SOLACI 2012 IVUS in coronary bifurcations: is it underused? A. Medina Servicio de Cardiología Hospital Universitario de Gran Canaria Dr. Negrín Canary Islands (Spain) No conflict of interest
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SOLACI 2012
IVUS in coronary bifurcations: is it underused?
A. MedinaServicio de Cardiología
Hospital Universitario de Gran Canaria Dr. Negrín Canary Islands (Spain)
No conflict of interest
Lesion in a non bifurcated segment Bifurcation lesions
{1,1,1}
LAD
Dg
Medina et al. Rev Esp Cardiol 2006;59(2):183
… BEYOND MEDINA´S CLASSIFICATION
SB: focal vs long (>10 mm) lesion
{0,1,0,0}
{1,1,1} {1,1,1}
Trifurcation (LM 10%)
balanced vs small SB
{1,1,1}
Angle: Y and T shape
{0,1,0}
LAD
DgDg
{1,1,1}
Proximal MB SB
Distal MB
Medis QAngio XA 7.1 dedicated bifurcation QCA system
Paieon CardiOp-B 3D
Long axis reconstruction
{0,1,1}
Proximal LAD Distal LAD
Dg
{0,1,1}
Dg
LAD
plaque
Virmani
plaque
plaque
{0,1,1}
Proximal LAD Distal LAD
Dg
p
p
DgLAD LADLAD
LAD LAD
After kissing
Carina displacement – Ostial damage Carina repositioning
stent
LAD
Dg
LAD
Dg
LAD
Dg
After MB stenting
{0,1,1}
Baseline
Ca
rin
a r
eg
ion A B C
…IVUS allows to monitor the treatment
Strategies for bifurcation lesion stenting:Impact of IVUS guided
Park SJ et al. Circ Cardiovasc Intervent 2009;2:167-77
Strategies for bifurcation lesion stenting:Impact of IVUS guided
Oval shape
LADLM
LCx
LADLM
LCx
LADLM
LCx
LADLM
LCx
“Vulnerable anatomy of the carina in ostial left anterior descendinglesions treated with floating stent”. Medina et al . Rev Esp Cardiol.2009;62(11):1240-9
“Ultrasound study of the prevalence of plaque at the carina in lesionsthat affect the coronary bifurcation. Implications for treatment withprovisional stent” Medina et al. Rev Esp Cardiol. 2011;64(1):43-50
“Predictors of ostial side branch damage during provisional stenting ofcoronary bifurcation lesions not involving the side branch origin: anultrasonographic study ”. Suárez de Lezo et al. Eurointervention (Suárezde Lezo et al. Eurointerv 2012;7:1147-54)
Ultrasound anatomy of bifurcation lesions and techniques
“Ultrasounds findings during percutaneous treatment of bifurcatedcoronary lesions”. Suárez de Lezo et al . Rev Esp Cardiol.2008;61(9):930-5
“Sequential side-main-side vessels balloon dilation (SMS technique) forbifurcation lesions treated with provisional stenting” Medina et al . ESCCongress 2011
Ult
raso
un
d a
na
tom
y o
f b
ifu
rca
tio
n
Eyebrow sign
CARINA MORPHOLOGY IN BIFURCATION CORONARY LESIONS
“spiky carina”
Medina et al. Rev Esp Cardiol 2009;62:1240-9Suárez de Lezo et al. Eurointerv 2012;7:1147-54
Carina shifting
2009
2011
Medina et al. Rev Esp Cardiol 2009;62:1240-9
Osuma et al. Eurointervention 2011;62:1240-9
Baseline After MB stenting Final kissing balloon
LM LAD
LCx
LM LAD
LCx (jailed)
LM LAD
LCx
Carina displacement Carina repositioning
{1,1,?}
{1,1,0}
{1,1,?}
Spiky carina
Spatial and phasic oscillation of non-Newtonian wall shear
stress in human left coronary artery bifurcation: an insight
to atherogenesis.
Soulis JV et al. Coron Artery Dis. 2006 May;17 (4):351-8.
Wall shear stress & carina
early systole
Virmani
*
*
*
*
LM LAD
LCx
LM LAD
LCx
LADp LADd
Dg
LCx MB
LCx
*
**
LM LAD
LCx Dg
LAD LAD
Dg
Plaque at the carina 63/195 (32%)
Carina free of plaque 132/195 (68%)
LM LAD
LCx
LADp LADd
Dg
LCx LCx
MB
Medina et al. Rev Esp Cardiol 2011;64(1):43-50
The carina is not always free of disease! Is it important or not?
Medina et al. Rev Esp Cardiol 2011;64(1):43-50
LCx LCx
MB MB
LCx {1,1,0}
*
SBMB
SBMB
Plaque at the carina might prevent carina shifting!!
LAD
Dg
Septal
LAD
Dg
Septal
LAD
LAD-DG {1,1,0}
Fro
m p
rox
ima
l to
dis
tal
Snow plow effect & provisional stenting
?
A B
C D
Medina et al. Rev Esp Cardiol 2009;62(11):1240-9
Floating stent in distal left main {0,1,0} and {0,0,1}
Ostial LAD (n=96): LM stenting or not
LM stenting (n=25)
Floating (n =71)
21
6 65
4
2002 2005 2008
“Precise” stent deployment “Floating” stent (IVUS guided)
LAD
LCx
LCx
LCx
FLOATING STENT TECHNIQUE & IVUS
LAD
LAD
LM
carina
Floating struts
Stent positioning at the level of the carina
(fluoroscopy & IVUS)
transducer
LCX
LADLM
LCX
LADLM
LADLCX
Floating
Outcome of floating struts n=37/49 (75%)
I know so
very little
about you…
7 months later
Outcome of floating struts
It is all right
LAD
0
200
400
600
800
1000
1200
LM 2002-2011 Technique
One stent Two stent
1138
905 (79%)
233 (21%)
350 (30%)
{1,1,1}
0
200
400
600
800
1000
1200
LM 2002-2011 Technique
{1,1,1} Others
DISTAL LEFT MAIN
Medina classification
One stent 238/350 (68%)
Two stent 112/350 (32%)
IVUS guided 815 / 1138 p (72%)
LM LAD
LCx
LM
LAD
LCx
LCxLCx
LM LM
LADLAD
{1,1,1}
##1
LCx
T and small protusion (LCx across)
LAD
LM
LM
LAD
LCxLM LAD
LCx
LM
LAD
LCxLM LAD
LCx
LM LAD
LCxLM
LCx pull-back
LAD pull-back
2010 March
4 x 18 mm LCx floating stent
Two stages modified V-stenting##2
{0,0,1}
Baseline
After stenting
15 months
later
LM LCx
LAD LAD
LCx
{0,1,0}
A B
C
MB
LM
LCx
LAD
LAD
LCxLM
LAD
LCx
LCx
LAD
##3
FFR 0,83
LAD
LAD
Dg
Dg
FFR 0,71
{0,1,1/2}
LAD
LAD
LAD
Dg
Dg
LADLAD
LADDg LAD Dg
IVUS Guided Intervention in Provisional Stenting
Precise lesion characterization (one or two pull-backs)
Predicts success of direct stenting (IVUS catheter crosses the lesion and there is not heavy calcification)
Anatomy of the carina region:
Carina (spiky vs non spiky / plaque at the carina)
Need of a jailed wire
Distribution of plaque in MB and SB
Measurement of distal MB reference diameter (selection of the stent Ø)
LE
SIO
N
AS
SE
SS
ME
NT
ST
EN
T
D
EP
LO
YM
EN
T
Ostium of the SB
No compromise
Carina displacement
Downstream axial plaque shift
MB proximal apposition of the stent.
SB
INT
ER
VE
NT
ION
Position of the guide wire (MB SB)
Evaluation of the SB after angioplasty
Evaluation after SMS or final kissing
Evaluation of a two-stent technique
Precise lesion characterization to select the strategy of intervention
IVUS Guided Intervention in Two-Stent Techniques
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