, 60–61,

110, 140–143, 176, 177–179 Finet laws, 20 First-In-Man (FIM) studies, 212, 214, 228, 229 Fractional ﬂow reserve (FFR), 67–68, 73, 74, 75,

143–144

Elective double stenting (EDS)

for left main coronary artery (LMCA) bifurcation

lesions, 149, 150, 155 angle of branch, 152–154 antithrombotic therapy, 180–181

Frontier

, 213

Gage-X metrology software,16 Glycoprotein IIb/IIIa inhibitor, 145, 181

branch size, 152 concomitant distal disease in the side branch,

154–155 crush technique, 163–167

Impella 2.5 system, 181 Internal mammary artery (IMA) graft, 118 Intra-aortic balloon pump (IABP), 139, 181

Index

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253

Intravascular ultrasound (IVUS), 19, 20, 38–39, 40,

41, 42, 43, 53, 68, 109, 111–113, 137, 142–143, 185, 188–189

Invatec Twin-Rail

, 219–221 Inverted culotte techniques, 61–62 ISAR-LEFT MAIN, 185

Jailed wire technique, 59, 109, 144 Jailed SBs, 69, 70

Kissing balloon inﬂation (KBI), 56, 193, 196 Kissing stent techniques, 100–103, 105

Left anterior descending artery (LAD), 71, 72, 73, 74 Left circumﬂex artery (LCX), 73, 134, 135, 140, 142,

144, 149, 150, 151, 152

Left main coronary artery (LMCA) bifurcation

lesions, 44–45, 149

elective double stenting for

patient preparation, 180–181 patient selection for, 150–155 technical planning, 181–189 techniques, 155–180

provisional stenting for, 134

anatomic considerations, 134–138 antiplatelet therapy, 145 patient preparation, 139–140 technique execution, 140–144 tips and tricks in, 144–145

Left ventricular ejection fraction (LVEF), 121

Main branch stent, 59 Major adverse cardiac and cerebrovascular events

(MACCE), 121, 124 Major adverse cardiac event (MACE), 28, 228, 229 Major adverse events (MAE), 121 MB balloon, 222, 224 Medina classiﬁcation, 4, 5, 20, 21, 25, 48, 51

of bifurcation lesions, 84

Medtronic bifurcation Y-stent

, 214, 218

Microfocus X-ray computed tomography (MFCT),

198

3-D model, 199, 201 after culottes tenting, 203 vs. IVUS, 193, 194 of SB stents, 207 after simultaneous kissing stenting, 203, 204 of T-stenting and protrusion (TAP), 204

after V-stenting, 204 Minicrush stent technique, 91–94 Modiﬁed balloon crush techniques, 163. See also

Step crush techniques Modiﬁed T-stent technique, 88–90, 175, 201–202 Multilink Frontier

, 214, 218–219 Multislice computed tomography (MSCT), 44 Murray’s law, 18, 19, 49 “MV to SB” stenting technique, 206–207, 208

Nile

, 213 Nile CroCo Nile Delta Nile Pax

, 222–224

, 222, 224

, 224

Non–left main coronary artery bifurcation lesions

elective double stenting (EDS) for, 83

bifurcation lesion anatomy, 83–85 optimal EDS technique, 113–114 patient selection, 83 technique description, 85, 103, 104, 105 technique execution, 103, 105–113

provisional stenting technique for, 48

anatomical characteristics of, 48–53, 54

side branch stenting strategy, 53–64 Nonthreatened SB morphologies, 10 Nordic bifurcation study, 61, 67, 71 Nordic Stent Technique Study, 113, 169

One-step kissing postdilation, 167 Optical coherence tomography (OCT), 40–41, 43, 44 Ostial SB lesion, treating, 68

FFR-guided provisional stenting, 69–70 limitations, 70–71

Paclitaxel-eluting stent (PES), 140, 185 Pathﬁnder

, 214, 218–219

Percutaneous coronary intervention (PCI), 22, 134,

149 vs. CABG, 121–122, 123, 124, 128 for ULMCAD, 118

PERFECT (PrE Rapamycin-eluting stent

FlExi-CuT), 184

Petal

, 229–233 Plaque shift, 22 Point of bifurcation (POB), 26 Polymer matrix of polysulfone (PESU), 225 Polyvinyl acetate (PVA) tubes, 193–194 Polyvinylpyrrolidone (PVP), 228 ProTeqtor



, 225

Provisional stenting (PS) technique, 53

in coronary bifurcation lesions, 67

case examples, 71–81 FFR-guided provisional stenting, 69–71 fractional ﬂow reserve (FFR), 67–68 ostial SB lesion, treating, 68–71

SB ostial lesions, 68 vs. elective double stenting (EDS), 2–3 guidewire recrossing into SB, 195 kissing balloon inﬂation (KBI), 196 for left main coronary artery bifurcation lesions,

134 antiplatelet therapy, 145 concomitant disease, in the distal circumﬂex

artery, 137, 138 distal LMCA bifurcation, 137, 138 guide selection, 140 lesion preparation, 140, 141 main branch stenting, 140 patient preparation, 139–140 plaque distribution and side branch lesion

severity, 134 SB (LCX artery), size of, 134–137 SB management, 140–142 stent deployment optimization, 142–144 tips and tricks in, 144–145

254

Index

Provisional stenting (PS) technique (Continued)

for non–left main coronary bifurcation lesions,

48 anatomical characteristics of, 48–54 angle between the branches, 48 ﬁnal kissing inﬂation (FKI), 60–61 lesion length, 48–49, 52 main branch, stenting, 59 observed/expected diameter, 49, 52 plaque distribution, 52–53, 54 predilation, 56–58 SB rewiring, 60 side branch stenting strategy, 53, 61–64 wiring both branches, 55

Provisional T-stenting, 142 Proximal Angle A, 152, 154 Proximal cross vs. distal cross, 58, 60 Pseudo-bifurcations, 60 Pseudostenosis, 154

Quantitative coronary angiography (QCA), 19, 26,

29–38, 39

Randomized controlled trials (RCTs), 48, 83, 116,

117, 211

generalizability of, 7, 9 Retrospective studies, 2 Reverse crush technique, 142 Rotational atherectomy, 58, 182, 183

T-stenting and protrusion (TAP), 61, 90–91,

204–205, 175

T-stenting technique, 175

classical T-stenting technique, 87–88 modiﬁed T-stent technique, 88–90

T And Protrusion (TAP), 90–91 T-techniques, 61, 170–175 Target lesion revascularization (TLR), 221 Target vessel failure (TVF), 121 Taxus Petal

, 229, 233 Threatened SB morphologies, 9, 10 TOP (TMI Ostial Preservation), 235 Transcatheter Cardiovascular Therapeutics (TCT),

219

True bifurcations lesions, 20, 54, 60, 83, 84, 245

Tryton Twin-Pass catheter, 159 Tw in -R ai l

, 212, 240–244

, 213

Two-step kissing inﬂation, 167

ULTIMA (Unprotected Left Main Trunk

Intervention Multicenter Assessment), 118 Unequivocal evidence, 116 Unprotected left main coronary artery disease

(ULMCAD), 116

CABG surgery

vs. medical therapy, evidence for, 117 vs. PCI, 118

clinical practice guidelines and clinical

judgment, 116–117

evidence beyond current guidelines, 118 SB lesion severity and length, 25–26 SB occlusion (SBO), 7, 8, 9 SB ostial lesions, 68 SB size and myocardial territory, 22, 24–25 Side branch rewiring, 60 Sideguard Sidekick

, 212, 235–240

, 213 Simple T technique, 61 Simultaneous kissing stent (SKS) techniques,

BMS vs. DES, 119–120 DES vs. CABG, 120–121

PCI vs. CABG, 121–122, 123, 124, 128 good-risk surgical patients with, 126–131 revascularization of patients, 122

neglected surgical endpoints, 125–126

V-stent techniques, 100–103, 104, 105, 156–163, 204 Virtual histology (VH), 40–41, 43, 44

156–163, 196, 197, 202–204 Sirolimus-eluting stent (SES), 140, 185 Sleeve technique, 98 Smartscope MVP100, 16 “Standard of care,” 116, 125, 130 Stent delivery systems (SDS), 212, 229

Stentys

, 213, 225–229

Wall Shear Stress (WSS), 52 Wire bias, 212 Wire twisting, 212 Wire wrap, 212

Y-med Sidekick

, 214, 218 Step crush techniques, 94–97, 163–164, 167 SYNTAX score, 121, 122, 124

Zeta stent, 173

Tips and Tricks in Interventional Therapy of

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Coronary Bifurcation Lesions

About the book

There is much discussion in the eld of interventional cardiovascular therapy as to what is the best approach to treating coronary bifurcation lesions. Many advocate for provisional stenting, stenting of the main vessel with subsequent stenting of the side branch as needed, while some advocate for elective double stenting of both branches. This book is the rst of its kind to take a unique approach to this issue by considering the management of bifurcation lesions in the context of the individual patient’s bifurcation anatomy. A highly-illustrated, evidence-based and practical guide, this text oers a patient-centered outlook on the technical decision making in the treatment of coronary bifurcation lesions.

Key features include:

• Anoverviewofthegapbetweenevidence-basedmedicineandpatient-centereddecisionmakingintheeldof

interventional treatment of coronary bifurcations

overviewofthefundamentalsofcoronarybifurcationanatomyanditsimportanceinmakingtreatmentdecisions

• An

• Guidance

• Practical

• Concludingchaptersthatconsidertheroleofinvitrobifurcationmodelingandthestateofdedicatedbifurcation

stent systems

About the editors

ISSAM D. MOUSSA, M.D., is Associate Professor of Medicine at the Weill Medical College of Cornell University and is the Director of Endovascular Services at the New York Presbyterian Hospital-Weill Cornell Medical Center’s Division of Cardiology. He received his medical degree from the Damascus University School of Medicine, Damascus, Syria. Dr. Moussa is a highly experienced specialist in complex cardiovascular interventions and has published extensively in the eld with a special focus

treatmentofcoronarybifurcations.HeisafellowofmultiplemedicalorganizationsincludingtheSocietyforCardiovascular

Angiography and Interventions, the American College of Cardiology and the American Heart Association. He sits on the editorial board of several peer reviewed medical journals and he is a section editor of the journal of Catheterization and Cardiovascular

Interventions.

ANTONIO COLOMBO, M.D., is a Visiting Professor of Medicine at Columbia University Hospital in New York. He is Director of

the Cardiac CatheterizationLaboratory,Columbus Hospital Milan, Italy andthe Cardiac CatheterizationLabandVascular

Interventions, San Raaele Scientic Institution, Milan, Italy. Since receiving his M.D. from the University of Milan School of Medicine, Dr. Colombo has gone on to become a foremost expert in the eld of Interventional Cardiology. He pioneered the concept of adequate stent deployment during coronary interventions, and he dened the role of intravascular ultrasound in this setting. He also played a pivotal role in development of the eld of coronary bifurcation interventions. An active member of many international medical societies, Dr. Colombo is a fellow of the American College of Cardiology and the European Society of Cardiology. He sits on the editorial board of multiple major journals including Circulation and the Journal of American College of Cardiology.

ontailoringtechnicalapproachestopatientswithleftmainandnon-leftmainbifurcationlesions

tipsandtricksthatwillhelptooptimizeresultsandmanagecomplications

Telephone House, 69-77 Paul Street, London EC2A 4LQ, UK

52 Vanderbilt Avenue, New York, NY 10017, USA

www.informahealthcare.com

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