Provisional Side Branch Stenting Research Articles

The “Crush” Technique for Coronary Artery Bifurcation Stenting: Insights From Micro-Computed Tomographic Imaging of Bench Deployments

This study provides insights into "crush" coronary bifurcation stenting through imaging of bench deployments. Although the strategy of provisional side-branch stenting is widely accepted for suitable bifurcation lesions, there is no consensus on the best option for elective stenting with 2 stents. The crush technique has the potential to scaffold and apply the drug to the side-branch ostium where restenosis is most common. Sequential steps of crush stent deployment and post-dilation were undertaken in silicone phantoms and recorded on cine angiography and microcomputed tomography. We assessed the effect of deployment strategies, post-dilation strategies, and cell size on side-branch ostial area. Side-branch ostial coverage by metal struts was 53% (95% confidence interval [CI]: 46 to 59) after 1-step kissing post-dilation and was reduced by 2-step kissing post-dilation to 33% (95% CI: 28 to 37; p < 0.0001). Although the residual stenosis after the classical crush strategy was 47% (95% CI: 39 to 53), it was 36% (95% CI: 31 to 40; p = 0.002) after mini-crush deployment. Stents with larger cell size (>3.5 mm diameter) had a residual stenosis of 37% (95% CI: 32 to 42) after crush deployment that was less than the residual stenosis for stents with smaller cell size (52%; 95% CI: 44 to 60; p < 0.0001). Side-branch ostial stenosis after crush stenting was minimized by mini-crush deployment, 2-step kissing post-dilation, and the use of stents with larger cell size. It is unknown if optimizing stent deployment at bifurcation lesions will reduce clinical stent thrombosis and restenosis.

Stenting des bifurcations

The optimal treatment of coronary bifurcation lesions remains a challenging theoretical and technical area for percutaneous coronary intervention. Questions remain unanswered regarding the optimal technique and devices to be used in order to achieve and maintain a safe and effective clinical result. Many studies or registries have shown that treatment of bifurcation lesions with drug eluting stents was associated with a lower risk of restenosis and reintervention. An increased risk of drug eluting stent thrombosis in bifurcation lesions has been shown but it seems that it is more related to a problem of optimal treatment than bifurcation or drug eluting stent by itself. Today there is a consensus for a “provisional side branch stenting approach with final kissing balloon inflation” and the remaining question is when and how to stent the side branch. Dedicated devices are now emerging as new tools which may solve some technical problems and improve the quality and reproducibility of treatment.

Culotte versus T-stenting in bifurcation lesions: Immediate clinical and angiographic results and midterm clinical follow-up

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.

Technique of left main stenting is dependent on lesion location and distal branch protection

The purpose of this study was to review our experience with left main stenting and evaluate initial results with drug-eluting stents (DESs). Drug-eluting stents delivered with contemporary techniques could change the traditional surgical approach to patients with significant left main disease. One hundred sixty-one patients underwent left main stenting (100 bare metal, 61 drug-eluting) after being excluded from surgery. In group A, disease was confined to the ostium or main stem; in group B, disease involved the bifurcation. Patients were classified as either unprotected (U) or protected (P) depending on the presence of a patent bypass graft. Study endpoints were any major adverse cardiac event (MACE). In-hospital MACE was 6% with no deaths; 74% of patients in group A underwent direct stenting, whereas 89% of the patients in group B had predilatation performed prior to stent implantation. A total of 98% of patients in BU had kissing balloon inflations after stent deployment; provisional side-branch stenting was required in one patient. V-stenting was performed in 13% of patients in group BU. The 1-year mortality in the bare metal stent group was 9% with the majority of deaths in group BU. There was one noncardiac death in the DES group at 6 months and five patients (8.2%) underwent target vessel revascularization for restenosis. Event-free survival at 6 months in group BU treated with DESs was 87%. Significant left main disease presents a spectrum of angiographic abnormalities and different interventional techniques are required depending on lesion location and distal protection. Although in-hospital complications with left main stenting were low in this single-center study, follow-up events were common in patients treated with bare metal stents. A randomized multicenter trial will be required to determine whether drug-eluting stents will improve survival in patients with left main disease.