Coronary bifurcations stenosis: definition, classification of lesions, classification of techniques, measurements

Transcription

1 Coronary bifurcations stenosis: definition, classification of lesions, classification of techniques, measurements Y. Louvard, ICPS, Massy, Générale de Santé, France European Bifurcation Club 10th anniversary meeting Bordeaux, France, October 17-18th 2014

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4 Presented by Bernard Chevalier in the 1st EBC meeting, september 16th 2005

5 Definition of a coronary bifurcation stenosis

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8 Fonctional hierarchy of coronary circulation: direct evidence of structure-fonction relation Kassab, Am J Physiol Heart Circ Physiol 289: H , 2005

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11 Scaling laws of vascular trees: of form and function Kassab, Am J Physiol Heart Circ Physiol 290: H894-H903, 2006

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13 Scaling of myocardial mass to flow and morphometry of coronary arteries Choy, Kassab, J Appl Physiol 104: , 2008

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15 How to define a bifurcation lesion? A coronary artery narrowing occuring adjacent to, and/or involving, the origin of a significant side branch A significant SB is a branch that you don't want to loose in the global context of a particular patient Y. Louvard Catheter Cardiovasc Interv Feb 1;71:175-83

16 Bifurcation or not?

17 Classification of bifurcation lesions

18 Classifications of bifurcation lesions Duke Sanborn Safian Icps-Lefevre Syntax classification Chen - Gao

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20 A New Proposed Simplified Classification of Coronary Artery Bifurcation Lesions and Bifurcation Interventional Techniques Movahed, J Invas Cardiol 2006;18:

21 A New Proposed Simplified Classification of Coronary Artery Bifurcation Lesions and Bifurcation Interventional Techniques BL1nT-CA BL1sT-LM BL2T-LM-CA? Movahed, J Invas Cardiol 2006;18:

22 Major Limitations of Randomized Clinical Trials Involving Coronary Artery Bifurcation Interventions: Time for Redesigning Clinical Trials by Involving Only True Bifurcation Lesions and Using Appropriate Bifurcation Classification Suggested algorithmic approach for randomized clinical trials involving coronary bifurcation intervention Movahed. Journal of Interventional Cardiology 2011

23 MB (Proximal) 0, 1 Medina Classification MB (Distal) 0, 1 SB 0, 1 1,1,1 1,1,0 1,0,1 0,1,1 1,0,0 0,1,0 0,0,1 Medina et al. Rev. Esp. Cardiol 2006; 59(2): 183-4

24 Name the bifurcation Why?: - for Medina classification (which branch is the SB?) - for stenting technique definition - for intention to treat analysis A B C D Cx1,Mg1,Cx2 1,0,0 LAD1,LAD1,Dg1 1,1,1 RCA2,RCA2,Mgr 0,1,1 LM,LAD1,Ram,Cx1 1,1,0,1 E F G H LAD1,LAD1,Dg1,Dg2 0,1,1,1 Mg2,Br2,Br1 0,1,0 RCA3,PDA,PLA 1,0,0 LAD1,Dg1,LAD2 1,1,1 Louvard Y. CCI. 2008, 71:

25 What is our Medina classification? Simple Easy to remember Research classification Incomplete (angle, SB lesion length, Ca++ ) Can be completed by quantification Visual / base on quantification IVUS Medina, OCT Medina, FFR Medina

26 Todaro, Burzotta, Rev Esp Cardiol. 2009;62(6):606-14

27 Evaluation of a Strategy for Treating Bifurcated Lesions by Single or Double Stenting Based on the Medina Classification Todaro, Burzotta.Rev Esp Cardiol. 2009;62(6):606-14

28 Evaluation of a Strategy for Treating Bifurcated Lesions by Single or Double Stenting Based on the Medina Classification Todaro, Burzotta, Rev Esp Cardiol. 2009;62(6):606-14

29 Quantification of a coronary bifurcation stenosis

30 D1 Murray s law 3* 3* 3* D 1 = D2 + D3 D3 Finet s formula D1= (D2+D3) X 0,678 D2 * 2.3 (Huo-Kassab) Adapted from G. Kassab

31 Traditional QCA for coronary bifurcation quantification: reference, MLD, %

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33 Dedicated bifurcation QCA

34 Bifurcation

35 Quantitative Angiographic Methods for Bifurcation Lesions: A Consensus Statement from the EuropeanBifurcation Group Subsegment analysis demonstrating the various segments that should be analyzed and reported separately Lansky, CCVI 73: (2009)

36 Classification of bifurcation stenting techniques

37 Classification of Treatments A B C D + High Tech meeting 1997

38 Classification of Treatments A Technique B Technique C Technique D Technique or 2 1 or «Skirt» Technique Y. Louvard, Heart 2004; 90 :

39 Exhaustive? Simple? Schematic description of interventional bifurcation techniques: OST = one stent technique; SBT = stent with balloon technique; KST= kissing stent technique; TST = T stenting technique; CRT = crush stenting technique; CUT = culotte stenting technique Movahed. J Invasive Cardiol May;18(5):

40 M Main prox. first A Main Accross side first D Double first S Side branch first 1 st stent PM stenting MB stenting across SB DM stenting Provisional SKS SB ostial stenting After balloon Skirt MB stenting + SB balloon MB stenting + kissing SB SB crush minicrush 2 stents Skirt + DM Skirt + SB Elective T stenting Internal crush Culotte TAP V stenting SKS Syst. T Stenting Minicrush Crush 3 stents Extended V Trouser legs and seat

41 M Main prox. first A Main Accross side first D Distal first S Side branch first 1 st stent Inv. MB stenting across SB Inv. Provisional SKS DM ostial stenting After balloon MB to SB stenting + DM balloon MB to SB stenting + kissing DM minicrush DM crush 2 stents Inv. Inv. Elective Internal T stenting crush Inv. Culotte Inv. TAP Inv. Inv. Syst. Minicrush Crush Inv. T Stenting 3 stents

42 Two-stent strategies for bifurcation lesions: which vessel should be stented first, the main vessel or the side ranch? Adjusted incidences of cardiac death, MI and stent thrombosis using inverse probability weight (A) and standardized mortality/morbidity ratio weight (B) Shin, J Korean Med Sci 2011; 26:

43 e- CRF? MB stenting accross SB first MB stenting with protection MB stenting with SB balloon Proximal MB stenting first 1st stent 2nd stent 3rd stent Proximal MB stenting Wires 1st stent? Helqvist Elective T stenting Internal Crush Culotte «Buchbinder?» Skirt technique 2nd stent DK-Crush technique, Chen, Eur J Clin Invest 2008; 38 (6): SB stenting first Distal branches stenting first Balloons SB ostial stenting SB Crush stenting 1st stent 1st and 2nd stent 3rd stent V stenting V + proximal stenting 1st stent Systematic T stenting Minicrush Crush technique ½ SKS SKS 2nd stent Intention Inverted

44 Conclusions Better definition of bifurcation stenosis? Possible? Useful? Do we need another classification than the Medina s? No Classification of treatments: how to take into account the complexity of techniques? What is missing?