LAD - summitMD.com

Antonio Colombo
m
Centro Cuore Columbus and
S. Raffaele
ff l Scientific
f Institute, Milan,
l
Italy
l
Case Examples
Simple Provisional: SB predilatation and
final dilatation following Main Branch BVS,
l
low
pressure fifinall KISS
Bifurcation Lesion
Baseline
EMO 28477/12
Bifurcation Lesion
Baseline
EMO 28477/12
Bifurcation Lesion
Incomplete expansion
proximal segment
High-Pressure NC Balloon 2.5mm
EMO 28477/12
Bifurcation Lesion
High-Pressure NC Balloon 2.5mm
IVUS after POBA
1.93 mm2
EMO 28477/12
Bifurcation Lesion
After
f
Cutting
g Balloon
IVUS after Cutting Balloon
2 31 mm2
2.31
EMO 28477/12
Bifurcation Lesion
BVS 2.5x18mm
3.0mm NC Balloon
Prox post-dilatation
EMO 28477/12
Bifurcation Lesion
Distal BVS 2.5x18mm
2.5mm NC Balloon
Distal BVS post-dilatation
EMO 28477/12
Bifurcation Lesion
After 2 BVS
EMO 28477/12
Bifurcation Lesion
2.5mm/2.0mm
Side-branch dilatation
Low Pressure Kissing
Low-Pressure
EMO 28477/12
Bifurcation Lesion
Final Result
EMO 28477/12
Bifurcation Lesion
Final Result
Final IVUS
3.20 mm2
EMO 28477/12
Bifurcation Lesion
Final Result
EMO 28477/12
When BVS has been dilated toward SB, I suggest Kissing
Balloon Inflation to correct Main Branch BVS deformation
Kissing Balloon Inflation should be performed at low
pressure with slow progressive inflations inflations with
minimal
i i l proximal
i l HUG off balloons
b ll
Mi i l proximal
Minimal
i l HUG off balloons
b ll
Kissing Balloon
Inflation should
be done at low
pressure with
ith
slow
progressive
inflations
at o s with
t
minimal
proximal HUG of
balloons
Proximal marker
SB balloon
Proximal marker
MB balloon
Bifurcation: BVS main branch and EES on side branch
as intention to treat
Baseline
EMO 28329/12
Pre-dilatation
DEB (Medtronic)
(M dt
i ) on LAD
EMO 28329/12
After DEB (Medtronic) on LAD
EMO 28329/12
EES Ostium Diagonal
T technique
After EES Ostium Diagonal
EMO 28329/12
LAD High-Pressure
Dilatation
l
IVUS Check
EMO 28329/12
BVS on LAD
After BVS on LAD
EMO 28329/12
After second BVS on LAD
EMO 28329/12
After third BVS on LAD
EMO 28329/12
Final Result
EMO 28329/12
SB compromise after BVS on MB: Wire SB 1.5 mm, 2 mm
p
result leave as it
balloon dilatation on SB. If acceptable
Kiss??
If result not acceptable: DES on SB: T or TAP
Provisional with Side Branch rescue following
BVS on Main Branch:
Balloon angioplasty on Side Branch
Branch, no need
for stenting Side Branch
Baseline
EMO 28322/12
Baseline
EMO 28322/12
Baseline
EMO 28322/12
Following LAD pre-dilatation
EMO 28322/12
First
F
rst BVS
VS implantation
mp antat on
F ll i Fi
Following
Firstt BVS iimplantation
l t ti
EMO 28322/12
F ll
Following
additional
dd
ld
dilatation
l
of
fL
LAD
D
EMO 28322/12
Additional dilatation
IVUS following two
additional BVS
EMO 28322/12
Angiogram check...
EMO 28322/12
Angiogram check...
EMO 28322/12
Crossing diagonal with
1.5mm balloon
Diagonal dilatation
EMO 28322/12
Diagonal dilatation with 2.5mm balloon
EMO 28322/12
Final Result
EMO 28322/12
Final Result
EMO 28322/12
Final Result
EMO 28322/12
Provisional with Side branch compromise
not responding to balloon inflation:
Need to stent Side Branch
T after BVS
Baseline
28741/12 EMO
T after BVS
3.25 NC Balloon
B
BVS
3.0x28mm
Post Dilatation
28741/12 EMO
T after BVS
Result after LAD BVS stent
28741/12 EMO
T after BVS
2.0mm
mm Balloon
POBA on Diag
After POBA on Diag
28741/12 EMO
T after BVS
Xience 2.25x15mm
Stent on Diag
After
ft r st
stent
nt on
nD
Diag
ag
28741/12 EMO
T after BVS
Need for additional BVS distal LAD
28741/12 EMO
T after BVS
BVS 2.5x18mm
2 5x18mm distal LAD
28741/12 EMO
T after BVS
Markers
28741/12 EMO
T after BVS
Final Result
28741/12 EMO
T after BVS
Final Result
28741/12 EMO
2 BVS as intention to treat : Main and Side
Branches with T technique
Case1
*LIMA-LAD:
LIMA LAD: patent
*SVG-RCA: occluded
CTO after
ft bifurcation
bif
ti llesion
i
Asahi Fielder-XT with Finecross, KBI 2.5/2.5mm
T
Two-step
t T
T-fashion
f hi stenting
t ti
BVS 2.5×28mm
BVS-balloon
Balloon
*To ensure ostial positioning of the BVS, a balloon was placed in the LCx
across the bifurcation.
*The BVS-balloon
BVS balloon was slightly withdrawn and re-inflated
re inflated along with the
balloon in the LCx.
T
Two-step
t T
T-fashion
f hi stenting
t ti
2nd BVS 3.0×18mm
3 0×18
*2
2nd BVS 3.0
3.0×18mm
18mm followed by NC
3.25mm
*No kissing balloon inflation
3rd BVS 2.5×28mm
3rd BVS 2.5×28mm
followed by NC 2.5mm
Position of 3 BVSs
OM1
BVS 3.0×18
3 0×18 mm
BVS 2.5×28
mm
OM2
BVS 2.5×28
mm
LCx
R di
Radiopaque
platinum
l ti
markers
k
A
B:
OM1
MSA 6.3mm2
A
C:
bif. of LCx/OM1
overlap of BVS
MSA 5.4mm2
OM1
B
C
D
E:
E
D
bif. of LCx/OM2
LCx
F
OM2
F
LCx
MSA 4.1mm2
MSA 4.0mm2
Minicrush with BVS
Coronary angiogram
Left Coronary
Coronary angiogram
Right
R
ght Coronary
PCI strategy
gy
• Bilateral access and antegrade approach for
LAD CTO
• In
I view
i
of
f young age BVS implantation
i l
i
• Adequate lesion preparation thus necessary
• Vessel calcified at level of CTO  Corsair as
microcatheter dilator  Rotablation
R t bl ti with
Rotablation
ith 1.5mm
15
b
burr
Follow ng rotablat
Following
rotablation
on and pre
predilatation in LAD and D2
ABSORB BVS implanted in mid LAD
((2.5
. x 28mm)
mm)
Platinum markers
Significant stenosis in D1 despite POBA
(treated with ABSORB BVS 2.5 x 18mm)
Platinum markers
OCT from D1 following BVS
Jailed LAD wire
BVS protruding into LAD with jailed LAD wire
Di t l D1
Distal
LAD wire in view
Second ABSORB in proximal LAD across
LAD/D1 bifurcation (3.0 x 28mm)
LAD
Diagonal
OCT from LAD
LAD
LAD
Diagonal
Inadeaquately crushed diagonal struts
A=0.82mm
OCT from LAD following post-dilatation and FKBI
(LAD
(L
D = 3.5mm
.5mm at 26
6 atm D1
D = 2.5mm
.5mm at 20 atm)
LAD
Diagonal
Xience 3.5
Xi
35x8
8mm implanted
i l t d att ostial
ti l LAD.
LAD BVS avoided
id d
to prevent excessive overlap with BVS at proximal LAD
Prior to Xience
Post Xience
Final angiographic and OCT result
O i l LAD
Ostial
Proximal LAD
prior to
crushed
h d
D1 stent
Distal LAD
LAD with diffuse disease
and lesions in the LCx
28436/12 CCC
BVS case: LAD
Diffuse lesion
CTO
6Fr XB 3.5, Finecross+BMW→Intermediate→Conquest pro
28436/12 CCC
BVS case: LAD
Pre-dilatation
After Pre-dilatation
28436/12 CCC
BVS case: LAD
Pre-dilatation
in prox LAD
First BVS 2.5×28 mm
After First BVS
28436/12 CCC
BVS case: LAD
DEB 2.5×40 mm
prox diagonal
g
in p
Aft DEB
After
28436/12 CCC
BVS case: LAD
Second BVS 3.0×28 mm
Third BVS 3.5×28 mm
28436/12 CCC
BVS case: LAD
Distal edge of BVS
After 3 BVS
28436/12 CCC
BVS case: LAD
BVS 2.5×28
2 5×28 mm
Distal edge of BVS
After 3 BVS
EES 2.25×12 mm
28436/12 CCC
BVS case: LAD
Final Result
28436/12 CCC
BVS case: LAD
A
A
BVS 3.5×28 mm
C
BVS 3.0×28 mm
B
B
C
BVS 2.5×28
2 5×28 mm
EES 2.25×12 mm
Final Result
28436/12 CCC
Our Experience
• B
Between M
May 2012 and
dM
March
h 2013
2013, we
have treated 89 lesions in 60 patients.
Baseline clinical characteristics
Patient number=60
A
Age,
years
65 7 ± 11.0
65.7
11 0
Male gender
51 (85%)
Hypertension
35 (58%)
Diabetes mellitus
16 (27%)
Insulin
Hypercholestrolaemia
Current smoker
4 (7%)
35 (58%)
7 (12%)
Family history of CAD
27 (45%)
Previous MI
18 (30%)
Previous PCI
30 (50%)
Previous CABG
LVEF, %
7 (12%)
55.9 ± 7.5
Stable angina
ng n
53 ((88%))
Triple vessel disease
25 (42%)
Lesion characteristics
Lesion number=89
Vessels treated
LAD
56 (63%)
LCx
19 (21%)
RCA
12 (13%)
LMCA
2 (3%)
Type of lesions
A
3 (4%)
B1
16 (18%)
B2
42 (47%)
C
28 (31%)
Bifurcations
f
34 ((38%))
Calcified lesions
26 (29%)
CTO
6 (7%)
( )
In-stent restenosis
4 (5%)
Procedural characteristics
Lesion number=89
Pre-dilatation
88 (99%)
Scoring balloon
15 (17%)
Cutting balloon
4 (4%)
Rotablation
6 (7%)
Post-dilatation
Max balloon size, mm
Max inflation pressure, atm
82 (92%)
3.1 ± 0.4
20.5 ± 5.5
IVUS
74 (83%)
OCT
19 (21%)
Number of BVS per patient
2.2 ± 1.1 (1 – 6)
Number of BVS per lesion
1.3 ± 0.6 (1 – 3)
Di
Diameter
of
f BVS,
BVS mm
Length of total BVS, mm
FKBI
Double-stenting with BVS
3 0 ± 0.3
3.0
0 3
32.4 ± 15.4
9/34 bifurcations
4 T-stenting and 1 mini-crush stenting
• TIMI 3 flow post PCI
• All p
patients have remained free of events
up until last week.
Ideal patient for BVS
• Diffuse disease of LAD requiring
q
g
long stents
• Diffuse disease of any vessel 2.5 mm or
l
larger
requiring
i i long
l
stents
t t
• Any lesion in a young patient
• Any lesion suitable for BVS