bvs in bifurcations, techniques, acute and long-term outcome · bvs in bifurcations, techniques,...
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BVS in bifurcations, techniques, acute and long-term outcome
Maciej Lesiak Department of Cardiology
University Hospital in Poznan, Poland
Potential conflicts of interest
Speaker's name: Maciej Lesiak
I have the following potential conflicts of interest to report:
Consulting, speaker bureau: Abbott Vascular, AstraZeneca, B Braun,
Boston Scientific, Tryton Medical
Bifurcation stenting & scaffold limitations
Device’s profile crossing through the struts of the side of the stent (SB scaffolding)
Dilatation limits fractal geometry of bifurcation
Struts’ thickness double / triple layers (overlapping stents, crush technique)
Struts’ fragility strut fracture (radial strength, floating struts…)
Ormiston, TCT 2013
124 SB dilatations at mean of 14 atm, 3.0 and 3.5 mm Absorb scaffolds. SB Balloons 2.0, 2.5 and 3.0mm diam (NC)
There were 20/124 strut fractures (16%) All were single
2.0 mm balloon inflation 0/27 (0%) 2.5 mm balloon 5/45 (11%) 3.0 mm balloon 15/52 (29%)
Hoop #
Strut crossing & dilatation
Poznan Bifurcation BVS Registry
Consecutive bifurcation cases treated with BVS
Informed consent
Any indication to PCI (stable or ACS)
Any Medina type
No excessive calcium & tortuosity
Inclusion / exclusion criteria
General stenting strategy
• Provisional technique – the treatment of choice
• Avoiding complex techniques with high probability of scaffold struts’ fractures (Crush, Culotte)
• Recommended complex techniques: T or TAP
Provisional technique
• Pre dilatation – MV only
• Scaffold sizing according to proximal MV RD (low pressure impl.)
• POT – short NC bal. max. 0.5 mm larger than the reference, high
pressure
• End of procedure if a SB ok (DS ≤ 75% & TIMI 3)
• Otherwise rewire and FKB with minimal protrusion with two short
NC balloons at maximum 8 ATM, +/- 2nd POT
• Bailout SB stenting if needed using T or TAP
Complex techniques
Only T or TAP technique used
In TAP metallic DES instead of BVS in case of difficulty with delivering BVS through the struts of a scaffold
Using Crush or Culotte strongly discouraged
OCT in complex cases strongly recommended
DAPT @ Discharge
Initial strategy ASA 75–100mg + Clopidogrel 75mg recommended for 12 months Since December 2013 Clopidogrel resistance testing (Multiplate) In patients with high on-treatment platelet reactivity -ticagrelor/prasugrel instead of clopidogrel Since March 2014 Ticagrelor 2 x 90 mg for 12 months after procedure
Clinical outcomes
*One case of fatal hemorrhagic stroke, on case of sudden death 9 days after procedure
**One definite ST 6 days after PCI, one probable 9 days after PCI (sudden death)
Follow-Up
Median observation time – 414 days. Mean observation time – 420 ± 152 days
58 patients completed 9-mo FU – 89%, 45 patients completed 12-mo FU – 69%
Only one patient prematurely stopped DAT (after 7 months), because of prostate cancer
Baseline characteristics and angiography 49YO man, stable angina class 3. Anterior MI & PCI of LAD in 2013 6 F Guide, femoral approach
Target vessel
Baseline characteristics and angiography 60 YO woman, stable angina class 2 6 F Guide, femoral approach
Medina 0,0,1
61 YO woman, stable angina class 2, Hypertension, IDDM 6 F Guide, femoral approach
06 DEC 2013
BVS for bifurcations Conclusion
• Bifurcation stenting with BVS is feasible in most of the anatomical variants
• In-hospital results are satisfactory with very few complications
• Subacute stent thrombosis may be an issue. Platelet function testing or routine use of modern P2Y12 inhibitors (at least in the early months) is strongly recommended