Drug‐eluting stents for coronary bifurcations: Bench testing of provisional side‐branch strategies

Abstract

The objective of this study was to bench-test provisional bifurcation stenting strategies to provide insights on how best to perform these with drug-eluting stents (DESs). Bifurcation stenting with DESs reduces restenosis compared with bare metal stents (BMSs). Outcomes with a single DES are better than with two DESs but if the main branch is stented, there needs to be a reliable strategy for provisionally stenting the side-branch with full ostial scaffolding and drug application. Stents were photographed in a phantom after deployment with different strategies. With provisional T-stenting, placement of the side-branch stent without gaps is difficult. The internal (or reverse) crush strategy fully scaffolds the side-branch ostium but is experimental. The culotte technique providing excellent side-branch ostial coverage is easier to perform with open-cell or large-cell stent design. In general, kissing balloon post-dilation improves stent expansion, especially at the ostium, and corrects distortion. However, a main-branch kissing balloon of smaller diameter than the deploying balloon causes distortion. Final main-branch postdilatation or sequential postdilatation prevents distortion after the internal crush strategy.

Randomized Comparison of Final Kissing Balloon Dilatation Versus No Final Kissing Balloon Dilatation in Patients With Coronary Bifurcation Lesions Treated With Main Vessel Stenting

“…It has been suggested that postdilatation would facilitate subsequent SB access. 14 We found that the need for TLR was Ͻ2% after 6 months, indicating that the need for subsequent SB access was low.…”

“…Meticulous bench testing has shown that stent deformation is consistently seen after opening of a stent, but this deformation can be corrected by FKBD. 13,14 Therefore, the present study compared FKBD and no FKBD to investigate both the clinical and angiographic effects of routine opening of the MV stent struts at the SB ostium in bifurcation lesions treated with MV stenting.…”

The EBC TWO Study (European Bifurcation Coronary TWO)

“…20,21 There are theoretical advantages of the culotte over a provisional-T strategy in lesions with large SB, such as SB protection and full ostial coverage. [22][23][24] In left main bifurcation, lesions culotte technique has compared favorably with the provisional strategy but was associated with increased major adverse cardiac event (mainly because of increased target vessel revascularization) when compared with the DK crush technique. 21,25,26 The 2 kissing balloon inflations intrinsic to the DK crush technique may improve ostial SB stent apposition resulting in less restenosis.…”

Dedicated bifurcation stents

“…The specific mechanism underlying restenosis at SB ostium is at the moment not completely clear and presumably many factors are involved. 1,8,[11][12][13] The British Bifurcation Coronary study 14 randomised 500 patients with coronary bifurcation lesion for simple or complex strategy using Paclitaxel DES. The simple group had provisional stenting where as the complex group had crush or Culotte technique with two DES.…”