Questions / Answers from August 18, 2009 Case
Questions / Answers
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How long do you recommend Dual AntiPlatelet RX with Xience SKS these days? |
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We are continuing DAPT in Xience SKS for more than one year and perhaps 3 years. We have routinely prescribed DAPT with Cypher for minimum 3 years. This policy has eliminated late SATs in these cases. |
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What do you think about Prasgral for bifurcation stenting? |
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I will recommend use of Prasugrel as a substitute for plavix in suitable cases (>60Kg, <75yrs age and no prior CVA history). With that note we will use Prasugrel once available at our center, in these bifurcation cases. |
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Is this V stent or SKS? |
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We have published that if Carina is <2mm then it is 'V' stenting and if >2mm than SKS. This case has Carina of about 5 mm and hence will be called 'SKS' technique. |
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What is the advantage of SKS over crushing method? |
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We do not use crush technique at our center but Crush will be good if SBr is angulated and is of moderate size (<2.8mm). There is no randomized trial comparing Crush vs. SKS technique. There has been a randomized trial which compared 'Crush' vs. 'Culotte' technique (NORDIC Bifurcation II Trial) and reported a statistically non-significant trend towards lower MACE and TVR with Culotte compared to Crush technique. |
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Is new carina in single gigits? |
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Yes. It seems to be about 5mm in length. |
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In bifurcation lesions, how do you decide to use Cutting Balloon, Rotablation, Angiosculpt or simply, a balloon? |
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Based on the lesion calcification and degrees of stenosis, our algorithm is as follows: Heavy calcium- Rotablator; >70% 10mm lesion length- Cutting balloon (may be Angiosculpt) and 50-70% long lesion then non-compliant balloon. We have found that Cutting balloon is more effective than Angiosculpt in ostial plaque modification. However, the Angiosculpt is good for treatment of ISR. |
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What criteria are you using to use a particular DES – for all lesions, not only the bifurcations? |
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Xience/Promus has become the DES of our choice in our cath lab being used in 80-85% of DES (82% DES and 18% BMS). We use Cypher in about 15% of cases especially for long lesion length (33mm) and bifurcation lesions. Also large ostial lesions such as left main Cypher gives the tensile strength which is not provided by XienceV DES. Also we use Endeavor DES in rare cases where we have to stop DAPT in less than 6 months but after minimum 3 months. |
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How concerned are you about the balloon overhang with DES with stent types that use compliant balloon materials? |
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Yes. That has been a beneficial factor for Cypher DES as the proximal edge may be a problem with Xience/Promus because of very compliant balloon material that may cause edge dissections. However, this problem is very easy to mitigate and to circumvent this issue, we routinely deploy Xience/Promus at 8-12 atm and post dilate with a short non-compliant balloon at 16-20 atm. This policy has eliminated the issue of edge dissection with XienceV DES. |
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What are your rates of restenosis with bifurcating lesions? |
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About 5% clinically which is consistent with various published Trials of DES in bifurcation lesions (NORDIC, CACTUS, SKS-PRECISE). Key technical points are final kissing balloon dilatation if you have crossed via the stent struts to dilate the side branch post stent deployment. SKS technique eliminated this issue of post-dilatation and recrossing the stent struts as it is rarely needed. |
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