Stenting Tips and Tricks Ppt Powerpoint Presentation slides Colin Berry Medical Slideshow Stenting: tips and tricks

Stenting Tips and Tricks

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Biggry on Aug 19, 2009 Says :

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Very nice presentation

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Show Notes

Slide 1 :

Stenting: tips and tricks Colin Berry University of Glasgow Scotland, UK i2 Fellows Bootcamp ? Tuesday, March 27, 2007

Slide 2 :

Dr Colin BerryDisclosure The presenter has received SIGNIFICANT research funding from Medtronic Inc. (Europe)

Slide 3 :

Learning objectives Primary / direct stenting Stenting in acute myocardial infarction Stenting tips and tricks in complex cases

Slide 4 :

Primary objective : avoid adverse outcomes Baseline angiogram Post mid - LAD stent

Slide 5 :

Tips and tricks for stenting:Guide catheter size 5 Fr simple procedures ‘+’ ve - direct stenting / reduced bleeding ‘-’ ve - ? risk air embolus / IVUS won’t go 6 Fr simple or complex procedures may accommodate 2 balloons (selected manufacturers) ?7 Fr complex procedures bifurcations, rotational atherectomy blood loss - consider hemostasis valve

Slide 6 :

Stenting tips and tricks :Guide catheter choice LCA specialized guide catheters appropriate for artery : XB LAD vs. EBU or AL for Cx left main length (short = less aggressive guide) RCA take-off superior vs horizontal vs inferior avoid side-hole catheters as pressure may falsely disguise wedging and vessel injury

Slide 7 :

PTCA vs. primary stent ? In general, stents are superior ? Acute complications; ? restenosis

Slide 8 :

PTCA technique Long balloon, low inflation pressure, long inflation time Standard balloon 2.5 x 20 mm Dilated @ 6 atmos Distal lesion

Slide 9 :

Stenting strategy

Slide 10 :

Stenting in acute MI Ensure wire is endoluminal If thrombus present – aspirate; medicate Occluded artery - establish antegrade flow by predilation Direct stent only if lesion adequately visualized Post-dilate, only if necessary

Slide 11 :

Direct stenting in acute MI Not appropriate Appropriate

Slide 12 :

Tips and tricks : lesion preparation PREDILATION Final balloon : lesion diameter 0.8 – 1.0 : 1 Consider incrementally larger balloons, 1.5 – 2 mm followed by 2.5 – 3 mm Adjunctive devices - rotational atherectomy for calcified lesions, including bifurcations OBJECTIVE Achieve optimal lesion modification prior to stenting

Slide 13 :

Which stent to use ? *SIRIUS : small < 2.75 & long > 18 mm vessels SCAI – ACC guidelines 2005; 2007

Slide 14 :

Risk of stent thrombosis SCAI CCI 2007

Slide 15 :

Stent dimensions Stent diameter artery : stent ratio = 1 : 1.1 do not oversize – acute complications plan possibility of post - dilation Stent length Lesion coverage DES – 1 - 2 mm proximal & distal to stent to ensure complete plaque coverage: normal to normal IVUS to asses result

Slide 16 :

Tips and tricks : stent deployment Stent procedure Slow inflation to nominal pressure (avoid balloon dumb-bell effect ) Short inflation (15 - 20 sec) Optimal inflation pressure > 14 A Analyze angiographic result in orthogonal views

Slide 17 :

Tips and tricks: stent deployment Post-dilatation Select semi-compliant or non-compliant balloon Routine high-pressure (> 18 A) to ensure adequate stent expansion Stent under-expansion (focal or generalized) ? IVUS for stent assessment, especially if DES

Slide 18 :

Tips and tricks Prevent stent malpositioning Stent motion prior to deployment can cause geographic miss (particularly in RCA) Partial inflation 1 – 3 A will lead to inflation of balloon at stent extremities prior to stent expansion. Therefore, small adjustments to the stent position can be made Ormiston CCI 2000

Slide 19 :

Tips and tricksBifurcations Provisional Stenting 1 stent is usually better than 2 Indications for 2 Stents SB is an important artery (large distribution, RD > 2 mm, dominant vessel) + SB disease CRUSH – wire position in MB secure; quick, procedure, limiting ischemic time CULOTTE – angle < 70° T – angle > 70

Slide 20 :

Can’t access side-branch access?

Slide 21 :

Tips and tricks : can’t access side-branch ? Guide cath: coaxial; correct configuration Guide-wire: recross stent Wire access to side-branch (SB) stent : floppy, hydrophilic Whisper; steerable-catheter 3. Balloon access to SB – conventional balloon; if it doesn’t pass then use a low profile & short balloon ie 1.5 x 8 mm; or 1.25 mm Main branch post-dilation at bifurcation Anchor technique – advance MB balloon beyond bifurcation, inflate, then advance SB balloon 6. Fixed wire system – balloon on a wire

Slide 22 :

Anchor technique : successful side-branch access?

Slide 23 :

Side-branch access achievedKissing balloons optimizes final result

Slide 24 :

Stenting tips and tricks:achieve what you set out to do

Slide 25 :

Stenting: tips and tricks Take Home Points: KEEP IT SIMPLE ! 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?

Slide 26 :

Thankyou for your attention

Slide 27 :

Primary objective :procedural success Acute stent thrombosis

Slide 28 :

Stenting: tips and tricksImportance of final kissing balloon dilation Ormiston CCI 2004; 63: 332-336

Slide 29 :

Stenting: tips and tricks Approach to Kissing Balloon inflations Individual balloon sizes should equal 2/3rds of proximal reference vessel diameter Final inflation should be an appropriately sized balloon in MB (especially for “Crush” SB balloons should be deflated before or simultaneous with MB balloon

Slide 30 :

Stenting: tips and tricks Bifurcation lesions T stents: angle < 90º, incomplete SB cover Crush technique: SB inflation then final kissing balloon inflation are essential ? 70° - kissing balloon’s are ideal > 70 ° - “ “ are inadequate stent expansion, therefore sequential post-dilatations followed by Kissing balloons

Slide 31 :

Stenting: tips and tricks Kissing Balloons ? Correct stent deformations, even when not-angiographically apparent Increase SB ostium minimum lumen area (> 5 mm2) .. Leading to reduced SAT and reduced TLR May facilitate reintervention

Slide 32 :

Stenting: tips and tricks Long lesions Stent length – independent predictor of intra-procedural stent thrombosis; sub-acute thrombosis, restenosis IVUS Anti-thrombotic treatments : IIbIIIa inhibitor, aspirin, clopidogrel

Slide 33 :

Reference vessel diameter Stent size: 1.1 : 1 - undersizing acute long term complications oversizing IPST, dissections Smaller arteries – less likely to achieve 100% stent expansion or > 5 mm2 stent area IVUS – to assess final minimum lumen area Stenting: tips and tricks

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