Provizyonel Stentlemede Yan Dal Girişimleri
Özet
Bifurkasyon lezyonları perkütan koroner girişimlerin %15-20'sini oluşturmakta ve güncel kılavuzlar ilk yaklaşım olarak provizyonel stentleme tekniğini önermektedir. Bu teknikteki en önemli klinik komplikasyon periprosedürel miyokard infarktüsü riskini artıran yan dal oklüzyonudur. Yan dal kaybı riskini tahmin etmek amacıyla; bifurkasyon çekirdeğindeki darlık, plak lokalizasyonu, stent öncesi TIMI akımı, bifurkasyon açısı, damar çap uyumsuzluğu ve yan dal darlık yüzdesi olmak üzere altı parametreyi değerlendiren V-RESOLVE skorlama sistemi kullanılmaktadır. İşlem sırasında yan dal açıklığını sağlamak amacıyla Jailed Wire, geleneksel, basitleştirilmiş, semi-inflated ve modifiye Jailed Balon tekniklerinin yanı sıra Balon Stent Kissing, Corsair Trifurkasyon, Prekissing, Highway, Aktif Plak Transfer, Kissing Balon ve POT-side-POT gibi çeşitli koruma yöntemleri geliştirilmiştir. Bu tekniklerin uygulanması sırasında karşılaşılabilecek en büyük zorluk ekipmanların tuzaklanmasıdır. Provizyonel stentleme sonrasında yan dala girişim için TIMI akımının <3, darlık oranının ≥%70, lezyon uzunluğunun >5 mm olması, tip A üzeri diseksiyon gelişmesi veya fonksiyonel olarak FFR değerinin ≤0.80 bulunması genel kabul gören kriterlerdir. Yan daldaki suboptimal sonuçların tedavisinde bifurkasyon açısı belirleyici olup, yetmiş derecenin altındaki açılarda double kissing culotte veya reverse crush, üzerindeki açılarda ise T ve TAP teknikleri önerilmektedir.
Bifurcation lesions account for 15-20% of percutaneous coronary interventions, and guidelines recommend provisional stenting as the primary approach. The most critical complication in this technique is side branch occlusion, which increases the risk of periprocedural myocardial infarction. To predict this risk, the V-RESOLVE scoring system is utilized, evaluating six parameters: stenosis in the bifurcation core, plaque location, pre-stenting TIMI flow, bifurcation angle, vessel diameter mismatch, and pre-stenting side branch stenosis. Various protection techniques have been developed to maintain side branch patency during the procedure, including Jailed Wire, traditional, simplified, semi-inflated, and modified Jailed Balloon techniques, as well as Balloon-Stent Kissing, Corsair Trifurcation, Prekissing, Highway, Active Plaque Transfer, Kissing Balloon, and POT-side-POT. The primary technical challenge associated with these methods is equipment entrapment. Following provisional stenting, intervention on the side branch is indicated if TIMI flow is <3, stenosis is ≥70%, lesion length is >5 mm, a dissection greater than type A develops, or functionally the FFR is ≤0.80. The bifurcation angle guides the treatment of suboptimal side branch results, with double kissing culotte or reverse crush recommended for angles <70°, and T or TAP techniques preferred for angles >70°.
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