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Stenting: tips and tricks
Colin Berry
University of Glasgow
Scotland, UK
i2 Fellows Bootcamp 飩� Tuesday, March 27, 2007
Dr Colin Berry
Disclosure
The presenter has received SIGNIFICANT
research funding from Medtronic Inc.
(Europe)
Learning objectives
鈥� Primary / direct stenting
鈥� Stenting in acute myocardial infarction
鈥� Stenting tips and tricks in complex
cases
Primary objective :
avoid adverse outcomes
Baseline angiogram Post mid - LAD stent
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
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
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
PTCA technique
Long balloon, low inflation pressure, long inflation time
Standard balloon
2.5 x 20 mm
Dilated @ 6 atmos
Distal
lesion
Stenting strategy
Direct
stenting
Predilation +
stenting
Lesion
characteristics
Non-ostial Ostial
Uniform Non-uniform
Non-calcified Calcified
Acute lesion
(thrombectomy)
Occluded
Simple Complex (long,
bifurcations)
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
Direct stenting in acute MI
Not appropriateAppropriate
Tips and tricks :
lesion preparation
PREDILATION
鈥� Final balloon : lesion diameter 0.8 鈥� 1.0 : 1
鈥� Consider incrementally larger balloons,
1.5 鈥� 2 mm followed by 2.5 鈥� 3 mm
Adjunctive devices - rotational atherectomy for
calcified lesions, including bifurcations
OBJECTIVE
鈥� Achieve optimal lesion modification prior to
stenting
Which stent to use ?
BMS DES
Patient
characteristics
No diabetes
Low-risk
Diabetes
Major co-morbidity
(surgery intended,
terminal cancer,
鈥榩alliative鈥� PCI 鈥� CABG
intended)
Low bleeding risk
Lesion
characteristics
RD 飩� 3.5 mm *RD 2.75 鈥� 3.5 mm
Ca2+ - achieve
optimal stent
deployment
*SIRIUS : small < 2.75 & long > 18 mm vessels
SCAI 鈥� ACC guidelines 2005; 2007
Risk of stent thrombosis
鈥� SCAI
CCI 2007
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
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
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
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
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
Can鈥檛 access side-branch
access?
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
Anchor technique : successful
side-branch access?
Side-branch access achieved
Kissing balloons optimizes final result
Stenting tips and tricks:
achieve what you set out to do
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?
Thankyou for your attention
Primary objective :
procedural success
Acute stent thrombosis
Stenting: tips and tricks
Importance of final kissing balloon dilation
Ormiston CCI 2004; 63: 332-336
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
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
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
Stenting: tips and tricks
Long lesions
鈥� Stent length 鈥� independent predictor of intra-
procedural stent thrombosis; sub-acute thrombosis,
restenosis
鈥� IVUS
鈥� Anti-thrombotic treatments : IIbIIIa inhibitor, aspirin,
clopidogrel
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

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  • 1. Stenting: tips and tricks Colin Berry University of Glasgow Scotland, UK i2 Fellows Bootcamp 飩� Tuesday, March 27, 2007
  • 2. Dr Colin Berry Disclosure The presenter has received SIGNIFICANT research funding from Medtronic Inc. (Europe)
  • 3. Learning objectives 鈥� Primary / direct stenting 鈥� Stenting in acute myocardial infarction 鈥� Stenting tips and tricks in complex cases
  • 4. Primary objective : avoid adverse outcomes Baseline angiogram Post mid - LAD stent
  • 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
  • 9. Stenting strategy Direct stenting Predilation + stenting Lesion characteristics Non-ostial Ostial Uniform Non-uniform Non-calcified Calcified Acute lesion (thrombectomy) Occluded Simple Complex (long, bifurcations)
  • 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
  • 11. Direct stenting in acute MI Not appropriateAppropriate
  • 12. Tips and tricks : lesion preparation PREDILATION 鈥� Final balloon : lesion diameter 0.8 鈥� 1.0 : 1 鈥� Consider incrementally larger balloons, 1.5 鈥� 2 mm followed by 2.5 鈥� 3 mm Adjunctive devices - rotational atherectomy for calcified lesions, including bifurcations OBJECTIVE 鈥� Achieve optimal lesion modification prior to stenting
  • 13. Which stent to use ? BMS DES Patient characteristics No diabetes Low-risk Diabetes Major co-morbidity (surgery intended, terminal cancer, 鈥榩alliative鈥� PCI 鈥� CABG intended) Low bleeding risk Lesion characteristics RD 飩� 3.5 mm *RD 2.75 鈥� 3.5 mm Ca2+ - achieve optimal stent deployment *SIRIUS : small < 2.75 & long > 18 mm vessels SCAI 鈥� ACC guidelines 2005; 2007
  • 14. Risk of stent thrombosis 鈥� SCAI CCI 2007
  • 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
  • 22. Anchor technique : successful side-branch access?
  • 23. Side-branch access achieved Kissing balloons optimizes final result
  • 24. Stenting tips and tricks: achieve what you set out to do
  • 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?
  • 26. Thankyou for your attention
  • 27. Primary objective : procedural success Acute stent thrombosis
  • 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
  • 32. Stenting: tips and tricks Long lesions 鈥� Stent length 鈥� independent predictor of intra- procedural stent thrombosis; sub-acute thrombosis, restenosis 鈥� IVUS 鈥� Anti-thrombotic treatments : IIbIIIa inhibitor, aspirin, clopidogrel
  • 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