Tiếp cận với chiến lược 2 stent two stent approach for bifurcation PCI

Two stent approach for bifurcation PCI Faisal Latif MD, FSCAI, FACC Assistant Professor of Medicine, University of Oklahoma Director, Cardiac Catheterization Laboratories Veterans’ Affairs Medical Center Oklahoma City, Oklahoma USA I Have No Financial Disclosures Learning Objectives • Upon completion of this presentation, learners will be able to: – Understand simple vs complex bifurcation stenting strategy – Review available data – Comprehend when a 2-stent strategy is better – Recognize role of 2-stent strategy in left main bifurcation Definitions • Simple strategy: – Stenting of the main vessel only • Complex strategy: – 2-stent technique (MB, SB) – Any bifurcation PCI technique 5-year F/U Provisional vs 2-Stent • 413 patients randomized: – simple (provisional) vs complex (2-stent) • All-cause death no different • Non–procedure-related MI 4% vs 8% (2stent) (p = 0.09) • TVR: 13% vs 18% (p = 0.14) • Stent thrombosis 3% vs 1.5% (p = 0.31) Primary: Cardiac death, MI, TVR, ST Secondary: All-cause death, MI, TVR, ST Provisional Strategy Better! Maeng, M, et al JACC 2013;62:30-34 “Simple is Better” • Compared to complex, simple one-stent strategy is the preferred due to: – Lesser incidence of MI peri-procedural and long-term • However, no difference in cardiac death Hildick-Smith D, et al Circulation 2010;121:1235-43; Colombo A, et al CACTUS Study Circulation 2009;119:71-8 Katritsis DG, et al Circ Cardiovasc Interv 2009;2:409-15 Zhang F, et al Heart 2009;95:1676-81 2-Stent Strategy • When we put in 2-stents, what we worry about? – Stent thrombosis – In-stent restenosis – Expertise and familiarity with the PCI techniques – Contrast volume; fluoroscopy time Simple vs Complex In DES Era: A Meta-Analysis • RCTs, 2569 patients • No difference: – CV death (p=0.98) and stent thrombosis (p=0.24) – side branch restenosis (p=0.07), TVR (p=0.09) • Simple strategy: Less risk of MI (p=0.01) Gao XF, et al EuroIntervention 2014 Sep 22;10(5):561-9 Large Side-Branch: Subgroup Analysis Simple Strategy Higher TVR (OR 2.27; p=0.01) Simple Strategy  Higher MV Restenosis (OR: 2.56; p=0.02) True bifurcation: Subgroup Analysis Simple Strategy Higher TVR (OR 2.04; p=0.02) Simple Strategy  Higher MV Restenosis (OR: 2.06; p=0.02) NORDIC Bifurcation Study • 424 pts randomized Crush (n=209) Culotte (n=215) • Peri-procedural increase in markers: – 15% (crush) vs 9% (culotte) (P=0.08) • Primary end point: MACE, cardiac death, • Fluoroscopy time and contrast volumes MI, TVR, ST at mths similar MACE (cardiac death, MI, TVR, ST) at months P=0.87 ISR of MB/SB: 10.5% Crush vs 4.5% Culotte (P=0.046) Erglis A et al Circ Cardiovasc Interv 2009;2:27-34 DK-Crush Technique • Stent SB  Balloon crush  First kissing balloon inflation  Stenting MV  Final kissing balloon inflation • Final kissing balloon inflation performed as a 2step kissing inflation – Inflate in the SB first, then kissing inflation at 16 atm – Two non-compliant balloons inflated at ≥16 atm were used for all final kissing balloon inflations DK-Crush vs Provisional Stenting • 2007-09 • 370 randomly assigned to either group • Primary endpoint: MACE at 12 months • Secondary endpoint: Angio restenosis at months • LM excluded • True bifurcation in >80% patients • Results • MACE & ST no different • Angiographic restenosis less with DK-Crush: – MB ISR (4% vs 10%; p=0.03) – SB restenosis (5% vs 22%; p < 0.001) • SB stenting in the PS group required in 29% lesions Survival Free from TLR Survival Free from TVR Chen SL, et al JACC 2011;57:914-920 Unprotected LM Bifurcation • 1-stent vs 2-stent using DES • 2004-07: 633 patients (232 in 1-stent; 401 in 2stent group) • Primary endpoint: MACE at years (composite of CV death, MI, TVR) • 2-stent group: DK crush (n=155) and other techniques (n=246) • Increased MI in one-stent group (10.5% vs 5.5%, p=0.025) Chen SL, et al EuroIntervention 2012;8:803-14 MACE at Years 1-Stent vs 2-Stent 1-Stent vs DK-Crush DK-Crush vs Other 2-Stent Techniques MACE TLR TVR Predictors of 5-year MACE for LM Bifurcation • Non-DK crush two-stent technique • High SYNTAX Score (≥33) or New Risk Stratification (NERS) score >20 • Incomplete revascularization LM Bifurcation: 2-stent technique is an independent predictor of MACE, unless DK-CRUSH is used Take Home Points • 2-stent strategy with: – Large side branches or true bifurcation – Improved TLR in medium-term • DK-Crush and Culotte better than other techniques • Overall, clinical outcomes no different • ?2-stent strategy better in LM bifurcation • Final kissing PTCA very important! Two stent approach for bifurcation PCI Faisal Latif MD, FSCAI, FACC Assistant Professor of Medicine, University of Oklahoma Director, Cardiac Catheterization Laboratories Veterans’ Affairs Medical Center Oklahoma City, Oklahoma USA