Dr Ch.

Martinez, CHU Sart Tilman, Belgium

Fractional Flow Reserve, when and why ?
Evaluation of the provisional side-branch strategy
for bifurcation lesion using FFR
Ch. Martinez, MD
University Hospital of Lige
Belgium
I do not have any potential conflict of interest
Dr Ch. Martinez, CHU Sart Tilman, Belgium
Evaluation of the provisional side-branch intervention
strategy for bifurcation lesion using FFR: Introduction
I. Even and specially with DES, bifurcation lesions
remains one of the most challenging lesion subset
in coronary intervention
II. No previous study as shown benefit for the 2
stents strategy, even with DES
III. The provisional side-branch strategy is actually
considered as the best for bifurcation lesions
Dr Ch. Martinez, CHU Sart Tilman, Belgium
Evaluation of the provisional side-branch intervention
strategy for bifurcation lesion using FFR: Introduction
I. The decision making for SB interventions remains
problematic
II. The visual estimation of severity for such lesions
is very difficult
III. QCA systems are frequently inaccurate and does
not reflect the functional severity of such complex
and ostial lesions
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Koo BK and al, Eur Heart J. 2008 Mar;29(6):726-32.
Stenting of the main branch with DES
IC Nitroglycerin
Visual estimation
Residual stenosis > 50 % Residual stenosis < 50 %
FFR measurement
0.014 pressure wire
IC adenosine bolus
+
IC adenosine infusion
Stop intervention
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Koo BK and al, Eur Heart J. 2008 Mar;29(6):726-32.
FFR measurement
FFR < 0.75
Functionally significant
residual stenosis
FFR > 0.75
No functionally significant
Residual lesion
Kissing balloon PTCA
+
FFR again
Stop intervention
If FFR < 0.75
Kissing stenting
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Clinical case: 60 years old man with unstable angina
Direct stenting
with a BMS 3.5 x 23
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Clinical case: 60 years old man with unstable angina
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
3 month later, recurrent angina at rest
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
3 month later, in-stent diffuse restenosis with side-
branch involved
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
two conventional wires
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Pre-PTCA of side-branch because TIMI 2 flow
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Direct stenting of the main branch with a DES 3.5 x 28
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Control after stenting => pressure wire
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
FFR measurement: 0.71
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Kissing balloon PTCA
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
FFR measurement after kissing balloon: 0.9
Dr Ch. Martinez, CHU Sart Tilman, Belgium
The FFR guided side-branch strategy
Angiographic result after kissing balloon
Dr Ch. Martinez, CHU Sart Tilman, Belgium
Percentage of SB lesions requiring further intervention at each
step of the FFR guided strategy: comparison of angiographic
and functional criteria.
0
10
20
30
40
50
60
70
Post-stent Post-kissing Follow-up
> 75 % Stenosis FFR < 0.75
68%
31%
32%
8%
48%
8%
Koo BK and al, Eur Heart J. 2008 Mar;29(6):726-32.
Dr Ch. Martinez, CHU Sart Tilman, Belgium
Conclusion
Measurement of FFR can be helpful in determining
functional significance of lesions at each step of the
provisional side branch intervention strategy