Crush Stenting Research Articles

Left Main Coronary Revascularization at the Crossroads

Percutaneous revascularization of left main coronary artery (LMCA) disease has remained controversial for more than 25 years, since LMCA balloon angioplasty was first performed by Andreas Gruentzig in 1978. Summarizing his experience, Gruentzig concluded, “We have not been too successful with dilating left main stems…although the procedure is relatively simple, the potential complications are both sudden and serious.”1 Following the evolution of percutaneous catheter-based therapies to include both bare metal stent and, more recently, drug-eluting stent (DES) platforms in conjunction with advances in periprocedural and postprocedural adjunctive pharmacotherapies, interest in percutaneous LMCA revascularization, particularly unprotected left main, has been renewed. Although studies performed with bare metal stents demonstrated a low rate of in-hospital mortality, the incidence of late coronary restenosis remained high.2–6 In the Unprotected Left Main Trunk Intervention Multi-Center Assessment (ULTIMA) registry, which enrolled 279 patients with unprotected LMCA disease who had percutaneous coronary revascularization (69% bare metal stent), mortality at a 1-year follow-up was proportional to clinical risk stratification (40% in high-risk versus 3.5% in low-risk patient cohorts), and repeated revascularization was required in 34% of cases.6 The experience gleaned from these studies continued to support the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations that in reasonable surgical candidates with LMCA disease, coronary bypass surgery is the preferred therapeutic option.7 After the introduction of DES, several small clinical series demonstrated the feasibility and short-term safety of LMCA stenting, while late clinical/angiographic outcomes appeared favorable as compared with historical (nonrandomized) patient cohorts treated with bare metal stents.3,8–11 The cumulative experience with DES treatment for LMCA demonstrated an apparent marked reduction in major adverse cardiovascular events, including target vessel revascularization, during 6 to 12 months of follow-up as compared with the precedent experience after bare metal stent deployment. Article p 2542 The clinical …

Bifurcation stenting with drug eluting stents: Illustration of the crush technique

A number of percutaneous stenting techniques have been proposed for optimal treatment of bifurcation lesions. However, to date the most favorable interventional approach still remains controversial, since bifurcation lesions are associated with high procedural complication and restenosis rates. In the era of drug-eluting stents, crush stenting technique simplified the procedure, concurrently allowing full lesion coverage. The purpose of the present report is to review three cases treated with crush stenting and to describe in detail the technique and its variations.

Stent Strut Fracture-Induced Restenosis in a Bifurcation Lesion Treated With the Crush Stenting Technique

Percutaneous treatment of a bifurcation lesion still shows a significant complication rate, mainly because of restenosis at the ostial site of the side branch vessel. Different techniques, such as V-stenting, culottes-stenting or crush stenting, allow full ostial coverage and may therefore achieve uniform drug distribution within the lesion. The crush technique results in a strong mechanical constraint on the side branch stent. A case of stent strut fracture-induced restenosis in a bifurcation lesion treated with the crush stenting technique is described.

Clinical and Angiographic Outcome After Implantation of Drug-Eluting Stents in Bifurcation Lesions With the Crush Stent Technique: Importance of Final Kissing Balloon Post-Dilation

The purpose of this research was to evaluate the long-term outcomes after implantation of drug-eluting stents (DES) in bifurcation lesions with the “crush” technique. The long-term outcome of “crush” stenting technique has yet to be determined. We identified 181 consecutive patients who were treated with DES with the “crush” stent technique from April 2002 to April 2004. Based on the usage of final kissing balloon post-dilation (FKB), the patients were divided into an FKB group (n = 116) and a non-FKB group (n = 65). Clinical follow-up at nine months was available in all patients, and angiographic follow-up in 80% of patients. Three cases (1.7%) of intraprocedural stent thrombosis and five (2.8%) cases of postprocedural stent thrombosis occurred. Restenosis rate of the main branch in the entire cohort lesions was 11.5%. Restenosis rate of the side branch was lower in the FKB group than that in the non-FKB group (11.1% vs. 37.9%, p < 0.001). The target lesion revascularization (TLR) rate for all patients was 14.9%. The lack of FKB was a predictor for TLR (hazard ratio [HR] 4.17; 95% confidence interval [CI] 1.30 to 14.3, p = 0.02). Diabetes was also a predictor for TLR (HR 1.79; 95% CI 1.14 to 2.80, p = 0.01). Premature discontinuation of dual antiplatelet therapy (odds ratio [OR] 16.8; 95% CI 1.31 to 159.5, p = 0.03) and age (OR 1.10; 95% CI 1.00 to 1.21, p = 0.048) was associated with the occurrence of postprocedural stent thrombosis. Compared to the absence of FKB, the “crush” stenting technique with FKB appears to be associated with more favorable long-term outcomes. When utilizing the “crush” stenting technique, FKB is mandatory.

Vascular endoscopic and macroscopic observations after crush stenting of coronary artery bifurcations in pigs

The crush stent technique has recently been proposed to limit the development of restenosis between drug-eluting stents implanted at coronary artery bifurcations. We studied the stent expansion, apposition to the vessel, and aspect of the overlapping stents after in vivo crush stent implantation. Crush stent implantation was performed at coronary bifurcations in anesthetized swines. The treated sites were examined using intravascular ultrasound and a vascular endoscope. The stents removed from the vessel were analyzed macroscopically. After final kissing balloon inflation, an adequate apposition of the stent to the vessel wall was confirmed by vascular endoscopy and visual inspection. However, the side-branch stent was narrowed at the site of stent overlap, and the overlapping stents in the main branch created a metal mass, which could promote the development of thrombosis. The technique of crush stent implantation with additional kissing balloon inflation is feasible and promising. However, it may be limited by thrombosis and restenosis at the carina because of stent overlapping and potential incomplete apposition. Additional studies are needed to confirm the safety and long-term clinical results of this technique.

Balloon crush: Treatment of bifurcation lesions using the crush stenting technique as adapted for transradial approach of percutaneous coronary intervention

The recent advent of drug-eluting stents has allowed the crush stenting technique to be adopted, thus simplifying the treatment of bifurcation coronary artery lesions. However, this can only be achieved in 7 Fr or greater guiding catheters, hence precluding most transradial percutaneous coronary interventions that are usually undertaken using 6 Fr or less guiding catheters. We assessed the feasibility of balloon stent crush as a stepwise procedure in achieving bifurcation crush stenting in 6 Fr transradial percutaneous coronary interventions. Since it is not possible to place two stents through a 6 Fr guiding catheter, we have adapted the crush stenting technique by initially placing a stent in the side branch and a balloon in the main vessel. The side branch stent is then deployed against the main vessel balloon that is later inflated, crushing the side branch stent within the main vessel. The main vessel is then stented and the side branch recrossed for kissing inflations. Seven patients (five males; age range, 47-78 years) with bifurcation lesions were treated using the above-described technique without major complications. Balloon crush of the side branch stent were successfully achieved in all cases without balloon trapping. In six cases where side branch recrossing was attempted, all were successful and kissing balloon inflations were undertaken in five cases. We have demonstrated that the modified crush stenting technique is feasible and can be safely adapted for use in a 6 Fr transradial percutaneous coronary intervention approach.

Crush stenting of bifurcational left subclavian‐vertebral artery stenosis

Left internal mammary artery (LIMA) has the best long-term patency in patients undergoing coronary artery bypass surgery. Stenosis of the proximal left subclavian artery (SA) may reduce flow to the LIMA, causing myocardial ischemia. We report a novel technique (crush stenting) for the treatment of a complex bifurcational left SA-vertebral artery (VA) stenosis in the presence of a patent LIMA bypass conduit. This technique limited plaque shifting, restored normal flow to all vessels, including the LIMA, and avoided devastating consequences of VA occlusion.