New Techniques Developed for Bifurcation Lesions
Emerging technologies aim to address needs of high-risk patients.
Emerging issues in the area of bifurcation lesions continue to be of interest to interventional cardiologists, even as the utility of double-stenting is debated.
“In the era of drug-eluting stents, there is no reason to implant a stent in the side branch when there is no significant stenosis,” said Yves R. Louvard, MD, of Hospital Jacques Cartier in France.
In reviewing the available literature, Louvard noted that there is no statistically significant evidence to support the belief that rates of target vessel revascularization are higher among patients who receive two stents vs. one. However, “there is definitely a trend,” Louvard said.
No second stent rationale
It may be possible to avoid unnecessary stenting of side-branch bifurcation lesions, Louvard said. He suggested beginning with main branch stenting with a jailed wire, and possibly adding a side branch drug-eluting stent after ballooning is unsuccessful. Side-branch stenting may be utilized after kissing balloon inflation or in cases of residual stenosis and/or abnormal fractional flow reserve.
Side-branch techniques
“It is generally agreed that one stent is better than two, but there’s no agreement on what technique to use if the side branch needs stenting,” said John A. Ormiston, MD, MBChB, of the Green Lane and Mercy Hospital in New Zealand.
One solution might be the crush technique, which cardiologists use to fully scaffold the side-branch ostium without gaps to support and apply antiproliferative drugs, Ormiston explained. Outcomes improved with the advent of the kissing balloon post-dilatation technique, which follows the crush technique, but this might predispose to restenosis and stent thrombosis.
Recent results seem to indicate that when using the crush technique, two-step kissing leads to the best side-branch ostium.
“If you look up through the side-branch, you’ll see that there’s no real metallic obstruction, and the main branch looks good as well,” he said. “Except for some cases where there’s some residual stenosis, kissing with a high-pressure side-branch post-dilatation gives a much better ostium.”
New technology
Early design features and preclinical/clinical data were also provided yesterday for three novel bifurcation stents. Each device has led to the initiation of first-in-man trials.
Aaron V. Kaplan, MD, of the Dartmouth Medical School, gave attendees an overview of the Tryton side-branch stent (Tryton Medical, Inc.), which is designed to eliminate the need for provisional stenting.
The Tryton stent is designed with three zones (side-branch, transition, and proximal), is balloon expandable, is tracked over a guidewire in the side-branch, and is compatible with bare-metal or drug-eluting stents. After deployment of the main vessel stent, a kissing balloon inflation is performed.
Antonio Colombo, MD, of the Centro Cuore Columbus in Italy, followed Kaplan’s presentation with a discussion of the SideGuard stent (Cappella, Inc.), which he described as “possibly the first self-expanding stent with drug-eluting features.”
Lastly, Eitan Konstantino, PhD, of Trieme Medical, Inc., discussed the TMI Artiste side-branch adaptive stent for bifurication lesions, which is delivered via single-balloon deployment with a radiopaque wire used to assist in alignment.