European Heart Journal Advance Access originally published online on November 11, 2008
European Heart Journal 2008 29(23):2868-2876; doi:10.1093/eurheartj/ehn512
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Culotte stenting technique in coronary bifurcation disease: angiographic follow-up using dedicated quantitative coronary angiographic analysis and 12-month clinical outcomes
,*Deutsches Herzzentrum München and 1. Klinikum rechts der Isar, Technische Universität, Lazarettstrasse 36, 80636 Munich, Germany
Received 17 March 2008; revised 21 September 2008; accepted 23 October 2008; online publish-ahead-of-print 11 November 2008.
* Corresponding author. Tel: +32 16344235, Fax: +32 16344240, Email: tom.adriaenssens{at}uzleuven.be
See page 2831 for the editorial comment on this article (doi:10.1093/eurheartj/ehn385)
Aims: 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.
Methods and results: 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.
Conclusion: 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.
Key Words: Bifurcation • Double-stenting technique • Culotte technique • Percutaneous coronary intervention • In-stent restenosis • Stent thrombosis • Quantitative coronary angiography
This paper was guest edited by Prof. Christiaan J.M. Vrints, Department of Cardiology, University of Antwerp-University Hospital Antwerp, Belgium.
Present address. University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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