Culotte Technique in Left Main Disease

3rd EBC Meeting ‐
3rd
EBC Meeting European Bifurcation Club
European Bifurcation Club
September 2007
PALAU DE LA MUSICA Sala Rodrigo –
PALAU DE LA MUSICA, Sala
Rodrigo VALENCIA, SPAIN VALENCIA SPAIN
Culotte Technique in Left Main Disease
Culotte Technique in Left Main Disease
Peter Barlis
Carlo Di Mario
Carlo Di Mario
Royal Brompton Hospital, London, UK
• No Disclosures
Culotte technique for LM Bifurcation
Culotte technique for LM Bifurcation
Pros
Can be used as a provisional C
b
d
ii
l
bifurcation strategy
Cons
Access to LAD/LCX lost during stent A
t LAD/LCX l t d i
t t
implantation with potential not to be able to re‐enter with the wire, balloon or 2nd stent
or 2
Is adaptable to varying angles between Left main often too large for the LAD d LC
LAD and LCx, even retrovert origin
i i
current drug‐eluting stent diameters
d
l i
di
Ensures complete lesion coverage (with Relatively few DES with proven low some exceptions …….!!)
restenosis (e.g. Cypher, Taxus, Promus/Xience) with struts that can be opened > 3.5mm (Promus/Xience ~ 4mm)
Side branch access
Cypher
Taxus
Express
p
Courtesy of Dr. Ormiston
LAD/LCx ANGLE
LAD/LCx ANGLE
• At
At the Royal Brompton, we will tend to the Royal Brompton we will tend to
use culotte when there is a narrow angle or a retrovert origin
• We tend to use T‐stenting when there is We tend to use T stenting when there is
a 90 degree right angle
Bifurcational Lesion Treatment and Bifurcation Angles
Bifurcation Angle
g Measured in 209 Consecutive Patients from 64 MSCT Volume
Rendering Images
LM-LCx
LAD-Diag
LCx-OM
RCA-PD
Average
Maximum
Minimum
121
121°
168°
63°
138
138°
170°
62°
134
134°
176°
63°
137
137°
168°
82°
<110 °
26%
8%
15%
12%
Courtesy of T. KAWASAKI, Shin-Koga Hospital, Japan
45 Culotte, 35 T-Stenting
52% Cypher,
yp , 48% Taxus;; 88% Final Kissing
g
Bifurcation Angle
Preprocedure
Postprocedure
Kaplan SS, Barlis PP, Di Mario CC. Am
Heart J 2007,
Culotte
T-stenting
P value
53.6±20.8˚
60.4±22.5˚
0.16
48.9±12.5˚
62.5±23.5˚
0.0014
Bifurcation angle
45 Culotte, 35 T‐Stenting
52% Cypher
Cypher, 48% Taxus; 88% Final Kissing
Culotte
30
26
T-stenting
25
17
20
%
15
10
9
7
9
2
5
0
9M-TLR
TLR-MV
TLR-SB
2
0
SST
Kaplan S, Barlis P, Di Mario C. Am Heart J in press
MAIN BRANCH
12
Post‐procedural QVA
Culotte
10,5
T-stenting
9
P=NS
75
7,5
6
4,5
,
P=NS3,37
3,15
3,11
3,27
SIDE BRANCH
P=NS
05
1,2 0,5
3
1,5
0
RVD (mm) MLD (mm)
%DS
12,5
12
10 5
10,5
9
7,5
6
4,5
3
1,5
0
Culotte
T-stenting
P<0.0001
P 0 63
P=0.63
P=0.08
35
3,5
2,56 2,49 2,39 2,18
RVD (mm) MLD (mm)
%DS
Kaplan S, Barlis P, Di Mario C. Am Heart J 2007, in press
Culotte as a provisional ƒ Male aged 57 y LM strategy
ƒ Risk factors: Positive Family History
Hypertension
Dyslipidaemia
y p
ƒ No significant comorbidities
ƒ Social history –
y former wrestling instructor
g
ƒ New onset angina December 2005
ƒ Physical examination normal
y
• Normal ECG and echocardiography
Diagnostic angiography – Left Main stem Left Main stem + 3 vessel disease 3 vessel disease
ƒ Diagnostic angiography (occluded RCA)
Baseline angiogram
Baseline angiogram
Baseline angiogram
Baseline angiogram
Collateralised RCA
5.3 mm2
5.9 mm2
Pre‐Intervention IVUS
Promus (Everolimus)
(
) stent implanted
p
Pre Intervention
Pre-Intervention
Single 4.0 mm
everolimus stent
Postdilatation 4.0 x 24 atm
into LM/LAD and final kissing into LAD and Cx with 4.0 and 3.5 mm at 14 atm
at 14 atm
10.6mm2
Fi l
Final IVUS
IVUS
79 yr, diabetic, multiple co‐
morbidities
LCx stent balloon retracted and inflated
• Kissing dilatation
left main OCT pullback – non‐
occlusive technique
Culotte stenting using DES
Culotte stenting using DES
• Multi‐centre registry
• 127 consecutive patients treated using 127 consecutive patients treated using
the culotte strategy as the primary/intended strategy (61%) or as part of a provisional strategy (39%)
part of a provisional strategy (39%)
• Implantation of either SES or PES
U
Unpublished data
bli h d d t
Participating Centres
Participating Centres
•
•
•
•
Royal Brompton Hospital, London (n=74)
Thoraxcenter, Erasmus MC, Rotterdam (n=26)
National University Hospital Singapore (n=12)
National University Hospital, Singapore (n=12)
St Thomas’ Hospital, London (n=15)
N=127
60%
53,5%
50%
40%
30%
21,3%
20%
16,5%
8,7%
10%
21
68
27
11
Left Main Bifurcation
LAD/Diagonal
LCx/OM
RCA Bifurcation
0%
Barlis et al, In preparation
Baseline characteristics
ALL n=127
SES n=52
PES n=75
Mean Age (yrs)
Mean Age (yrs)
64 3±10 7
64.3±10.7
62 9±9 6
62.9±9.6
65 3±11 4
65.3±11.4
Male
97 (76.4)
42 (80.8)
55 (73.3)
Hypertension
82 (64.6)
34 (65.4)
48 (64.0)
Dyslipidemia
96 (75.6)
42 (80.8)
54 (72.0)
Family History
52 (41.0)
19 (36.6)
33 (44.0)
Current smoker
(
)
24 (18.9)
9 (17.3)
(
)
15 (20.0)
(
)
Diabetes Mellitus
35 (27.6)
16 (30.8)
19 (25.3)
Prior MI
65 (51.6)
28 (53.8)
37 (49.3)
Prior PCI
Prior PCI
44 (34 6)
44 (34.6)
18 (34 6)
18 (34.6)
26 (34 7)
26 (34.7)
Prior CABG
8 (6.2)
4 (7.7)
4 (5.3)
Multi‐vessel disease
56 (75.7)
31 (72.1)
25 (80.6)
Ejection fraction
50.3±19.3
52.3±17.9
48.9±20.2
Stable angina presentation
86 (68.3)
36 (70.6)
50 (66.7)
Unstable angina presentation
41 (32.3)
15 (29.4)
25 (33.3)
Glycoprotein IIb/IIIa Inhibitor
76 (59.9)
32 (61.5)
44 (58.7)
89% kissing
inflation
Mean duration of follow up 18 months
Mean duration of follow‐up 18 months
8
7
7,1
46% angio follow‐up
6
%
5
4
4
4
,
3,1
3
2,4
2
1
0
9
5
4
5
3
0
Onlyy 1 event in the LM g
group
p - TLR at distal
stent edge of LCX, no cases of thrombosis
0,8
1
Culotte Stenting ‐ Complete lesion coverage??
• 77 yr old, prior CABG, LIMA‐
LAD SVG RCA
LAD, SVG‐RCA
• Worsening angina, inducible Worsening angina, inducible
ischaemia lateral wall
Right caudal view
Right caudal view
Balloon to open struts in
direction of main branch
Pinched ostium
Further kissing, initially 30atm to each branch
hb
h
Technical pitfalls
p
New wire crosses LAD and 2.5mm balloon used to pre‐dilate
3.5x28mm Cypher Select+ positioned in the LAD
Kissing inflation 3.5mm balloon in LAD, 2.5mm balloon to diagonal
LAD – 22Atm
Diagonal‐
14atm
OCT Pullback
DIAGONAL
Prox LAD
Mid LAD
LAD
LAD
Diagonal
Diagonal
B
A
C
Diagonal
A
B
LAD
C
Why so many unapposed struts at the carina?
i ?
Summaryy
• The culotte technique is more technically demanding compared to other bifurcation g
p
strategies
• It is not routinely applied in LM given the It i
t
ti l
li d i LM i
th
relative large size of the LM compared to the available DES diameters
• It is adaptable as a truly provisional It is adaptable as a truly provisional
strategy, with the second stent being implanted only if required
only if required
• It can be applied to varying angles, particularly retrovert origin