Crush/Mini-Crush: When to
Choose and How to Do
7.00-7.08
Alaide Chieffo, MD
Interventional Cardiology Unit
S Raffaele
San
R ff l Scientific
S i tifi I
Institute,
tit t Mil
Milan, It
Italy
l
Disclosure Statement of Financial Interest
I, Alaide Chieffo, DO NOT have a
fi
financial
i l
i t
interest/arrangement
t/
t
or
g
affiliation with one or more organizations
that could be perceived as a real or
apparent conflict of interest in the
context of the subject
j
of this
presentation.
True Bifurcation
( i ifi
(significant
t stenosis
t
i on the
th main
i and
d side
id b
branches)
h )
No
Provisional SB stenting
No
Stent on MB
S
“Keep It Open” for SB
Yes
Is SB suitable for stenting?
Yes
SB di
disease iis diff
diffuse &/
&/or not llocalized
li d
to within 5 mm from the ostium?
No
Yes
Provisional SB
st ntin
stenting
Elective implantation of two stents
(MB and
nd SB)
An approach for bifurcation lesions
when using
g 2 stents as intention to
treat
Very short left ma
main
n
V-Stent
P
Pre
Cross Section
Main branch disease
extending proximal to the
bifurcation and side
branch
h which
h h has
h origin
with about 90°
90° angle
T-Stent
Pos
P
t
P
Pre
Pos
P
t
Main branch disease
extending proximal to the
bifurcation and side
branch
h which
h h has
h origin
with about 60°
60° angle
Short-Mini
ShortCrush/Culotte
P
Pre
Pos
P
t
The Traditional Crush Technique
Advantages:
Applications:
pp cat ons
- All true bifurcation,
especially non-Left Main
- Immediate patency
of both branches
- Angulation < 75
75°
- Full coverage of the
SB ostium
Considerations:
Drawbacks:
- Single high pressure
-balloon
C inflation in the
- High metal
concentration at the
bifurcation carina,, less
with “Mini Crush”
- Re-wiring into SB
SB before FKB may
y be
hepful to optimize
stent expansion
Iakovou I. et al, JACC
2006;46:1446-1455.
FKB fi
FKB:
finall ki
kissing-balloon
i b ll
SB: side branch
Crush Case
Elective IABP Implantation
PRE DILATATION
PRE-DILATATION
LAD
DIAG
LM-CX
CRUSH
DES 3.5x16mm
E 3.5x32mm
DES
2-STEP
2
STEP FKI
FKB with NCB
LAD: NCB4.0x15mm
LAD
NCB4 0 15
att 18 atm
t
Cx: NCB 3.5x12mm at 18 atm
4 5 20
4.5x20mm
at 20 atm
Before
After
IVUS g
guidance during
g DES
Left Main PCI associated
with reduction in mortality;
HR=0.43; CI, 0.21-0.87
FINAL RESULT
NORDIC II:
rad t onal CRUSH
SH vss CULOTTE
LO E
Traditional
In--segment
In
Primary end point
6 ms MACE
Crush 4.3% vs 3.7% in culotte,
P=NS
In--stent
In
Erglis A. Circ Cradiovasc interv 2009; 2:27-34
Minicrush
M
n crush vs Traditional
rad t onal Crush
rush
• Less protrusion of SB stent into MB ((mini
mini-crush)
crush
h)
• 2-step
p Kiss:
Kiss: first SB p
post--dilatation at
post
high pressures with a NCB then FKI with
2 NCB.
NCB
2-Step
p Kiss
K
No Kiss
A
One-step Kiss
B
Two-step Kiss
C
Slide courtesy of John
Ormiston
Case 11--Mini Crush
Baseline
Mini Crush Case
EE 2.5x18mm
EES
EES 3
3.0x28mm
0x28mm
MINI--CRUSH
MINI
After Stent on LAD
8Fr Guide
Re--crossing into Diag
Re
Mini Crush Case
NCB 2.5x15 mm 28 Atm
NCB 3.0x15m /2.5x15mm
2-Step FKI with NCB
Mini Crush Case
Final
Fi l R
Result
l
Conclusions
• Mini Crush is suggested in spite of
Crush
• Indications for Minicrush: disease in
MB
extending proximal to the
bifurcation and side branch of adequate
diameter, disease extending more than
5 mm from the ostium or unfavourable
angle which has origin with about 60°
angle
l
• 2 Step FKM is mandatory
• IVUS is recommended