IVUS analysis of complex techniques (Crush, culotte)€¦ · • All IVUS recordings were made with...

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IVUS analysis of complex techniques (Crush, culotte) IVUS analysis of complex

techniques (Crush, culotte)

Andrejs ErglisLatvian Centre of Cardiology

Pauls Stradins Clinical University HospitalRiga, LATVIA

DisclosuresDisclosures

• Consultant agreement with J&J Cordis• Consultant agreement with Boston

Scientific Corp

IntroductionIntroduction

• IVUS has become an integral part of all interventional studies. Fundamental IVUS parameters characterizing the success and failure of different stenting techniques are:– % neointimal volume obstruction – acute and late malapposition– edge effects

• PCI of bifurcation lesions is complex and challenging. Despite the advance of DES, restenosis at the side branch (SB) ostium continues to be a problem. Still bifurcation lesions have not been studied with IVUS extensively.

IVUS in bifurcations lesionsIVUS in bifurcations lesions

• Pre-intervention:– Involvement of the SB in bifurcation lesion? → diseased?

stenotic? → stenting technique• Postintervention:

– Has SB been compromised (after provisional stenting)?– Is there adequate stent expansion (after stenting both

branches)?• Follow-up:

– Development of neointimal hyperplasia?– Late malapposition, edge effects?

• IVUS can not adequately assess the SB from the main vessel (MV); therefore it is necessary to image the SBdirectly

IVUS and Optical CoherenceTomography

PurposePurpose

• There is little data on IVUS findings in both branches after bifurcation lesion intervention regardless of the approach

• Our goal was to acquire and analyze the IVUS images in both branches of bifurcation lesions after different stenting strategies at 8-month follow-up (Nordic Bifurcation Study)

The Nordic Bifurcation Study The Nordic Bifurcation Study

• It was a prospective, multicenter, randomized trial that compared outcomes between 2 different interventional strategies with the sirolimus-eluting stent for the treatment of bifurcation lesions:– Stenting the main vessel with optional stenting of the side branch

(provisional)– Stenting both the main vessel and side branch (routine)

• At 8-month follow-up IVUS substudy was introduced in two centers (Stradins Hospital in Riga, Latvia and SkejbyHospital in Aarhus, Denmark)

MethodsMethods

• IVUS assessment of main vessel or both branches was performed at the time of follow-up angiogram in 115 patients:– 68 patients in Riga and 53 patients in Aarhus

• All IVUS recordings were made with an automated pullback speed of 0.5 mm/s, aiming to start at least 10mm distal and to end at least 10 mm proximal to the stent

• IVUS analysis performed with computer-based quantitative analysis system (QCU–CMS version 4.14 MEDIS Medical Imaging Systems Inc, Leiden, Netherlands)

• IVUS analysis included:– Segment identification– Qualitative analysis– Quantitative (volumetric) analysis

In-stent segmentsIn-stent segments

IVUS analysisincluded 5 segments:

1: SB distal stent

2: MB distal stent

3: MB “bifurcation”

4: MB multiple layersof stent

5: MB proximal stent

Pitfalls for IVUS analysisPitfalls for IVUS analysis

Stent = 23 mm

Bifurcation segment analysis:

True or phantom results?

The challange for software and/or interpretation?

Volumetric analysis – to be or not to be?

Bifurcation segment = 2 mm

“Crush” technique“Crush” techniqueAngiography:

75% stenosis of RPD/RPL bifurcation

Procedure:1. RPD stenting:

Cypher 2.5x13mm @ 15 atm

2. RPL stenting: Cypher 3.0x23 mm @ 17atm

3. Kissing balloon postdilatation:

• RPD: Maverick 2.5x12mm @ 8atm

• RPL: Larus 3.5x20mm @ 8atm

“Crush” technique“Crush” technique

Final result 8 mo follow-up

Restenosis in side branch

“Crush” technique“Crush” technique

RPLRPL

RPDRPD

Proximal Stent Distal Stent

Minimum lumen area:MB Distal = 7.30 mm2

MB Bifurcation = 7.34 mm2

MB Crush = 3.47 mm2

MB Proximal = 6.64 mm2

SB MLA = 3.11mm2

33 22 11

22334455** **

RPDRPD

RPLRPL

**** ****

Side branch

Proximal MB Crush MB Bifurcation MB Distal MB

Multiple layers of stent strutsMultiple layers of stent struts

Stent = 23 mm

MLS area = 4.5 mm

Crush area (↑) with eccentric intimal hyperplasia (↑ ↑) next to or opposite to multiple layers of stent metal

“Culotte” technique“Culotte” techniqueAngiography:

75% stenosis of LAD/diagonal bifurcation

Procedure:1. Pre-dilatation of LAD:

Maverick 3.0x12 mm @10atm

2. LAD stenting: Cypher 3.5x23 mm @ 16atm

3. Opening struts to diagonal: Maverick 2.5x12mm @ 16atm

4. Diagonal stenting: Cypher 2.75x18mm @ 16 atm

5. Postdilatation of LAD: Aqua 4.0x10 mm @ 10atm

6. Kissing balloon postdilatation:

• LAD: Asahi 3.5x20mm @ 8atm

• D1: Asahi 2.75x18mm @ 8atm

Preintervention

“Culotte” technique“Culotte” technique

Final result 8 months follow-up

“Culotte” technique“Culotte” technique

LADLADProximal Stent

Distal Stent

Cullote zone

Major concern:

The MLD and MLA of both branches atthe bifurcationpoint

Minimum lumen area:

Distal Stent = 6.54mm2

Bifurcation = 6.00mm2

Cullote = 6.80mm2

Proximal = 9.97mm2

ResultsResults

• Data from Riga centre are summarized for 35 patients after complex stenting technique:– 23 Crush – 2 Culotte– 12 T-stent

• IVUS was performed in both branches in 30 patients and hyst themain branch in 5 patients

• Overall, MB minimum lumen area (MLA) was larger than the SB: 5.5±1.4 mm2 vs. 4.2 ±1.1 mm2

• In MB, MLA was found in:– Distal stent segment in 15 patients (43%)– “Bifurcation” segment in 11 patients (31%)

2 stents vs 1 stent2 stents vs 1 stent

Main Branch

2 stent 1 stent

5.5 5.4

Main Branch

2 stents 1 stent

%NIV = Neointimal Volume x 100 / Stent Volume

P=0.720

P=0.734

Results of 35 patients after complex stentingand 27 after one stent strategy

5.7 5.5

Main Branch

2 stents 1 stent

P=0.504

Minimum Lumen Area (mm2)

Minimum Stent Area (mm2)

Minimum Lumen and Stent Area(2 stents)

7.58.1

7.88.3

Proximal MainBranch Stent

Multiple layer MBstent

Distal Main BranchStent

Distal Side BranchStent

Lumen Stent

Results of 35 patients after complex stenting:

21 – Crush technique

2 – Culotte technique

12 – T-stent technique

Minimum lumen area p ANOVA < 0.001

Minimum stent area p ANOVA < 0.001

Minimum Lumen & Stent Area (mm2)

Percent neointimal volume obstruction(2 stents)

0.4 0.5

Proximal MainBranch Stent

Multiple layer MBstent

Distal Main BranchStent

Distal Side BranchStent

%NIV = Neointimal Volume x 100 / Stent VolumeResults of 35 patients after complex stenting:

21 – Crush technique

2 – Culotte technique

P=0.778 P=0.312

Crush/Cullote vs T-stentCrush/Cullote vs T-stent

0.50.7

0.30.1 0.2

Proximal Main Branch Stent Distal Main Branch Stent Distal Side Branch Stent

Crush/Culotte T-stent

Results of 35 patients after complex stenting:

21 – Crush technique; 2 – Cullote technique;

Minimum Lumen Area (mm2)

Minimum Stent Area (mm2)

ConclusionsConclusions

• First results from Nordic Bifurcation Studydemonstrates a trend toward increased neointimal hyperplasia in the main branch segment with multiple layers of stent strutsdespite the minimum lumen/stent area at the side branch

• The major limitation of our study is the lack of pre-interventional and post-implantation IVUS images

ConclusionsConclusions

• Serial IVUS studies are needed to completely assess the success and failure of different complex stenting strategies in bifurcation lesions

• Both branches should be examined to exclude a contribution of stent under-expansion to restenosis and to obtain adequate assessment of SB.

• Standards for the IVUS acquisition and measurements in bifurcation lesions must be established

IVUS analysis of complex techniques (Crush, culotte)€¦ · • All IVUS recordings were made with...

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