LAD Archives - European Bifurcation Club

Coronary CT Guided Left Main Bifurcation PCI

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain LM SESSION Coronary CT Guided Left Main Bifurcation PCI Author: Masaaki Okutsu, MD, New Tokyo Hospital, Chiba, Japan Introduction Current consensus of LMT bifurcation PCI recommends single stent strategy. However, LCX ostium has sometimes severe stenosis or occlusion after crossover stenting unexpectedly. There are some factors that affect to jailed LCX ostium. – MB plaque, SB plaque, low angle, and ...Calcification is one of them. Objective To investigate the relationship between calcium thickness at LMT bifurcation and LCX ostium deterioration after LMT-LAD crossover single stenting. Conclusion Coronary CT might be able to measure calcium thickness. Calcium thickness of ostial LAD might affect LCX ostium stenosis deterioration after crossover stenting from LMT to LAD.

Ivus guided LAD CTO/LM – bifurcation stenting

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain CASE SESSION - TIPS & TRICKS Ivus guided lad cto lm bifurcation stenting Author: Dr Joby K Thomas, MD, DM, Caritas Hospital Kerala, India SUMMARY Patient underwent CABG and mitral valve repair in 2014 at a different hospital Had effort angina which revealed occluded LIMA and both SVGs(2017) They attempted PTCA , did RCA and ‘ramus ‘ stenting LAD was ostial CTO , which they could not succeed in doing Patient still has angina Check angio showed patent stents in RCA and ‘ramus’ That converted a 0,1,1 LM distal bifurcation to 0,1,0 But LAD ostial CTO with no stump

A case of LAD CTO reperfusion guiding by IVUS

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain TIPS AND TRICKS IN BIFURCATION PCI - THE SYNERGY BETWEEN EBC AND ASIA A case of LAD CTO reperfusion guiding by IVUS Author: Xiaoping Peng, The First Affiliated Hospital of Nanchang University, China CLINICAL FACTS Liao, male, 59-year-old, admitted to hospital in 2018-09-15 Chest tightness for 2 years, aggravating for 2 months TREATMENT STRATEGY The treatment strategy of this patient is to deal with right coronary lesions first. Selective treatment is LAD CTO lesions

LAD CTO and LM treated with TAP

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain TIPS AND TRICKS IN BIFURCATION PCI - THE SYNERGY BETWEEN EBC AND ASIA LAD CTO and LM treated with TAP Author: Jaskaran Singh Dugal, MD, Jehangir Hospital, India HISTORY 40 year old patient Had anterior wall MI 10 years ago. He was given thrombolytic therapy with STK and subsequently continued on medical management Now presented with retrosternal pain and DOE with minimal exertion ECHO showed anterior wall RWMA hypokinesia EF 50% Risk profile - Hypertension, Hyperlipidimia Syntax Score 30 JCTO score - 2 PLAN Address CTO antegrade/retrograde • LCX/OM Bifurcation LAD/LCX/LMCA Bifurcation LAD/diagonal What Technique?

Extreme Left Main Stem Calcification

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain AWARD CASE SESSION - VOTING Extreme Left Main Stem Calcification: Rotashock combination therapy Author: Peter O'Kane, MD FRCP, Royal Bournemouth Hospital, UK CLINICAL PRESENTATION 79 year old lady Unstable angina, Troponin 250, eGFR 38 Exertional dysopnea for several months Echo: LVEF 45%with akinetic apex but good regional wall motion elsewhere PCI STRATEGY 7F EBU3.5 Guide RT wire LAD & SB wire LCx Sapphire 2.0x20 balloon not cross LAD •Rotational atherectomy 2 stent technique - culotte of DK Crush • IVUS guided throughout

A patient with distal LM disease and large diameter discrepancy between LAD and LM

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BOSTON SYMPOSIUM A patient with distal LM disease and large diameter discrepancy between LAD and LM Author: Jens Flensted Lassen, MD, PhD, Odense University Hospital, Denmark PATIENT HISTORY Male, 60 years, Severe COL, Reduced FEV 1, EF 35 %, Diabetes, Hypertension. Family history of ischemic heart disease. Mid LAD stenosis Ostial LAD stenosis, With plaque in LM FFR: 0.67 (distally LAD) and 0.79 (between LM and proximal LAD.) Heart team decision: PCI

Risk of stent sizing according to the distal MV in LM bifurcation

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BENCH & COMPUTATIONAL BIFURCATION STENT SIMULATIONS Risk of stent sizing according to the distal MV in LM bifurcation Author: Yutaka Hikichi, MD, PhD, Saga University, Japan BACKGROUND AND PURPOSE OF THE EXPERIMENT Size selection: according to the distal MB reference? Hypothesis: Stent size influence the acute outcome Implantation methods CONCLUSION When performing a crossover stent to LMT-LAD, the stent size should be selected according to the vessel diameter on the proximal side of the bifurcation. By selecting a larger stent size, the incomplete stent apposition area can be reduced at the LCx ostium after KBT. By doing so, incomplete stent apposition volume can be reduced at the LM-shaft after KBT , and the stent expansion rate can be greatly increased. The risk of injury on the LAD distal side during stent implantation can be reduced by thorough pre- dilatation and devising the stent placement method.

Flow disturbance due to incomplete stent apposition

European Bifurcation Club 2019, EBC 2019 - Barcelona, Spain BENCH & COMPUTATIONAL BIFURCATION STENT SIMULATIONS Flow disturbance due to incomplete stent apposition Author: Kiyotaka Iwasaki, PhD, Waseda University, Japan BACKGROUNDS In left main bifurcation, difference between LMT (proximal) and LAD (distal) diameters is lager compared with that in other bifurcation. Stenting without POT would induce incomplete stent apposition at proximal bifurcation side. KBT is recommended to open overlaying stent of side branch ostium especially in LM Bifurcation, because the overlaying jailed stent will potentially occupy larger at LCx and become a source for future thrombus formation, neointimal formation, and late narrowing. Although stent-size selection based on distal diameter is recommended, there is a dilemma that currently available stents have smaller expansion capability when stent-size is chosen based on distal stent-landing diameters in LAD. SUMMARY AND TAKE HOME MESSAGES POT and KBT are mandatory to reduce incomplete stent apposition. Otherwise, abnormal slow flow regions were induced at left main trunk and/or behind jailed stent crowns during the cardiac cycle, which would be a potential cause of thrombus formation and may necessitate life-long DAPT. Stent-diameter selection based on the proximal- vessel diameter is feasible to preserve stent platform design at LMT and bifurcated region, and to reduce jailed stent crowns at LCx ostium. Three-times kissing balloon inflation is feasible for reducing jailed stent crowns.

Use of a microcatheter to overcome complex side branch access

European Bifurcation Club 2014, EBC 2014 - Bordeaux, France CASES: TIPS & TRICKS AND COMPLICATIONS Use of a microcatheter to overcome complex side branch access Author: Gregor Leibundgut, MD, Kantonsspital Baselland, Switzerland

Inverted culotte

European Bifurcation Club 2018 - EBC 2018 - Brussels, Belgium BIFURCATION CLUBS AT EBC: CASE SESSION Inverted culotte Author: Mohamed Zahran, MD, PhD, Ainshams University, Egypt