Culotte versus T-stenting in bifurcation lesions: Immediate clinical and angiographic results and midterm clinical follow-up
Royal Brompton and Harefield NHS Foundation Trust, Harefield, England, United Kingdom American heart journal
(Impact Factor: 4.46).
09/2007; 154(2):336-43. DOI: 10.1016/j.ahj.2007.04.019
Stenting the main vessel with provisional stenting of the side branch (SB) is the method of choice for most bifurcation lesions. There is limited data on which of the two techniques of bifurcation stenting compatible with a provisional approach, culotte or T-stenting, offers the best outcome.
Between February 2004 and October 2005, 80 consecutive patients with bifurcation lesions requiring a second stent on the SB were treated with either culotte (n = 45) or T-stenting (n = 35). Coronary angiograms were analyzed using a quantitative angiography system dedicated to bifurcations. Propensity scores were used to adjust for baseline differences between groups.
Acute procedural success was 100% for both groups. Residual diameter stenosis of the SB ostium was 3.44% +/- 7.39% in the culotte group versus 12.55% +/- 11.47% in the T-stenting group (P < .0001). One patient (2.2%) in the culotte group had subacute thrombosis 2 days after the procedure. The culotte group had a lower target lesion revascularization rate compared with the T-stenting group (8.9% vs 27.3% propensity score adjusted; P = .014) and a trend toward lower major cardiac adverse events at 9 months (13.3% vs 27.3%; P = .051).
Both techniques of provisional SB stenting in bifurcation lesions achieve high procedural success with low complication rates. The culotte technique yields a better immediate angiographic result at the SB ostium, and, using drug-eluting stents, a better clinical outcome at 9 months.
Available from: Azeem Latib
- "Which Is a Randomized Study Author, Year (Ref. #) Aim No. of Bifurcations Follow-Up Restenosis, % TLR, % ST, %* Restenosis, % TLR, % ST, %* MB SB MB SB FKI No FKI Ge et al., 2005 (19) Crush with FKI vs. without 181 9 months 8.9 11.1 † 9.5 2.6 15.5 37.9 † 24.6 3.0 Hoye et al., 2006 (18) Crush 241 9 months 6.4 9.6 † N/A 9.7% overall 4 10 41.3 † N/A 9.7% overall 4.2 Moussa et al., 2006 (20) Crush 120 6 months N/A N/A 11.3% overall 1.7% overall N/A N/A 11.3% overall 1.7% overall Sharma et al., 2005 (21) Simultaneous kissing stents 200 9 Ϯ 2 months N/A N/A 4 1 N/A N/A N/A N/A Galassi et al., 2007 (22) Mini-Crush 52 8 months 12.2 2.0 12.2 2.2 N/A N/A N/A N/A Burzotta et al., 2007 (23) T-stenting and small protrusion 73 9 months N/A N/A 6.8 1.4 N/A N/A N/A N/A Crush (n ؍ 121) T-stenting (n ؍ 61) Ge et al., 2006 (24) Crush vs. T 182 1 yr 16.2 19.2 14 † 1.6 13 26.1 31.1 † 0 Culotte (n ؍ 45) T-stenting (n ؍ 35) Kaplan et al., 2007 (25) Culotte vs. T 80 9 months N/A N/A 8.9 † 2.2 N/A N/A 27.3 † 0 Crush (n ؍ 210) Culotte (n ؍ 215) Niemela et al., 2007 (26) Culotte vs. Crush 425 6 months N/A N/A TVR ϭ 3.3 1.9 N/A N/A TVR ϭ 3.3 1.4 "
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ABSTRACT: The percutaneous treatment of coronary bifurcations has moved past an important milestone in that the 1- versus 2-stent debate appears to have been resolved. The provisional approach of implanting one stent on the main branch should be the default approach in most bifurcations lesions. Selection of the most appropriate strategy for an individual bifurcation is important. Some bifurcations require 1 stent, whereas others require the stenting of both branches. Irrespective of whether a 1- or 2-stent strategy is chosen, the results after bifurcation percutaneous coronary intervention (PCI) have dramatically improved. Dedicated bifurcation stents are an exciting new technology that may further simplify the management of bifurcation PCI and change some of these concepts.
JACC. Cardiovascular Interventions 07/2008; 1(3):218-26. DOI:10.1016/j.jcin.2007.12.008 · 7.35 Impact Factor
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ABSTRACT: Percutaneous coronary intervention for the treatment of bifurcation lesions is associated with a lower success rate and increased risk of subacute stent thrombosis and restenosis. The goal of this manuscript is to review the current classification of coronary bifurcation lesions and techniques. An algorithmic approach for the treatment of bifurcation lesions based on the recently published simplified and comprehensive classification is proposed in this manuscript.
Expert Review of Cardiovascular Therapy 03/2008; 6(2):261-74. DOI:10.1586/14779072.6.2.261
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ABSTRACT: Percutaneous treatment of coronary bifurcation disease remains challenging. In patient subsets in which a two-stent strategy is necessary, the culotte technique is a widely used method. We sought to examine the clinical and angiographic outcomes of patients treated in this manner at our institution. As quantitative coronary angiographic analysis using standard measurement programmes is problematic, we used a dedicated bifurcation analysis system.
We prospectively enrolled patients undergoing culotte stenting with drug-eluting stents (Cypher, Endeavor, polymer-free rapamycin-eluting, Taxus) in two German centres. Lesions were classified according to the Medina classification. Angiographic follow-up was scheduled between 6 and 12 months post-index procedure. Clinical follow-up was available up to 12 months. Culotte technique was used in 134 lesions in 132 patients. Of these, 124 (92.5%) represented 'true bifurcation' lesion morphology. Kissing balloon inflation was used in 62% of patients. Procedural angiographic success was achieved in all lesions. Follow-up coronary angiography was performed in 108 (81.8%) patients. Median (IQR) late lumen loss was 0.10 (-0.04-0.38) mm in the proximal main vessel, 0.34 (0.03-0.66) mm in the distal main branch, and 0.30 (-0.01-0.72) mm in the side branch. The incidence of binary angiographic restenosis was 22% for the whole bifurcation lesion, 0% in the proximal main vessel, 9.1% in the distal main branch, and 16% in the side branch. At 12 months, 28 of 132 (21%) patients had undergone target lesion revascularization. The incidence of stent thrombosis (at 1 year) was 1.5%. Predictors of angiographic restenosis were older age, increasing bifurcation angle, more severe distal main branch stenosis, and smaller side branch reference diameter; kissing balloon post-dilatation tended to have a protective effect.
The culotte stenting technique is associated with high procedural success and a relatively low risk of angiographic restenosis. Safety results in our cohort were favourable in terms of a low risk of stent thrombosis.
European Heart Journal 12/2008; 29(23):2868-76. DOI:10.1093/eurheartj/ehn512 · 15.20 Impact Factor
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