Transcription
Welcome to Europe PCR 2025. My name is Yens Flassan and I'm an interventional cardiologist from Denmark. I'm here today with Decepti Diola who is an interventional cardiologist from uh Italy and we are here to discuss and talk about the essentials of the provisional strategy uh for left main bifocation treatment and uh JB why do you find the the provisional strategy so appealing?
Well, uh, Yans uh, it's a great question. Actually, it is appealing because, you know, with a relatively simple procedure, we are able to tackle the majority of bifurcation lesions. Uh, and, uh, by implanting the least amount of metal possible, but if needed, we can upgrade it to a two-stand technique.
Ah, so so it's it's not a two-stand technique from the beginning. It's actually stepwise that they can develop.
Yeah, exactly. It's stepwise but it's it's not a two-stand technique but it's not even a one-sand technique. It's a it's a philosophy you know it's a strategy. You implant the first stent with the correct uh um steps and then you know that you are ready uh if needed to implant a second stand.
Yeah. So it's it's a technique with different steps that develops over time. Could you try to pinpoint where we do have the decision points for what to do as the next step?
Well, actually the uh implantation of the the first stent is crucial and what is even more crucial is the post-optimization technique in the proximal main vessel because it should be done uh pending uh possible complication if you don't do it especially uh crashing the stand once you rewire uh and it should be done properly. So we should take care not to um go over uh um with the with the shoulder of the balloon in the distal main vessel or else we could have a plaque shift towards the oium of the side branch.
Yeah. So true because it's it's pretty tricky exactly that state because you deterate the stent actually enlarge it to a large amount in the proximal part and and keep a a more smaller diameter in the distal part. But you have to be so precise.
Yes. So one of the crucial part is actually if you're not precise, you can actually ruin the entire procedure. Do you have some protection system when you when you're doing this? Um I'm thinking of wires.
What um well actually what you can do is first is you can use imaging to identify your lending zones for your stent. Uh and you have to make sure that you have enough stent in the proxim branch in order to perform pot. Uh basically once you have your wire in the side branch even if you close the side branch by performing pot then you know that you can always come back and reopen it if need be. So that is one of the good ideas with two wires. I have a jailed wire which is actually both a guide and and a lifeline if if if it closes.
Yeah. You you were talking about imaging. Uh where do you all also use imaging in in in in these kind of u of treatments?
Well, imaging is uh I think it's always nice to have imaging especially in complex lesions because it gives you really a good idea about the distal and proximal landing zone about the caliper uh and also if uh some complication happen or something unexpected happens it can uh help you identify what has happened and how to fix it. So it's it's actually a help during the procedure both for decision making and for evaluating what is going on and for final evaluating of the result. So it actually make it more easy for us to be happy with the final re result.
But all the steps in in in in the first stent uh implantation uh is actually very crucial. We have mentioned the pot the proximal op optimization but when we have done with that we need to evaluate the site branch exactly and and where is the the problematic decisions around that.
Yeah exactly so there is a there's a big decision to make and I'm going to tell you right away there is no right answer because it's really depending on operator's experience and confidence about what to do with the with the side branch. What we know is is that if the operator feel confidence to leave the side branch maybe it's not too big uh then after the first pop the procedure can be stopped but if the the the the operator thinks that something else should be done he can do the rewiring and uh kissing balloon and repot or he can decide to implant a new stand. But the most important um innovation that has emerged over the last few years is the use of the drug coded balloons because by using drug coded balloons we could potentially um save even more metal uh by saving the uh the the stent in the side branch. So actually we have introduced an a new decision point where to actually reduce the amount of metal by introducing the drug losing balloon in in in the steps in the the provisional pathway. So this is really an a a new invent but don't keep it too simple.
So thank thank you very much. So what we really have emphasized here today is that we do have a technique a philosophy that develops stepwise build on one stent and there are decision points where you can stop the procedure but you can also continue if needed and end with two stances and a final result but keep it simple but not too simple and avoid the amount of metal.