PCI for Bifurcations: Which is the best strategy

DK Crush,Culotte,SKS,T or TAP

Subhash Chandra, MD,DM,FACC

Chairman,Cardiac Sciences BLK Super Speciality Hospital,

Pusa Road, New Delhi

CSI 2018

Selection of Technique

DEFINITION Criteria of LM bifurcation

• Simple: SB <70% stenosis,Length <10 mm

• Complex: If 2 of 6 minor criteria present

1. Calcification

2.Angle >70

3.MB diameter >2.5 mm

4.Multiple lesions

5.Thrombus

6.MB lesion length >25mm

Factors Influencing 2-Stent Approaches

• Size of SB @ to MB

Important discrepancy: Avoid Culotte

• T-Stenting

• Crush/DK-Crush

• Bifurcation Angle

>70°: T-stent, or T and Protrusion (TAP)

<70°: Culotte, Crush, DK Crush

(Secures the precious,most angulated SB as first stent)

T-Stent: Step-by-Step

• Wiring of MV and SB

• MV and/or SB dilatation (recommended but optional).

• Stenting MV with wire in place in SB (alternatively SB may be stented first).

• Rewiring SB and removal of jailed wire.

• Dilatation of SB though MV stent.

• Stenting SB though MV stent with no stent protrusion in MV (or placement of the MV stent if the SB was stented first).

• Final kissing balloon inflation.

Good if angle is --- 90 degree

T-Stent Technique Advantages and Limitations

• Simple

• High rate of ostial restenosis of the SB due to suboptimal stent coverage in the bifurcation area, particularly the ostium

Not true if TAP technique used (similar to a “mini-mini” crush)

Culotte Technique: Step-by-Step

• Wiring of both MV and SB.

• Predilatation of MV and/or SB (optional but recommended).

• Stenting of the MV.

• Rewiring SB through MV stent and removal of jailed wire in SB.

• Dilatation of SB through MV stent.

• Stenting proximal MV and SB through MV stent.

• Rewiring MV through SB stent.

• Final kissing balloon inflation.

Typically, the first stent should be placed in the

branch with the most angulated entry, whether

the MB or SB Should not be used if a large difference (≥1.5

mm) in vessel diameter between the MV and SB

exists

Culotte: Stent MB & POT before re-wiring

Culotte: Balloon SB after rewiring SB in most distal strut

Culotte: Stenting SB Remove wire from main branch

Culotte: Stenting SB & second POT

Culotte: Final Kissing After rewiring MB (Ideally also a final POT?)

Culotte Techique Advantages and limitations

• Full coverage of the bifurcation area

(especially the carina and SB ostium),

• 2 layers of metal in the proximal MV

• Multiples steps with necessity of re-wiring SBs twice

NORDIC Bifurcation Study: Crush vs. Culotte

DKCRUSH-3

Crush Technique

• Wiring of both MV and SB.

• Predilatation of MV and/or SB (optional but recommended).

• Stenting of the SB first, with an un-inflated stent (or balloon) positioned in the MV. The proximal end of the SB stent should be several mm in the MV, but the proximal edge of the un-inflated MV stent (or balloon) must be proximal to the proximal edge of the SB stent.

• SB wire and stent balloon are removed.

• Crushing the SB stent with MV stent or balloon inflation (followed by MV stent).

• Rewiring the SB through MV stent.

• High-pressure inflation of SB (optional).

• Final kissing balloon inflation (mandatory).

Crush: 2 stents in place; SB stent deployed first :

Pre-dilation

Crush Technique: MB stent then inflated crushing SB stent previously

deployed; SB wire removed

Crush Technique: Final kissing

Crush Technique Advantages and limitations

• Difficulty in SB rewiring for final kissing inflation (less with DK-Crush; hydrophilic wire can help)

• Presence of multiple layers of crumpled stent at the SB ostium, substantially increasing the rate of SB ostial ISR

DK-Crush Technique: Baseline

DK-Crush Technique: Stent LCx+ Deflated Balloon LAD

DK-Crush Technique: Crush of the LCx Stent with LM-LAD Balloon

DK-Crush Technique: Pre-dilatation ostium LCx (facilitate passage)

DK-Crush Technique: First Kissing

DK-Crush Technique: LM-LAD stent

DK-Crush Technique: POT

DK-Crush Technique: Second-Final kiss

DK-Crush Technique: Final

DK crush vs Classical crush

DKCRUSH-4 Trial(LM) Simple vs. Complex Strategy

Chen et al,JACC 2017

DEFINITION-2 Trial

• Prospective,Multicentre,Randomized controlled, superiority clinical trial at 45 sites world wide

• 660 Pts

• Provisional Vs.Two –stent approach in complex coronary bifurcation lesions

• Surprisingly DK crush has not gained desired acceptance.

• FKBI in classical crush technique is not always possible

• High adverse events in Crush tech. such as ST and ISR.

• Uniformly positive data from the DK crush trials.

• DK Crush is straightforward, reliable, safe and effective for complex LM bifurcation lesions and with all bifurcation angles.

• V stenting, SKS, Mini crush, Culotte may not be suitable in wide angled (≥70°) bifurcations.

Why DK Crush advantageous

Simultaneous Kissing Stent (SKS)

• Wiring of MV and SB

• Predilatation of MV and SB

• Placement of stents in both branches with minimal proximal protrusion in MV.

• Placement of balloons in both branches and simultaneous (or sequential) deployment of stents.

• Final kissing balloon inflation.

-Creation of a Neo Carina

-Management of ISR extremely complex…

-Really Challenging if proximal dissection

occurred…

Simultaneous Kissing Stent (SKS)

• Several limitations…Double Barrel

• The most “primitive”, “un-sophisticated”, and anti-physiological technique!

• Used in cased of real life-threatening situation

Simultaneous Kissing Stent (SKS) Advantages and limitations

Tips to remember • Importance of balloon sizing for post dilation

If too large distally, risk of carina shift

Proximal MB: know the maximal stent expansion capacity

• Importance of Final Kissing

• Importance of POT and Final POT

• Importance of IVUS guided PCI

• Choose the technique you are the most comfortable with…and avoid SKS as a first choice!

• DK Crush is going to supplant other stenting techniques and become sine-qua-non in LM bifurc.

Thanks for kind attention Subhash.Chandra@blkhospital.com