<v ->Thank you. Great talking.</v> In the interest of time, we need to go up onto Yves Louvard. Yves Louvard is the father of the bifurcation clubs that we set up many, many years ago in France that really fascinated me. He really started the European Bifurcation Club, bringing worldwide attention to bifurcation. So, let's get Yves started. All right, Dr. Yves. <v ->Oh, I'm trying to...</v> Maybe (indistinct). <v ->You're on, the screen is on.</v> <v ->Okay, okay, okay.</v> Yeah, I am, nice. So, good evening to you all. First of all, I want to thank SCAI and especially Tanveer Rab, John Lisko for this invitation for this webinar, dedicated to what I consider my last project, European Bifurcation Club and Coronary Bifurcation Stenting. I was asked by Tanveer to present the case of provisional stenting technique. Stenting is the most standard. The talk is on my recent publication of the Club, I will show here is the 13th consensus written by Francesco Burzotta, which is in 2018. EBC Main was cited already written by (indistinct), and more recently, a stent study of this prior written by Sandeep Arunothayaraj dedicated two technical details. I choose a case of left main bifurcation stenting on a 60-year-old woman. She's my colleague and my friend and she's suffering a severe stable angina. This was spectacularly changed during stress test. She was previously treated for Hodgkin disease with radiotherapy. The lesion is angina, number one, left main LAD-CX. This my patient tell you that I consider LAD as a main distal vessel. There is also an ostial lesion, moderate, on the RCA. The provisional strategy, begin always was set by a systematic double (indistinct), which will help you to keep the side branch open, localize the side branch basal occlusion and allow the use of a salvage technique using, for example, a small balloon on the jailing wire to regain a side branch flow. For wires, we always begin with the most difficult branch access. During wire insertion, we limit wire rotation to 180 degrees. We keep and change the positions of the two wires on the table to avoid crisscross. Using hydrophilic wire, avoid deterioration of the wire during POT. For example, on removal choose a wire distal shape longer than proximal segment diameter, use sometimes a double shape if necessary, hairpin shape for reverse wire technique. In terms of failure to enter a side branch, we can use a shaped microcath or even rotablation of the main vessel. Then most of the predilation is performed, as you can see here, with the balloon which is selected from the LAD diameter. In this case, side branch, the complex was not prepared. After balloon, the side branch is still there as you can see. Main vessel crossover stenting is then performed with a DES size 1:1 according to LAD diameter, here 3.5 millimeter. The proximal part of the stent has to be at least 6 to 8 millimeter long to allow the use of the 6 to 8 bigger balloon for POT. But here, in this situation, the stent is positioned at the ostium. So, it's okay, we have not risk of geographic risk. Stent deployment has to be long enough to deploy proper resistance. And I currently do two or three inflation with duration depending of the tolerance of blood pressure adapted to the diameter of LAD. (indistinct) balloon to carry high pressure, you may push the carina into the side branch. In the crossover stenting, the circ is important, and clearly the stent is under deployed in (indistinct). The predictor of side branch TIMI flow less than 3 from Sandeep Arunothayaraj. No influence of angle, no influence of medina, no acute coronary syndrome, even side branch preparation and jailed wire, but only the presence of moderate to severe classification. So the predilated ostium of the side branch TIMI classified is probably (indistinct). Systematic first POT is done with a balloon sized 1:1 to the left main here of 4.58 millimeter. Of course, this is POT balloon in the aorta regarding the shortness of the left vein. In POT, the distal marker of the balloon is in front of the carena. If the proximal part of the stent is long, more proximal POT has to be performed to avoid the negative effects. The consequence of the tapering of coronary vessel at the level of each bifurcation only, we have to choose the crossover stent adapting to the two diameter, the distal and the proximal. And here is a chart showing is quite old showing how to choose a stent to adapt to a 4.5 left main and a 3.5 LAD. After POT, we see, I think clearly here, if you look cautiously, two diameter along the stirrup is still patent. These are wrapped around very tight stenosis. In fact, this is certainly a parallel sheath. Technical advantages of POT are avoiding wire exchange outside the proximal part of the stent was shown by Francesco. Open the cells for easier wire and balloon cushion. Now, it is time to wire recharge. So for the left main, we don't remove the LAD wire and push the circ and then remove the circ to put in LAD. We use a third wire in order to improve the stability of the guiding catheter. Pull-back from LAD is used to enter the most distal cell towards the circumflex using a long shape in the tapered wire then take of guiding catheter. Keep it out of the ostium to avoid longitudinal distortion during side branch wire dejailing. So on the left, you see a proximal recrossing which is responsible of a neocarina. And on the right top bottom, you have a distal recrossing where you push the metal on the lateral wall of the side branch. When the crossing is proximal, then you create neocarina. I'm sorry, I missed something. When the recrossing is disturbed then the proximal part of the stent is projected to the (indistinct). So it is a case of left main longitudinal stent distortion. You can see dark dots representing overlapping struts seen only easily with stent enhancement. A certain stent had to be implanted proximally in this case. Here is a series from EXCEL by Akiko Maehara during the clinical consequences of mainly unrecognized distortion. So this is, as you can see, a severe problem with an increased rate of MACE and decreased rate of left main-related MI and left main ischemia-driven TLR. After wire exchange, side branch predilation. The only one predictor of failure to rewire was the absence of jailed wire. This is an important validation for jailed wire. After wire exchange, it is time to prepare the side branch with the NC balloon using pressure to fully open the vessel. I don't explain why you use the NC balloon, was explained by Francesco. Followed by kissing with main vessel balloon size 1:1, I call the distal main vessel and side branch balloon (indistinct). Size of the side branch diameter. This is the best technique to put the carena in its physiologic position. Now, it's time to decide the extent of the side branch. I have to say that from the beginning, I was thinking I will have to put circles there, but we can, for example, looking at this picture, can decide not to put. Requirement for further side branch intervention funded by Sandeep following preparation of the side branch but not perform non NC-only kissing balloon and see it's important it was set. Only a trend for side branch disease more than 10 millimeter. So this means that we don't have yet a total value from EBC met of double stenting. The side branch show, this one, the side branch preparation is in fact of dissection. After kissing balloon, I decided to stent the circumflex artery maybe because I consider this lesion was related to radiotherapy because my colleague have a very safe life and no problem factor. So how to choose the technique. Sorry, how to choose the... I said the distal crossing is associated with favorable main vessel stent deformation. You can see here very clearly with stent enhancement. After ballooning to perform the T-stenting without stent protrusion, stent enhancement is so very useful. If you have a side branch lateral wall metal projection then you can perform a T-stenting. If you not have it, you have a neocarina and then you have to perform TAP and you see on the two picture in the middle, at the top, projection of metal inside the vessel. So, neocarina and at the bottom a projection of metal laterally, ideal for stenting. You can also use mini-culotte using double stent, any DV stenting disease provisional. This is part of the provisional strategy. So I decided to implant a stent in the side branch as a T-stenting regarding the provision. And you can see here that it's a bit proximal, black forward dot. So a good positioning of the side branch is essential in the best available position, best radiology position. If too... a second side branch stenting will be necessary. If too proximal for TAP, you have to convert the procedure to internal crush. It will be necessary. The performance of an additional light pressure following partial withdrawal of the stent balloon is recommended in order to achieve optimal stent expansion before the final kissing, which is here perform immediately after the stent deployment using the side branch stent and main vessel balloons. Simultaneous balloon deflation to avoid carena. The result was considered good but all nearly always doing a final POT. I think it was said by Azeem. This is to correct ovalization and this POT of course has to be more optimal than the first POT because we don't want to crush the stent or to move the carena. This very good result without any acute mass persisting at seven years without symptoms. So the predictor of periprocedural MI non-NC only kissing balloon inflation and there is a trend for when the side branch was not rewired. So I'm coming to my conclusion which is coming from David Hildick Smith. So the stepwise provisional approach is rigorous, logical. This is flexible, versatile, which I change mind all along the procedure and it offers option to do less rather than more. And I think this part is important regarding the long term outcome that was shown by Francesco. Thank you very much.

Dr. Yves Louvard

bifurcation clubs

bifurcation procedures

left main bifurcation stenting

provisional stenting technique