News:Culotte is better than crush for bifurcation lesions: Results from the Nordic Stent Technique study

March 29, 2008 By Vijayalakshmi Kunadian MBBS MD MRCP [mailto:vkunadian@perfuse.org]

Dr. Paal Gunnes from Feiring Klinikken, Feiring, Norway, presented the results of the Nordic Stent Technique study at the SCAI-i2 summit Annual Scientific Sessions in Chicago today.

A previous study from the Nordic Stent investigators demonstrated that the use of main branch and side branch stenting with sirolimus eluting stents was associated with increased procedural time, fluoroscopy time and an increase in post-PCI biomarker release. Hence this study recommended the use of main branch stenting only with provisional side branch stenting.

Subsequently, these investigators performed a study among patients who underwent both main and side branch stenting to determine the best stenting technique. Patients were randomized either to crush stenting or culotte stenting and underwent angiographic evaluation at eight months. The 6 month results were presented at TCT 2007 which demonstrated no difference in combined cardiac death, myocardial infarction, target vessel revascularization and stent thrombosis between the crush and culotte groups.

The present study consisted of 425 patients with bifurcation lesions randomized to treatment with drug eluting stents implanted using either a culotte [n=209 (160 had angiographic follow-up at 8 months)] or crush technique [n=215 (164 had angiographic follow-up at 8 months)].

Briefly, the culotte technique involves inserting two stents (one into the main branch and the other into the side branch) and the two stents overlap in the main branch. Whereas the crush technique involves inserting the side branch stent first so that a small segment of the side branch stent protrudes into the main branch. Upon implantation of the main branch stent it crushes the overlapping segment of the side branch stent against the intima of the main artery.

This study investigated at 8 months the following angiographic parameters:
 * In-lesion >50% stenosis of the entire bifurcation
 * In-stent >50% stenosis of the entire bifurcation
 * In lesion >50% stenosis of main vessel (MV)
 * In lesion >50% stenosis of side branch (SB)
 * Late loss of MV and SB

The procedural success and the incidence of true bifurcation lesion was comparable between the crush and culotte groups [(98.8% vs. 100%) and (78% vs. 85%) respectively]. At 8 months, there were no differences in the angiographic parameters such as in-lesion >50% stenosis of the entire bifurcation (12.1% vs. 6.6%, p=0.1), in lesion >50% stenosis of MV (4.7% vs. 2.0%, p=0.16) and in lesion >50% stenosis of SB (9.2% vs. 4.5%, p=0.1)] except the rate of in-stent >50% stenosis of the entire bifurcation (10.5% vs. 4.5%, p=0.046) and late lumen loss of SB (9.8% vs. 3.8%, p=0.04) between the crush and culotte techniques respectively.

This study concluded that crush and culotte bifurcation stenting using sirolimus eluting stents were associated with low rates of restenosis at 8-month angiographic follow-up. The restenosis that occurred with the crush technique were primarily located in side branches. The investigators demonstrated that the culotte bifurcation stenting technique was associated with a reduced restenosis rate and may be preferred in suitable bifurcation anatomies. Further follow-up data is required to ascertain the risk of long term outcomes.

Source
Presented at the SCAI Annual Scientific Sessions in partnership with ACC i2 summit, March 29-April 1, 2008 Chicago