1. 29th ANNUAL SCIENTIFIC SESSIONS – SCA&I
CHICAGO, IL – MAY 10-14, 2006
Main Session - Drug Eluting Stents
Bifurcation lesions
Antonio Colombo
Centro Cuore Columbus Milan, Italy S. Raffaele Hospital Milan, Italy
Columbia University, NY, USA

2. Minor stock holder in Cappella Inc. Manufacturing side branch stent
Conflicts:
Minor stock holder in Cappella Inc.
Manufacturing side branch stent

3. 1 or 2 stents?
A) If the side branch is significantly diseased at its ostium or nearby, it is sufficiently large to be stented, safety and duration of PCI are an issue: 2 stents
B) In all other conditions 1 stents and then evaluate

4. Baseline Final Result Treatment of Bifurcation Lesion with two stents
Can you really use one stent ?
Baseline
Final Result
11186/02

5. Treatment Baseline Treatment of Bifurcation Lesion with two stents
11162/02

6. Treatment of Bifurcation Lesion with two stents
Final Result
11162/02

7. Crush
Standard Crush: 7F, two stents in position together, side branch inflated first, main branch stent crushes side branch
Reverse Crush, used when provisional stenting requires another stent in the side branch: 6F, main branch stent deployed first, side branch stent is crushed against the main vessel stent with a balloon
Inverted Crush, makes recrossing easier and improves side branch coverage: 7F similar to Standard Crush but the side branch stent is positioned more proximally than the main branch stent, the side branch stent will crush the main branch stent.
Step Crush, as standard Crush but can be done with 6F.Advance and deploy stent in side branch

8. About the side branch: wires for recrossing and Kissing Balloon dilatation
Dilate the main vessel stent at high pressure
The original Universal Balance wire
Prowater/ Rinato (Asahi Intech wire)
Intermediate wire
Pilot 50 or 150 wire
Always perform high pressure inflation in the side branch before doing kissing

9. DES in Bifurcation Lesions (Milan experience April 2002 – March 2005)
Total number of patients: 368
Total number bifurcations: 389
True bifurcational lesions: 60%
Bifurcations treated with Cypher stent: 54%
Bifurcations treated with Taxus stent: 46%
Type D
Type F
Type G

10. DES in Bifurcation Lesions Lesion location
(389 de-novo bifurcations)
Lesion location
25% 6%
51%
18%

11. DES in Bifurcation Lesions
Stent technique
390 bifurcations
193 (49.6%)
One stent
on the MB
197 (50.4%)
Stent on
both branches

12. Stent technique (one stent vs two stents)
DES in Bifurcation Lesions
Stent technique (one stent vs two stents)
Left main
(n=98)
Other locations
(n=292)
32%
58%
42%
68%
= One stent only
= Stent on both branches

13. Stent technique (one stent vs two stents)
DES in Bifurcation Lesions
Stent technique (one stent vs two stents)
True bifurcations
(n=232)
Other bifurcations
(n=158)
41%
63%
59%
37%
= One stent only
= Stent on both branches

14. DES in Bifurcation Lesion in 292 lesions Two-stent techniques NO LMT lesions3%
83% 7% 7%

15. DES in Bifurcation Lesion in 292 lesions
Two-stent techniques Left main lesions
54% 9%
27%
10%

16. DES in Bifurcation Lesion
Milan Experience
Baseline Clinical Characteristics (II)
Group 1S
(n = 155 patients)
Group 2S
(n = 119 patients)
P Value
Diabetes mellitus, %
37 (24%)
24 (21%)
0.5
SYNTAX score
26.80±18.1
37.69±23.4
0.001
LVEF, %
54±9
53±9
0.2
Prior CABG, %
10 (7%)
10 (9%)
Prior MI, %
68 (54%)
41 (43%)
0.8
Unstable angina, %
49 (43%)
40 (35%)
0.7
GP 2b/3a inhibitors, %
17 (11%)
27 (23%)
0.009

17. Clinical Follow-Up at 12 months (n=367) All patients
DES in Bifurcation Lesion
Milan Experience
Clinical Follow-Up at 12 months (n=367) All patients
Group 1S
(n = 185 patients)
Group 2S
(n = 183 patients)
P Value
Death
3 (1.7%)
5 (2.7%)
0.5 MI
(after hospital discharge)
1 (0.6%)
4 (2.2%)
0.2
TLR
18 (5.0%)
40 (11.0%)
0.002
TVR
25 (6.9%)
52 (14.4%)
0.001
Cumulative MACE
28 (7.6%)
55 (15.0%)

18. Clinical Follow-Up at 12 months
DES in Bifurcation Lesion
Milan Experience
Clinical Follow-Up at 12 months
NO left main (n=274)
SES
(n = 156 patients)
PES
(n = 118 patients)
P Value
Death
2 (1.3%)
1 (0.9%)
0.7 MI
(after hospital discharge)
4 (2.6%)
0.08
TLR
25 (16%)
14 (12%)
0.3
TVR
33 (21%)
18 (16%)
0.2
Cumulative MACE
35 (22%)
19 (16%)

19. Angiographic follow-up (performed in 85% of lesions)
DES in Bifurcation Lesion
Milan Experience
Angiographic follow-up
(performed in 85% of lesions)
P=0.07
17.0%
10.0%
Restenosis
rate (%)
8.6%
6.6%

20. Angiographic follow-up
One stent only
Stents on both branches
P=0.03
P=0.04
23%
28%
12.0%
11%
restenosis rate (%)
5.6%
7.3%
4.0%
4.6%
= final kissing
= No kissing

21. DES in Bifurcation Lesion
Milan Experience
Stent thrombosis
0.5% 2.5%
0.5% 1.5%
(%) 2T 1C
0% 0.5% 4T 1C 1C
1 C 1C

22. Provisional SB stenting

23. Provisional Balloon – T stenting of Bifurcation Lesions1 2 3
Taxus 2.75/32: LAD
(wire protection of Septal)
Baseline
Balloon: D1

24. Provisional Balloon – T stenting of Bifurcation Lesions
3 STEPS:
-stent at 15-18atm.
KISS
-stent balloon down to 8 atm.
-main branch balloon up to 20 atm. 4 5 6
Intermediate result
Taxus 2.5/24: D1
Balloon: LAD
RESULT

25. Provisional Balloon – T stenting of Bifurcation Lesions
(8)
(7)
Additional Taxus at proximal LAD
(wire protection of RIM)
Final result

26. Baseline: LAD/ Diagonal
Provisional Bifurcation Crush Stenting with IVUS control
Baseline: LAD/ Diagonal

27. Provisional Bifurcation Crush Stenting
Rotablation prox/mid LAD burr 1.5mm
After Rotablation

28. Provisional Bifurcation Crush Stenting
Result after LAD stent
Stenting prox LAD, Cypher 3.5/33

29. Result of SB Dilatation
Provisional Bifurcation Crush Stenting
Wiring SB
Dilatation SB
Result of SB Dilatation

30. Provisional Bifurcation Crush Stenting
3 STEPS:
-stent at 15-18atm.
KISS
-stent balloon down to 8 atm.
-main branch balloon up to 20 atm.
Cypher stenting at side branch ostium: 2.5/18mm MB: Quantum Maverick 3.5 mm

31. Provisional Bifurcation Crush Stenting
FINAL RESULT

32. Provisional Bifurcation Crush Stenting IVUS controlled (Main Branch)
After Rotabltor at MB, before SB balloon dilatation
Post bifurcation stenting

33. Provisional Bifurcation Crush Stenting Final IVUS: from MB to SB
diagonal

34. Provisional Bifurcation Crush Stenting Final IVUS: from SB to MB
LAD
Into the
diagonal

35. Provisional Bifurcation Crush Stenting Final IVUS: from MB and from SB
LAD
dia
LAD
dia

36. Ostial disease: Type B, Type 4

37. V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Baseline
HSR 39456

38. V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Step 1
HSR 39456

39. V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Step 2
HSR 39456

40. V Stent-Balloon Technique
For bifurcational ostial lesions (IIIB and IV)
Final Result
HSR 39456

41. Randomized study MB vs MB and SB stenting Steigen et al ACC I2 Summit 2006
MB stenting 207 pts randomized vs MB+SB stenting 209
Procedural and fluoro time, contrast use and biomarkers > when 2 stents where implanted
6 months MACE rates < 5% in 1 or 2 stents strategy with no difference
No report about angio FU,
We do not know how many bifurcations where “True” bifurcations: the lesion length in the SB was 6 mm vs 16 mm in the MB

42. “ Crushing” CYPHER™ SELECT Provisional T CYPHER™ SELECT
CACTUS:
A prospective randomized study
n = 250 patients
“ Crushing” CYPHER™ SELECT
n = 125
1- month
Clinic.
F/U
6- month
Angio.
F/U
12, 18, 24- month Clinical F/U
de novo TRUE bifurcation lesions of the native coronary arteries R
Pre-dilatation
Provisional T CYPHER™ SELECT
n = 125

43. Conclusions for bifurcations
Most bifurcations need the SB to stay open at the end of the procedure, residual stenosis appears less relevant
If optimal result on the side branch is important, in a true bifurcation 2 stents may be needed at least 50% of the time
1 stent strategy
Angio F-U only if clinically needed