Bifurcation Lesions - T-Stenting
From Ask Dr Wiki
May be used for provisional stenting of side branch if angiographic result is poor. Can Use 6Fr guide system Restenosis is usually very focal
Very difficult, if not impossible to completely cover side branch ostium Requires final kissing balloon inflation Modified T-stent technique requires 7Fr guide system
May use a 6Fr Guiding system Final Kissing balloon inflation required due to high Restenosis rate Ideal angle of bifurcation is at or near 90 degrees.
Technique (Modified T-Stenting):
1) A 6Fr guide system may be used with standard T-stenting in which the side branch stent is deployed, followed by delivery and deployment of the parent stent. The modified technique, which is preferred by this operator, requires a minimum of 7Fr guide system.
2) Both the parent and side branch are wired. Predilation is recommended to ensure optimal balloon expansion and ease stent delivery. It is important to identify which wire is placed in which branch. We recommend either using 2 separate colored guide wires, keeping a marker on 1 wire, or covering a wire with a sterile towel while not in use.
3) Any disease in the distal side branch or parent vessel should optimally be repaired before the bifurcation stents are deployed.
4) The 1st stent is advanced into the side branch. This may require further predilitation. Generally, the stent is advanced beyond the delivery point.
5) The 2nd stent is advanced into the parent vessel and placed across the side branch.
6) The side branch stent is deployed. (Another option is to place a balloon in the parent branch and inflating to low atm while pulling the side branch back. This may help ensure adequate coverage of the ostium.
7) Side branch wire is removed once adequate angiographic result confirmed.
8) The parent stent is deployed across the side branch.
9) Angiography should now be performed to ensure adequate side branch coverage and stent deployment. The parent stent is deployed.
10) The side-branch is rewired. It is sometimes necessary to change wires to either a hydrophilic wire eg. Whisper, (Guidant, Temecula, California) or Pilot 50 or 150 (Guidant, Temecula, California), or Fielder (Abbott Vascular Devices, Redwood City, California), one of increasing stiffness eg. ASAHI Miracle Bros 3 (Abbott Vascular Devices, Redwood City, California), or both eg. Shinobi (Guidant, Temecula, California) or Confienza (Abbott Vascular Devices, Redwood City, California).
11) Kissing balloons are inflated at the bifurcation. It is sometimes necessary to dilate the sidebranch with a small balloon (1.5 mm middle marker balloon) to facilitate a larger balloon for the kiss.
12) Repeat angiography is performed. Wires are removed and final angiography completed.
*Provisional T-Stenting involves the stenting the parent vessel and only the side branch if there is less than adequate side branch angiographic result. In this situation, the side branch may need to be serially dilated with up to a 2.5 mm balloon to ensure stent delivery. Final kissing balloons should be repeated.
**Sometimes the side branch stent impinges on the parent lumen making delivery of the parent stent impossible. If this happens, dilation of the parent lumen with a balloon allows for stent delivery. This may create a partial or small area of crushed stent at the bifurcation and should be followed with kissing balloons.