What is the preferred stenting technique, tap stenting or t stenting, for patients undergoing stent placement?

TAP vs T Stenting in Peripheral Artery Disease

TAP (T And small Protrusion) stenting is preferred over traditional T stenting for bifurcation lesions due to better technical success rates and lower risk of restenosis. 1

Overview of Stenting Techniques

Stenting is a common endovascular treatment for peripheral artery disease (PAD), particularly for aortoiliac lesions. When treating bifurcation lesions, the choice of stenting technique becomes crucial for both immediate procedural success and long-term outcomes.

TAP Stenting Technique

• Involves main vessel stenting followed by side branch rewiring
• Small protrusion of the side branch stent into the main vessel
• Creates better coverage of the bifurcation carina
• Requires less precise positioning compared to traditional T stenting

T Stenting Technique

• Involves placing stents in a T-configuration
• May leave gaps at the carina (bifurcation point)
• Requires more precise positioning
• Higher risk of restenosis at the bifurcation point

Evidence Supporting TAP Stenting

The most recent evidence from a prospective registry study demonstrated that a provisional TAP stenting strategy for bifurcation lesions resulted in excellent clinical outcomes 1:

• Only 8.2% major adverse cardiac events at 1 year
• Very low cardiac death rate (0.4%)
• Low target vessel revascularization rate (4.5%)
• Similar outcomes between patients requiring only main vessel stenting and those requiring double stenting with TAP

A technical advancement called Snuggle TAP (S-TAP) has further improved the precision of the TAP technique by using a balloon in the main vessel as an anvil during side branch stent deployment 2.

Considerations for Stent Selection and Placement

Anatomical Considerations

• For TASC A-D iliac lesions, primary stenting has shown similar 1-, 3-, 5-, and 10-year primary patencies 3
• However, TASC C and D lesions have significantly higher complication rates compared to TASC A and B lesions 3

Stent Types

• Self-expanding stents are typically used for more flexible arterial segments
• Balloon-expandable stents are preferred for rigid, calcified lesions
• Covered stents may provide higher patency rates compared to bare metal stents in certain situations 3

Approach Considerations

• Endovascular approaches are now favored over open surgical intervention due to lower perioperative risks 3
• Transfemoral access is traditionally used, but transradial access may be considered for certain lesions to reduce vascular complications 3

Clinical Decision Making Algorithm

1. Assess lesion complexity:

   • Simple bifurcation: Consider provisional stenting (main vessel only)
   • Complex bifurcation with significant side branch disease: Consider TAP technique

2. For bifurcation lesions requiring two stents:

   • TAP technique is preferred over traditional T stenting 1
   • If precise positioning is challenging, consider S-TAP technique 2

3. Post-stenting management:

   • Dual antiplatelet therapy is recommended following stent placement 3
   • Regular follow-up with duplex ultrasound to assess stent patency 4

Potential Pitfalls and How to Avoid Them

• Stent thrombosis: Ensure adequate antiplatelet therapy post-procedure 3
• Restenosis: Use appropriate stent sizing and consider drug-eluting options for high-risk lesions 3
• Side branch occlusion: When using TAP technique, ensure proper rewiring of the side branch and optimal stent protrusion 1, 2
• Stent dislocation: Use specialized delivery systems designed for the specific technique 5

Conclusion

When comparing TAP versus T stenting techniques for bifurcation lesions, the evidence supports TAP stenting as the preferred approach due to better technical success rates and lower risk of restenosis. The TAP technique provides better coverage of the bifurcation carina and requires less precise positioning compared to traditional T stenting, resulting in improved clinical outcomes.