Post on 19-Jun-2020
transcript
33--dimensional Computed dimensional Computed TomographicTomographicImagingsImagings of Bifurcation Stentingof Bifurcation Stenting
Yoshinobu Murasato MD, PhDYoshinobu Murasato MD, PhD
Division of Cardiovascular Medicine, Division of Cardiovascular Medicine, Chikuho Social Insurance HospitalChikuho Social Insurance Hospital
Coronary Physiology & Imaging Summit 2007, February 10
BackgroundBackground
►► In the drugIn the drug--eluting stent era, eluting stent era, various stenting techniques various stenting techniques have been proposed for thehave been proposed for thetreatment of left main treatment of left main coronary artery (LMCA) coronary artery (LMCA) bifurcation. bifurcation.
►► However, these techniques However, these techniques have not yet been have not yet been investigated systematically investigated systematically in a 3in a 3--dimensional (3D) dimensional (3D) structure. structure.
2D experiment
3D structure
Same results?
Stent+POBA T
Y or V“V”2
1
2
Culotte
1 2
Provision-T
Crush
2 1
Kissing
2
2
211
1
2
Crush stenting in swine LCX bifurcationCrush stenting in swine LCX bifurcationFinal kissing balloon inflation (+)Final kissing balloon inflation (+)
However, the crushed stent was rather squeezed at the ostium and extended proximally from lateral to myocardial site.
Murasato Y et al. Catheter Cardiovasc Interv. 2005; 66: 237
Adequate stent apposition
Real 3D structure affected the stent expansion and caused distortion.
26.0
7.8
15.012.2
0
10
20
30
LMCA LAD-Diag LCX-OM RCA AV-PDKawasaki T. Am J Cardiol. 2006; 97 (8B): 14D
(%)
Distribution of high bifurcated angles (> 80Distribution of high bifurcated angles (> 80°°))
LMCA bifurcation has an especially wide bifurcated angle.
RAO LAO
AP caudal spiderColumn: Ø7.5cm
polyvinyl chlorideLMCA-LAD tube: Ø4.0mmLCX tube: Ø3.0mmLMCA-LCX angle = LMCA-LAD angleLAD-LCX angle = 90 °
Fluoroscopy33--dimensional LMCA bifurcation modeldimensional LMCA bifurcation model
LMCA
LADLCX
90°
135°135°
Murasato Y. Catheter Cardiovasc Interv. Online, Jan 8, 2007
MethodsMethods►► The following stentings were performed in the LMCA The following stentings were performed in the LMCA
bifurcation model:bifurcation model:Crush stenting with final kissing balloon inflationCrush stenting with final kissing balloon inflationModified crush technique with double kissing balloon Modified crush technique with double kissing balloon inflation (DK crush stenting) inflation (DK crush stenting) Kissing stentingKissing stentingModified TModified T--stentingstenting
►► HighHigh--resolution computed tomographic (CT) observations resolution computed tomographic (CT) observations were performed to investigate the following aspects:were performed to investigate the following aspects:
Stent expansion Stent expansion Stent deformationStent deformationStent apposition to the vesselStent apposition to the vesselGap formationGap formation
LMCA
LAD
LCX
LAD
LCX LMCA
Balloon overlapping inside distal LMCABalloon overlapping inside distal LMCA
Red: LAD balloon(Arashi 3.5/20)
Blue: LCX balloon(Ryujin 3.0/20)
1. LAD balloon over LCX balloon1. LAD balloon over LCX balloon 2. LCX balloon over LAD balloon2. LCX balloon over LAD balloon
AP caudal
Spider
Murasato Y. Catheter Cardiovasc Interv. Online, Jan 8, 2007
Crush stentingCrush stenting
Gap
Cross sectional viewCross sectional viewproximal
distal
(1) LAD stent over LCX stent(1) LAD stent over LCX stent
Crush stenting Crush stenting with with BxBx Velocity Velocity
Gap between the two stents
abcd
a
b
c
dCircle
Murasato Y. Catheter Cardiovasc Interv. In print
Cross sectional viewCross sectional viewproximal
distalGap
Crush stenting Crush stenting with with BxBx VelocityVelocity
(2) LCX stent over LAD stent(2) LCX stent over LAD stent
abcd
a
b
c
dCircle
Murasato Y. Catheter Cardiovasc Interv. In print
Crush stenting Crush stenting with Express IIwith Express II
Circle
Gap
Magnified view of the SB ostium
Adequate strut dilation at the SB ostium
SB stent MV stent
The gap at the SB ostium was larger compared with crush stenting with Bx velocity stent.
Absence of the strut
Strut configuration of MV stent at SB ostiumStrut configuration of MV stent at SB ostiumBx Velocity Express II
Better case
Worse case
DK crush stentingDK crush stenting►► AdvantagesAdvantages
Widely opened strut of Widely opened strut of the SB stent by first KBthe SB stent by first KBEasy reEasy re--crossing of the crossing of the guide wire and the guide wire and the balloon system before balloon system before second KB second KB Good apposition of the Good apposition of the stent to the vessel at stent to the vessel at the SB ostiumthe SB ostium
Jim MH, Catheter Cardiovasc Interv. 2006, 67, 403
1st KB
2nd KB
DK crush stenting DK crush stenting
After first KB inflationAfter first KB inflation
Dilated strut
Raised up strut
MV vascular bed
Circle
After MV stenting, is it possible to keep the dilated shape of the strut by first KB inflation?Maybe, but it has a low probability.
Crush stenting Crush stenting Worse caseWorse case
Circle
a b c dMagnified view of the SB ostium
a b c dCross sectional view
Absence of the strut of SB stent
Gap
63 y.o. Male, CTO in LCX P/S CABG (LITA-LAD, Ao-SVG-RCA: recurrent degenerative lesions)
Baseline CAG
Collateral flow from
RCA to LCX
After predilatationDK crush stenting
MV: OM branch to proximal LCX, Cypher 2.5/28 mm.
SB: middle LCX, Cypher 2.5/18 mm crushed at the proximal site.6-Mo follow up
Horiuchi M, Murasato Y. CCT, 2006
Kissing stentingKissing stenting
Stent overlapping created a gap beneath the Stent overlapping created a gap beneath the overlapped portion of the stent. overlapped portion of the stent.
LMT LMT
LAD LAD
LCXLCX
Gap
Murasato Y. J Invasive Cardiol. 2006, 18 :E279
LAD over LCXLAD over LCX
LAD: 3.5mmLCX: 3.0mm
LAD: 3.0mmLCX: 3.0mm
LCX over LADLCX over LAD
Kissing stenting using different size stents produced Kissing stenting using different size stents produced compression of the LCX stent at distal LM.compression of the LCX stent at distal LM.
LAD
LAD
LCXLCX
Stent distortion
Stent distortion
No remarkable difference in stent expansion between LAD and LCX
Murasato Y. J Inv Cardiol.
2006, 18 :E279
Murasato Y. J Invasive Cardiol. 2006, 18 :E279
Cypher 3.5/23Cypher 3.0/28
75 y.o. Female, Unstable AP
Overlap of the two stents
LCX
LAD
LAD
LADLCX LCX
Murasato Y. J Invasive Cardiol. 2006, 18 :E279
66--Mo follow upMo follow upA-P caudal RAO cranial
Spider
Cross sectional viewCross sectional viewproximal
distal
Kissing stentingKissing stenting
Gap
Compressed LCX stent
Circle
Murasato Y. Catheter Cardiovasc Interv. Online, Jan 8, 2007
Long kissing stenting Long kissing stenting in LMCAin LMCA
a
b
c
d
e
a
b
c
d
e
Cross sectional view
Circle
Multilink Zeta 4.0/33
Multilink Penta3.0/28
LCXLAD
Axis of LCX stent
Axis of LAD stent
LCXLAD
LMCA
myocardium
Differences in both longitudinal and circumferential Differences in both longitudinal and circumferential axes between LAD and LCX cause overlapping of axes between LAD and LCX cause overlapping of stent system in distal LMCA.stent system in distal LMCA.
Longitudinal sectionCircumferential section Murasato Y. Catheter Cardiovasc Interv. Online, Jan 8, 2007
PCI with DES deployment for LMCAPCI with DES deployment for LMCA
12Mo12Mo20Mo20Mo12Mo12Mo6Mo6Mo12Mo12MoF/U periodsF/U periods
DLMD 13%DLMD 13%NDLMD 3%NDLMD 3%
8%8%
NRNR
ValgimigliValgimigli44
38.0%38.0%10.0%10.0%12.9%12.9%2.0%2.0%TLRTLR
44.0%44.0%NRNR14.1%14.1%7.0%7.0%RestenosisRestenosis
2.0%2.0%4.0%4.0%3.5%3.5%0%0%Cardiac Cardiac mortalitymortality
PricePrice55LeeLee33ChieffoChieffo22ParkPark11
Crush SKS or V T Culotte
15%
24%
1%
0%
60%51%
20%
7%
8%
14%9%
6%
16%
18%
51%
40%
17%10%
0%
33%17%
74%
0%0%9%
Single stent
1. JACC 2005, 45, 3512. Circulation 2005, 111, 7913. JACC 2006, 47, 8644. JACC 2006, 47, 15305. JACC 2006, 47, 871
Modified TModified T--stentingstenting
1. Stent implantation in LCX
2. Balloon inflation in LM-LAD
3. Stent implantation in LM-LAD
4. Recross GW into the orifice of LCX stent and kissing balloon inflation
Stent distortion
5. Final fluoroscopy
Decrease in unstented segment
Minimum overlapping of the stents
Modified TModified T--stenting stenting
unstented segment
Gap
Cross sectional viewCross sectional viewproximal
distal
Modified TModified T--stentingstenting
Metallic carina
Slice at lower horizontal level
Circle
Murasato Y. Catheter Cardiovasc Interv. In print
The gap at the The gap at the epicardialepicardial site is likely to site is likely to be generated in a 3D structure.be generated in a 3D structure.
LCX
LAD
myocardium
The protrusion of the LCX stent is confirmed at the positioning.
LCX
LAD
However, the LCX stent is stretched straight after its dilation.
Gap
IVUS like view (1)IVUS like view (1)
►►The consecutive cross sectional view is The consecutive cross sectional view is available. available.
►►View from distal site of the side branch to View from distal site of the side branch to the main vessel with 0.1mm slice.the main vessel with 0.1mm slice.
►►Can you reconstruct this 3Can you reconstruct this 3--D image D image accurately?accurately?
View
IVUS like view (2)IVUS like view (2)
Absence of the strut
Incomplete crush
a
a
b
b
c
c
CypherCypherDistribution of stent strutDistribution of stent strut
a b c
a b c
TaxusTaxus ExpressExpressDilated cell
Absence of strut
ConclusionConclusion
►► In each double stenting on a 3In each double stenting on a 3--dimensional LMCA bifurcation dimensional LMCA bifurcation model, the style of stent overlap model, the style of stent overlap greatly affects stent expansion, greatly affects stent expansion, distortion and the potential for distortion and the potential for gap formation. gap formation.
►► 33--D CT imaging is very useful for D CT imaging is very useful for analyzing the condition of the analyzing the condition of the double stenting in detail.double stenting in detail.
Both plays are attractive. However, the cooperation is necessary for “Ren-jishi”.
“Sukeroku”with one
actor
“Ren-jishi”with two actors