Tackling bifurcations: What can and cannot be done

1. Tackling Bifurcations: What Can and
Cannot Be Done
Alaide Chieffo, MD
San Raffaele Scientific Institute,
Milan, Italy

2. Nothing to disclose related to this
presentation

3. • It is current practise in our center to
select radial access as the access of
choice even in complex cases and
bifurcations.
• However there is still a 5-10% of
procedures performed through
femoral access.

4. • Most of the bifurcation lesions are
currently treated through radial access,
both provisional or 2 stent techniques
• However, we still perform femoral access
in case of a not optimal back up or need for
simultaneous implantation of 2 stents or
trifurcations

5. What We Do through a Radial Access
1. Bifurcations with Provisional Approach

6. • 82 yrs, female, dyslipidemia, hypertensive,
prior smoker, PVD
• Recent history of GI bleeding
• Euroscore 15
• Presenting with NSTEMI
• At echo in ER LVEF 25%
• Preloaded with clopidrogel+ASA

7. 1° Case
Heart Team decision > PCI on LM/LAD

8. DES 3.5x30mm
Slow Flow >> hemodynamic instability

9. IABP was implanted, Aggrastat ic was given

10. A 2nd stent was implanted
Final Result

11. What We Do through Radial Access
2. Bifurcation with 2 stent technique

12. • 78 yrs, male, hypertensive
• Prior (2003) PCI with stent on LAD and
diagonal on LAD> NSTEMI on 2010
• Euroscore 5
• Positive Scintigraphy in inferolateral wall and
pt symptomatyc for angina CCS 2.

13. PP
Pt randomized in EBC 2 trial to Culotte Strategy

14. Culotte Stenting Technique
DES 2.5x14mm
DES 3.0x14mm

15. Culotte Stenting Technique
2 Step FKBI with NCB 2.5mm on OM e 3.0mm on Cx

16. Culotte Stenting Technique
Final IVUS
Final Angio

17. • 58 yrs, male, dislipidemia, hypertensive,
positive family history for CAD
• Prior multiple PCI with DES on LAD and OM>>
pt strongly refused CABG
• Euroscore 2
• Pt asymptomatic but at 2 year fup coronary
CT scan : occlusion of LAD mid

19. DES 2.5x33 mm su diag and DES 3.0x38 mm su LAD (“inverted TAP”)
DEB on LAD distal

20. NCB postdilatation on SB
FKB

21. Final Angiogram

22. • Cross Over Radial to Femoral.. Bad
Back up

23. • 85 yrs, male, dislipidemia, hypertensive, prior
TIA
• Recent history of GI bleeding, baseline Hb
9.5 mg dL
• Euroscore 12
• Presenting with NSTEMI

25. Not optimal guiding catheter support>> cross over to femoral access

26. 2 x2.5x12 mm BMS implanted through femoral access

27. Final Angiogram

28. Conclusions
• Most of bifurcation lesions can be
safely done through radial access
either with provisional or 2 stent
technique approach
• Consider femoral approach in case of
not optimal guiding catheter support
or bad back up or in case of
simultaneous 2 stent implantation
needed (conventional minicrush or V
stenting)