Ostial LAD: Single stent approach is the best. Antonio A. Pocoví, MD, FSCAI, MTSAC, Advisory Council Member, CACI

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1 Ostial LAD: Single stent approach is the best Antonio A. Pocoví, MD, FSCAI, MTSAC, Advisory Council Member, CACI Chair, Interventional Cardiology Sanatorio San Lucas Instituto Alexander Fleming Buenos Aires - Argentina

2 Disclosure Statement of Financial Interest I, Antonio A. Pocovi, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3 Background Coronary bifurcation lesions were considered high risk for angioplasty in the early interventional era because of higher rates of dissection, myocardial infarction, and acute vessel closure. The advent of coronary bare metal stents reduced the risks, but in-stent restenosis was noted to be frequent at the ostium of the side branch. The introduction of DES restored interest in more complex bifurcation techniques because of the low observed rates of restenosis.

4 Background One vs.two Stents NORDIC TRIAL Circulation 2006;114: BBK (Bifurcations Bad Krozingen) Eur Heart J. 2008; 29(23): CACTUS Circulation 2009;119: BBC ONE Circulation 2010;121:

5 %TLR Background One vs.two Stents 10.9 TLR One Stent Two-Stent Nordic I BBK CACTUS BBC One N=

6 Cumulative % death, MI, TVF Background BBC ONE Primary End-Point: Death, MI, TVF 20 Complex Simple p= Follow-up time (months) Complex Simple

7 Clinical Case 51 years old male. Cardiovascular risk factors: Hypertension. Hyperlipidemia. Current smoker. Overweight. Previous Treatment: Valsartan. Statins. No previous coronary history. The patient was admitted to the intensive care unit for chest pain lasting more than 10 hours.

8 EKG DI DII DIII avr avl avf V1 V2 V3 V4 V5 V6 Sinus rhythm. RBBB. Q waves and ST elevation from V1 to V4.

9 Clinical Case Diagnosis: Anterior wall STEMI Treatment: Aspirin and Clopidogrel (600 mg) Urgent coronary angiography and PCI

10 Coronary Angiography

11 Coronary Angiography Medina 0,1,0

12 PCI Revascularization Strategies Elective stent in LAD and provisional kissing balloon/stent in Cx. When the Cx ostium has mild to moderate focal disease AND when the Cx is suitable for stenting ( 2.5 mm): 1. Wire both branches, LAD and Cx. 2. Dilate LAD. 3. Dilate Cx only if needed. 4. Stent LAD leaving a wire in Cx. 5. Angio and if both branches are ok, finish the procedure. First Stent Deployment in LAD: Stent Crossover Technique, or Exact Ostial Site Stenting (Floating Stent).

13 PCI Revascularization Strategies Kissing Balloon and/or Second Stent in Cx. In case of plaque shift in the ostium of Cx with diameter stenosis >50% and/or TIMI flow I or II : 1. Re-wire Cx and then remove jailed wire. 2. Balloon in Cx and then Kissing balloon. 3. Angio and if we have a suboptimal result in Cx, a second stent in the SB should be deployed. In this case we have the following options: If the first stent in LAD crossover the Cx and ends in the LM. Reverse T-Stent technique TAP: T-Stenting and Small Protrusion. If the first stent in LAD doesn t crossover the Cx. V-Stent technique.

14 Reverse T-Stenting Gap Indications: bifurcation lesions with an angle between LAD and Cx of ~ 90 degrees. First stent LAD trapping wire. Rewire Cx. Dilate through struts of LAD stent. Deliver Cx stent exactly at the ostium. Drawback: the technique is easy but when trying to position the Cx stent exactly at the ostium without minimal protrusion into the LAD the stent often misses the ostium (gap).

15 TAP: T-Stenting and Small Protrusion Indications: bifurcation lesions with an angle between LAD and Cx more than degrees and less than 90 degrees. First stent LAD trapping wire. Rewire Cx. Dilate through struts of LAD stent. Deliver Cx stent (proximal end of Cx stent 1 mm into LAD). Deploy Cx stent (balloon in LAD). Pull back CX deployment balloon slightly and kiss.

16 V-Stenting

17 PCI TIMI flow 0 TIMI I-II flow Guiding Catheter: Wisiguide TM VL 3.5 (Boston Scientific). Two Wires: Kinetix TM (Boston Scientific) in LAD and Cx. IV ReoPro TM

18 PCI TIMI flow 0 TIMI I-II flow Guiding Catheter: Wisiguide TM VL 3.5 (Boston Scientific). Two Wires: Kinetix TM (Boston Scientific) in LAD and Cx. IV ReoPro TM

19 PCI TIMI II flow TIMI II flow

20 PCI The stent was positioned in the LAD with Stent small deployment crossover at 18 atm. in the LM. Biomatrix Flex TM (Biosensor) 3.5 x 33 mm.

21 PCI Final result Final result

22 PCI Final result Final result

23 IVUS

24 IVUS

25 Conclusions Ostial LAD lesions remains a challenge area for stenting because of the frecuent involvement of the distal LM. Ostial LAD lesions (Medina 0,1,0) can be safetly treated with one stent, using cross-over stent or floating stent techniques. In case of plaque shift, we have the following options: Kissing balloon. Reverse T-Stent Technique. TAP: T-Stenting and Small Protrusion. V-Stent Technique.

26 Thanks very much for your attention

27 Thanks very much for your attention

28 Thanks very much for your attention

29 Thanks very much for your attention

30 Thanks very much for your attention

31 Thanks very much for your attention

32 Thanks very much for your attention

33 Thanks very much for your attention

34 Thanks very much for your attention

35 Bifurcation PCI Multiple Challenges Clinical/Anatomical Variations Clinical presentations Myocardial jeopardy Vessel size variations SB accessibility SB takeoff angulations (3D) Plaque distribution Plaque volume Plaque compliance Peripheral Vascular Issues Procedural Options IVUS guidance Single vs. double vs. triple wire Balloon predilation MB and SB Adjunctive debulking or plaque modification Provisional vs. multiple stents DES vs. BMS Kiss? Multiple stent deployment strategies Adjunctive pharmacotherapy

36 Clinical Case 51 years old male. Cardiovascular risk factors: Hypertension. Hyperlipidemia. Current smoker. Overweight. No previous coronary history. Previous Treatment: Valsartan. Statins.

37 Clinical case EKG

38 Coronary Bifurcation Lesions Medina Classification Medina A, Rev Esp Cardiol 2006;59(2):183

39 Coronary Bifurcation Lesions Medina Classification 0,1,0 1,1,1 Medina A, Rev Esp Cardiol 2006;59(2):183

40 Coronary Bifurcation Lesions Medina Classification Medina A, Rev Esp Cardiol 2006;59(2):183

41 PTCA

42 PTCA

43 PTCA

44 PTCA

45 PTCA

46 %TLR One Stent vs.two TLR 10.9 One Stent Two-Stent % Crossover; TIMI 0 post SB PTCA % Crossover; >60% and/ or flow-limiting dissection Nordic I BBK CACTUS BBC One % Crossover; >50% and/ or flow-limiting dissection N= % Crossover; >70% and/ or < TIMI 3

47 Reverse T Stenting Indications Bifurcation lesions with an angle between MB and SB of ~ 90 degrees. Advantages The technique is easy, fast and not technically demanding. Drawbacks When trying to position the SB stent exactly at the ostium without minimal protrusion into the MB the stent often misses the ostium (gap).

48 Provisional Modified T-Stenting TAP Technique

49 IVUS

50 Clinical Case EKG: Sinus rhythm. RBBB. Q waves and ST elevation from V1 to V4.

51 Coronary Angiography Total Oclusion LAD Medina 0,1,0 Medina 0,1,0

52 PCI

53 PCI TIMI I-II flow

54 PCI Angio post deployment.

55 PCI Angio post deployment.

56 PCI Angio post deployment.

57 PCI Angio post deployment.

58 PCI Final result.

59 PCI Final result

60 IVUS

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