Presentations text content in Dedicated Bifurcation Stent Technology:
Slide1
Dedicated Bifurcation Stent Technology:Implications for Everyday Practice
Jens Flensted Lassen MD, PH.D., FESC
The
Heart Centre, Rigshospitalet
University of
Copenhagen
Denmark
Slide2Disclosure Statement of Financial Interest
I, (Jens Flensted Lassen) 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.
Slide3Disclosure Statement of Financial Interest
……. BUT !!!
I, (Jens Flensted Lassen)
a
m a Board member and one of the Directors of the European Bifurcation Club (EBC) and my view on bifurcation stenting is heavily influenced by the thoughts and consensus statements of EBC.
Slide4Slide5Slide6Treating coronary bifurcationsWhy is it difficult?
True versus non-true
bifurcations
Small
and Large SB
Diameter difference between MB and SB
MB tapering
Angels between MB and
SB
4-D movements
Extension of disease in SB
Slide7© 2015 EuroIntervention. All rights reserved.
4-D movements
Slide10Treating Bifurcation Lesions
Why is it difficult?
Anatomic Variation
Side Branch : Main Branch Diameter
Angle of Bifurcation
Disease Burden: Wide Variation Difficult to Assess
Slide12Workhorse DES: Optimized for Straight LesionsPoorly Suited to of Bifurcation Lesions
Wide Variety of Techniques Required
Poorly Characterized/Inconsistently Performed:
crush,
culotte
,
reverse
culotte
,
internal crush, reverse crush, T, provisional T, Y, extended Y, V, SKS, shotgun,
Helqvist
, sleeve, modified crush,
Buchbinder
,
minicrush
,
mini crush, short back and
sides,
DK
crush, flower
Slide13Predilate side branch and/or main branchSafety wireP.O.T.Kiss/No KissPost DilateNon vs Semi CompliantSizing
Many Techniques: Many Questions
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Slide14EuroIntervention
2015;11:V96-V98
Slide15Patient level meta analysis of BBC1 & NORDIC 1
Circ Cardiovasc interv. 2011;4:57-64
Slide16"Life can only be understood backwards; but it must be lived forwards.“Søren Kirkegaard(1813-1855 Danish philosopher)
The dilemma in the provisional side branch stenting in Bifurcation lesions
Slide18EBC
Consensus:
Side branch diameter and length can both be used visually as surrogates for volume of muscle at risk.
Large side branches with
ostial
disease extending >5mm from the carina are likely to require two stents.
Side branches whose access is particularly challenging should be secured by stenting once accessed.
Slide19Bifurcation Lesions: Defining The Need
Coverage
Radial Strength
Addresses AllAngulationSB-MB Diameter DifferencesDisease Burden
Ease-of-UseTracking (Single Wire) Equipment (Operator’s Choice) Guide Catheters (5 or 6 Fr) GuidewiresCompatibility: Workhorse stent (DES or BMS)
USER ISSUES
CLINICAL REQUIREMENTS
Slide20Dedicated Bifurcation Stents:
Difficult Design Problem: Many Failures
Slide21Historical Dedicated Devices
Failed Clinically
Not ‘easy to use’
Larger profile than workhorse stents
Rotational orientation required
Two wire tracking
Poor Clinical Outcomes
Lower Procedural Success than standard stenting
Higher Event Rates than standard stenting
Slide22The Ideal Dedicated Device
Easy to use and safe
Simplify the procedure
- Shorten procedural time, reduce X-ray exposure
- reduce contrast media
Allow continuously SB access (wire)
Predictable successful
ostial
SB-stenting
High rate of procedural success
Optimal long terms results (restenosis & ST-rates, low)
Abel
to treat all kinds of
bifurcations.
Abel to be flexible during cardiac cycles
Slide23Slide24Tryton
Tryton Pivotal Trials (RCT and Confirmatory):
Landmark studies
I
mprovement
in clinical outcomes in large
branches. Long-term results required.
Simplified 2-stent technique
New guidelines include incorporation of dedicated stents (Tryton).
Slide25Complex (1.1.1) Bifurcation Lesion Involving a Large Side Branch (LAD-D1)
Baseline
Tryton
Slide26- Dedicated devices should focus on:Easy, safe and quick, treatment of the Left MainProtection of a side branch the operator don´t want to loose
ESC & EBC 2014 (15) Consensus
Slide27Conclusion – the way forward
Evaluate dedicated devices in “significant” SB
Dedicated devices
already challenge
2-stent techniques
Ease of use (simplified technique)
Designed, tested, and approved for
bifurcation
Indications for dedicated
devices
Large Side branches
Complex Disease
Left
Main
Dedicated devices may challenge provisional stenting
-
Ease of use (simplified technique)
Slide28Thank you for your attention
"Life can only be understood backwards; but it must be lived forwards.“Søren Kirkegaard(1813-1855 Danish philosopher)
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