Randomized Comparison of Coronary Bifurcation Stenting With the Crush Versus the Culotte Technique Using Sirolimus Eluting Stents

Abstract

Background-In a number of coronary bifurcation lesions, both the main vessel and the side branch need stent coverage.Using sirolimus eluting stents, we compared 2 dedicated bifurcation stent techniques, the crush and the culotte techniques in a randomized trial with separate clinical and angiographic end-points. Methods and Results-A total of 424 patients with a bifurcation lesion were randomized to crush (nϭ209) and culotte (nϭ215) stenting. The primary end point was major adverse cardiac events; cardiac death, myocardial infarction, target vessel revascularization, or stent thrombosis after 6 months. At 6 months there were no significant differences in major adverse cardiac event rates between the groups; crush 4.3%, culotte 3.7% (Pϭ0.87). Procedure and fluoroscopy times and contrast volumes were similar in the 2 groups. The rates of procedure-related increase in biomarkers of myocardial injury were 15.5% in crush versus 8.8% in culotte group (Pϭ0.08). A total of 324 patients had a quantitative coronary assessment at the index procedure and after 8 months. The angiographic end-points of in-segment and in-stent restenosis of main vessel and/or side branch after 8 months were found in 12.1% versus 6.6% (Pϭ0.10) and in 10.5% versus 4.5% (Pϭ0.046) in the crush and culotte groups, respectively. Conclusions-Both the crush and the culotte bifurcation stenting techniques were associated with similar and excellent clinical and angiographic results. Angiographically, there was a trend toward less in-segment restenosis and significantly reduced in-stent restenosis following culotte stenting. (Circ Cardiovasc Intervent. 2009;2:27-34.)

Incorporation of a Balloon-Cushion Stenting Technique into the Culotte Stenting Technique in Left Main Coronary Artery Bifurcation Interventions

“…Main-branch stenting associated with provisional side-branch stenting is the current strategic technique of choice in PCI for LMCA bifurcation lesions in selected patients [5,6,13].Using this procedure poses the challenge of acute SB occlusion, which occurs in about 6-15% of cases [7,8,14].While the crush stenting technique is useful to avoid such acute SB occlusion [9], it has a higher side-branch restenosis rate than the culotte stenting technique [10]. Consequently, the ballooncushion technique has been devised to incorporate the culotte stenting technique into an LMCA bifurcation intervention, using a 3-step procedure with the following rationales.…”

“…Using this procedure in the complex setting of an LMCA true bifurcation, however, poses the challenge of acute sidebranch (SB) occlusion, which occurs in about 6-15% of cases and can potentially lead to catastrophic events, such as massive myocardial infarction or death [7,8]. While the crush stenting technique is useful for avoiding acute SB occlusion [9], it has a higher side-branch restenosis rate than the culotte stenting technique [10].…”

Coronary bifurcation stenting with dedicated Tryton side-branch stent. Early and 6-month results of 40 patients

“…The "culotte" technique did not work out in the BMS era, because of the very high frequency of restenosis [23]. However, the use of DES seems to make this technique safe and very efficacious [24][25][26][27]. The NORDIC study demonstrated that the "culotte" technique is safer than the "crush" technique (lower rate of periprocedural infarctions) and is related to lower risk of restenosis in the long term (4.5% vs. 10.5%) [27].…”

Dedicated bifurcation stents

“…9,10 However, whether FKI is mandatory with provisional stenting is still unsettled. The 'Nordic-Baltic Bifurcation III Study: A Prospective Randomised Trial of Side-Branch Dilatation Strategies in Patients with Coronary Bifurcation Lesions Undergoing Treatment with a Single Stent' was presented by Niemela at transcatheter cardiovascular therapeutics (TCT) 2009 conference.…”