Transcription
Okay. Uh, I'm going to invite, uh, the next speaker, who, uh, is an preeminent, uh, cardiologist, uh, in in Thailand, Dr. Wash, to talk about tips and tricks for complex bifurcation PCI with cases and demonstrations.
First, uh, good, good morning, everybody, and thank you for the, uh, this, uh, chance to have a chat, something, uh, here. My talk is a topic of tip and tricks, so this is something I gather from my experience and some learning from my point. So it's a compilation of cases. This is my disclosure. So, first of all, uh, yeah, strategy for every PCI. I now, day for complex PCI, lesion preparation is the most important.
Here's a, a case of the post CBG patient, 70 years old, with a calcified bifurcation. He have a failed the graft to, uh, so we have to fix this, uh, left main lesion. So, at first, the IAS can, uh, enter the, uh, calcified plaque, but because of the angle of the calc, the circumflex, the IAS cannot enter. So we prepare the lesion by using a roa into the circumflex, and you can appreciate that pre and post, uh, lot better. You change the geometry of this bifurcation angle. So that this may, uh, facilitate the standing of the, uh, next, uh, procedure process, and we can make the, uh, to stand, uh, technique by the decay crush easier and have a nice result. And this is a, uh, uh, we have a chance to follow up the patient a year later, and the result is still very good. So the lesion preparation is the key of everything.
Now, for the, uh, technique for this bifurcation, most of us will have a difficult side branching, uh, problem. Uh, this is a very classic, uh, technique, the deflection technique. You use a balloon to block the distal main branch to facilitate the dry it into the angular side branch. But sometime in my practice, I did not, uh, blow the balloon. So I just make use the juice balloon so that the, the bulky of the balloon can also, uh, replace this, uh, uh, the, the full infected balloon. And this is an example for the wing technique with the deflection. This, this case, I used a very low pressure balloon and then, uh, use a stripply wire. This is a, a whisper wire so that this can, uh, uh, move into the angulated side branch easier.
The other way, uh, at, at the time we do not have a special device. This is the last and the least, not least, the technique we change the geometry by modify the plaque, either by balloon or sometime by rotator. But today we have a lot of the special catheter, such as the dual lumen microcatheter, the angulated tip microcatheter that can help us to, uh, uh, enter this difficult side branch, such as this technique of the dual lumen microcatheter. However, you have to be familiar with the use of this catheter as well.
And the most, uh, talk, uh, technique is the reverse Y technique, which you use the, uh, looped Y combined with the micro, uh, dual lumen and microcatheter to send the Y beyond the bifurcation and then use this, uh, loop Y to go back into this, uh, side branch. However, uh, you have to learn that sometime it's randomly. You sometime the Y is not always pointing to the, uh, direction of the side branch. So in case that, uh, uh, you, the Y is opposite, you have to manipulate the Y. But when it's become a loop, the direction of Y movement will be opposite to your hand movement. So you have to practice, uh, to gain some experience to do that.
Uh, the second is, this is one of my complications, I, but I cannot find the picture. So this is an illustration that sometime if you have a diffused, uh, lesion in the distal main branch, a loop Y can sometime cause injury of the vessel, either dissection or perforation. So should be careful. And the, uh, also always have a controversy about the how long of the bending part of the loop. Uh, the longer of the bending cup, the loop, you have to, uh, be careful that the zipper part of the tip of loops, but it's make it easier to, uh, enter the side branch as well.
So this is a case example of the use of this, uh, uh, reverse Y technique. You have to see that. You can see that, although the Y can, uh, go easily, but sometime you have to face with the like loop, uh, to how to release this loop before you, uh, can send this, uh, Y, uh, inside the reverse takeoff. Otherwise, when you push the Y directly, it will collapse into the main branch as well. So the most important is set how to, uh, exchange the angle to replace the angle of the loop before you push the wire, uh, further into the side branch.
The other one is the electrical device. I think, for bifurcation technique, especially the, uh, two stent technique, you have to deal with the many device passing, wide angle, stent. And this is a case of the very complex, uh, left main, uh, angulated. And this, this patient, even the diagnostic catheter cannot, uh, make a nice picture. When we do the PCI, we have to use a kite wire to facilitate the catheter, uh, engaging. And then, uh, after we tried, uh, to, uh, modify the plaque with a rotablator, both LAD and circumflex ostium, and also we, uh, use a balloon to pre-dilate this, uh, look like that. The result is quite good enough. First, uh, stent, we will always put in the difficult, uh, angle, uh, branch, this is circumflex, but you can appreciate that stent could not pass easily. Either use of the, uh, guy extension catheter, sometime is also not enough to support in case that the catheter is not, uh, well, uh, coaxial to the, uh, this one. So we have to more modify the lesion with a balloon many, many, many times, and also use the, uh, dual sort of body wire technique to help modify the direction of the, uh, stent and the vessel geometry to allow the center to push inside. This is, uh, how to deliver stent in the complex situation. You, I will pass this slide.
One of the, uh, technique that is, for the difficult one is the, I call it's the action balloon technique. You can use one small balloon to go inside the, this, main branch and then pull it back, uh, simultaneous with the pushing the stent. Sometime it also can help to, uh, deliver the stent in the very difficult anatomy angle. So, in in some case, the, no perfect guiding catheter that you can, uh, find. You have to be familiar with the various balloon and stent technique to help you to push the to send the device inside. Otherwise, many, uh, technique to protect the side branch, such as JY technique. Uh, but should be careful that when you use the JY technique, uh, in the case that calcified, uh, proximal main branch or a previous stent, proximal main branch, this, uh, may make, they can cause the entrap of the part of the Y that's at the proximal main branch. In this case, there's a previous stent in the proximal, and after we put Joe XTY inside the diagonal and before stenting, the Y cannot be removed. And with the various, uh, microcatheter and, uh, small balloon also failed to retrieve this, uh, uh, Y. And at last, it's become uncoiled and snapped. And this become a long, um, communication. Uh, so, be careful of the jing. I recommend that not to, uh, put the the JY in a very calcified proximal main branch, or sometime if you want to put it over there, try to deploy the stent with the lower pressure first before you go, uh, post it should be changed to the re-engaging first.
And another one is a gel balloon. There are two gel balloon techniques, the classic one and the modified one. Uh, it's up to your experience that which one you prefer. But when, when I tried the modified one, this one case that almost caused some complication because, uh, the few long calcified lesion, I put the, uh, main branch, then in the P, this RCA to PR branch with a small balloon in the, uh, side branch. After I deploy the stent, I also, uh, inflated the side branch balloon. But when I inflated the side branch balloon, the balloon become bulky and it's difficult to remove, especially when you have a, a long proximal main branch. Then, so try to estimate the appropriate main branch, uh, length before you put, uh, this modified shell balloon.
Another one is a difficult side branch rewiring after stenting. I think this is the problem of the, uh, the new, uh, the beginner, but sometime for the experienced one is also very difficult. For my experience, I, I prefer to use a single curve Y, and the curve is about diameter plus one to, uh, 2 mm to use to make it easier to cross into the Y. Otherwise, you can use the mic double lumen microcatheter to help, uh, to fast support this Y as well.
And, uh, the main, the most difficult in the modern bifurcation thing is the POT because the POT can face the rewiring into the side branch as well as the balloon. Sometime if you lost the Y, be, uh, in, uh, during the procedure, the, the loop Y, uh, is, uh, something we recommend to cross the, uh, previous stent, but be careful of the, uh, space, uh, between behind the stent. Even a loop Y can make a cross in the, this, SP. So after that, if you have this situation, I still prefer to use a use balloon, or sometime if you have imaging, try to be careful to push the imaging catheter inside, not to force, because even IS can cross, uh, behind the stent as well. And, uh, this is, uh, some technique to help, uh, the to support the balloon pushing into the side branch. That's I always use is a, uh, balloon anchoring technique in the main branch. Otherwise, this is my, uh, always practice that, you have to do a two-step inflation of the balloon. After the tip of balloon can cross the strut of the stent, inflate into the, uh, low pressure first, and after that, uh, it deflates a little bit further, it will be easier to push the balloon inside.
And, uh, if the difficult thing to push a balloon across this bifurcation, always think of the Y, uh, filing or Y wrapping. Uh, this, uh, problem, I try to find the way to protect, but it's still up to now, have no way to protect it. It's always happen when you, uh, uh, uh, when you put a device in and out many, many times, and then that is or will make the wire become wrapping. The the only question we have to remove the Y.
Uh, the other one, you have to be familiar with the stent design and the bifurcation. This is a case that, uh, uh, uh, consult me for the, uh, stent operation because of the previous stent in the crossover meant to, uh, already have a, uh, stenosis at the OM of the, uh, circumflex. This stent was done by using a, a previously a 30 stent, but did not have a POT done. So, I asked them to do the stent enhancement technique, and you can see that the stent actually is over a calcified part and did not, uh, fully expand. So the easiest way is to do it, to do a expansion of this stent, using a, a bigger balloon. And this is the, uh, something you should know well that sometimes the stent design have a different, uh, platform between the small and the, uh, the last one, in the different, in between the the brand. And in this case, I use a big balloon, 345, to post it up to 16 bar, and the balloon fully, full, fully expand, and then make the balloon easily cross this, uh, circumflex, uh, the, the ostium of circumflex. However, because of the this distance, this distance is a proximal, uh, proximal premier, which you have a four link at the two proximal most proximal strut. So I have to use a lobator to do a stent operation before, make it fully expand, and later, use a, uh, dark balloon for, uh, both part, for both branch of the LAD.
And this is another case that the CTO of the LAD, and I, after I opened it and stand with the signature I, and did a mistake because I used a 3.5 synergy stent to send cross over the left main to the LED. What happened? After I use a POT 5 mm balloon POT, you can appreciate in the IAS that the stent did not fully expanded, not fully opposition. Why? Because the synergy have a, uh, the different, uh, division of platform. The 3.5 still the workhorse platform, which the most, uh, expansion capacity is only 4.2, 2 mm. In this case, you should use the 401, or in the other brand, the 3.5 may be appropriate. The other point is that the side branch expansion capacity of the stent, you should know well, because otherwise, if you, uh, set put a stent with a small side expansion, you cannot, uh, make a fully expand of the side branch as well.
So this is all the case that I, uh, show gather to, to in my, uh, practice to show how to do, uh, with the complex bifurcation. The, and this means that you should know well about the various technique, various equipment, and also study the angiogram first very well to make a plan to enter the to to facilitate the, uh, success of your procedure without complication. Thank you. [applause]
>> Uh, thank you very much, Dr. Voice. Uh, we wish that we had more time to hear from you, but, uh, because we have run out of time, so I think we leave the comment in discussion by the end of these sessions.