This document discusses tips and tricks for stenting procedures. The key points covered are:
1) Lesion preparation through predilation is important for optimal stent deployment.
2) Stent strategy should consider possible scenarios like bifurcations to plan accordingly.
3) The goal is to do what is best for the patient by weighing risks of restenosis and stent thrombosis between drug-eluting and bare-metal stents.
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1. Stenting: tips and tricks
Colin Berry
University of Glasgow
Scotland, UK
i2 Fellows Bootcamp 飩� Tuesday, March 27, 2007
5. Tips and tricks for stenting:
Guide catheter size
5 Fr simple procedures
鈥�+鈥� ve - direct stenting / reduced bleeding
鈥�-鈥� ve - 飩� risk air embolus / IVUS won鈥檛 go
6 Fr simple or complex procedures
may accommodate 2 balloons
(selected manufacturers)
飩�7 Fr complex procedures
bifurcations, rotational atherectomy
blood loss - consider hemostasis valve
6. Stenting tips and tricks :
Guide catheter choice
LCA
鈥� specialized guide catheters appropriate for
artery : XB LAD vs. EBU or AL for Cx
鈥� left main length (short = less aggressive guide)
RCA
鈥� take-off superior vs horizontal vs inferior
鈥� avoid side-hole catheters as pressure may
falsely disguise wedging and vessel injury
7. PTCA vs. primary stent ?
PTCA Primary Stent
Anatomy Distal location + / -
Tortuous
vessels
+ / -
Lesion Non-calcified + / -
RD < 2.0 mm RD 飩� 2mm
Distribution
Patient
Small jeopardy
score
Low risk
> Small
In general, stents are superior
飩� Acute complications; 飩� restenosis
8. PTCA technique
Long balloon, low inflation pressure, long inflation time
Standard balloon
2.5 x 20 mm
Dilated @ 6 atmos
Distal
lesion
10. Stenting in acute MI
鈥� Ensure wire is endoluminal
鈥� If thrombus present 鈥� aspirate; medicate
鈥� Occluded artery - establish antegrade
flow by predilation
鈥� Direct stent only if lesion adequately
visualized
鈥� Post-dilate, only if necessary
15. Stent dimensions
鈥� Stent diameter
artery : stent ratio = 1 : 1.1
do not oversize 鈥� acute complications
plan possibility of post - dilation
鈥� Stent length
Lesion coverage
DES 鈥� 1 - 2 mm proximal & distal to stent to ensure
complete plaque coverage: normal to normal
IVUS to asses result
16. Tips and tricks :
stent deployment
Stent procedure
鈥� Slow inflation to nominal pressure
(avoid balloon dumb-bell effect )
鈥� Short inflation (15 - 20 sec)
鈥� Optimal inflation pressure > 14 A
鈥� Analyze angiographic result in orthogonal
views
17. Tips and tricks:
stent deployment
Post-dilatation
鈥� Select semi-compliant or non-compliant
balloon
鈥� Routine high-pressure (> 18 A) to ensure
adequate stent expansion
鈥� Stent under-expansion (focal or generalized) ?
IVUS for stent assessment, especially if DES
18. Tips and tricks
Prevent stent malpositioning
鈥� Stent motion prior to deployment can cause
geographic miss (particularly in RCA)
鈥� Partial inflation 1 鈥� 3 A will lead to inflation of
balloon at stent extremities prior to stent
expansion.
鈥� Therefore, small adjustments to the stent
position can be made
Ormiston CCI 2000
19. Tips and tricks
Bifurcations
Provisional Stenting
1 stent is usually better than 2
Indications for 2 Stents
鈥� SB is an important artery (large distribution, RD > 2
mm, dominant vessel) + SB disease
CRUSH 鈥� wire position in MB secure; quick, procedure,
limiting ischemic time
CULOTTE 鈥� angle < 70掳
T 鈥� angle > 70
21. Tips and tricks :
can鈥檛 access side-branch ?
1. Guide cath: coaxial; correct configuration
2. Guide-wire: recross stent
Wire access to side-branch (SB) stent : floppy,
hydrophilic Whisper; steerable-catheter
3. Balloon access to SB 鈥� conventional balloon; if it
doesn鈥檛 pass then use a low profile & short balloon ie
1.5 x 8 mm; or 1.25 mm
4. Main branch post-dilation at bifurcation
5. Anchor technique 鈥� advance MB balloon beyond
bifurcation, inflate, then advance SB balloon
6. Fixed wire system 鈥� balloon on a wire
25. Stenting: tips and tricks
Take Home Points: KEEP IT SIMPLE !
1. Lesion preparation
for optimal stent deployment
2. Stent strategy
think through the possible eventualities
3. What is best for the patient
Restenosis : thrombosis ratio DES vs. BMS
Risk of stent thrombosis? Duration of clopidogrel?
28. Stenting: tips and tricks
Importance of final kissing balloon dilation
Ormiston CCI 2004; 63: 332-336
29. Stenting: tips and tricks
Approach to Kissing Balloon inflations
鈥� Individual balloon sizes should equal 2/3rds of
proximal reference vessel diameter
鈥� Final inflation should be an appropriately sized
balloon in MB (especially for 鈥淐rush鈥�
鈥� SB balloons should be deflated before or
simultaneous with MB balloon
30. Stenting: tips and tricks
Bifurcation lesions
鈥� T stents: angle < 90潞, incomplete SB cover
鈥� Crush technique: SB inflation then final kissing
balloon inflation are essential
鈥� 飩� 70掳 - kissing balloon鈥檚 are ideal
鈥� > 70 掳 - 鈥� 鈥� are inadequate stent
expansion, therefore sequential post-dilatations
followed by Kissing balloons
31. Stenting: tips and tricks
Kissing Balloons ?
鈥� Correct stent deformations, even when not-
angiographically apparent
鈥� Increase SB ostium minimum lumen area (> 5 mm2)
鈥� .. Leading to reduced SAT and reduced TLR
鈥� May facilitate reintervention
33. Reference vessel diameter
鈥� Stent size: 1.1 : 1
- undersizing acute long term complications
- oversizing IPST, dissections
- Smaller arteries 鈥� less likely to achieve 100% stent
expansion or > 5 mm2 stent area
鈥� IVUS 鈥� to assess final minimum lumen area
Stenting: tips and tricks