Coronary interventions - Mini focus on bifurcation lesions

Double-kissing culotte technique for coronary bifurcation stenting

EuroIntervention 2020;16:e724-e733. DOI: 10.4244/EIJ-D-20-00130

Gabor  G. Toth
Gabor G. Toth1, MD, PhD; Viktor Sasi2, MD, PhD; Danilo Franco3, MD; Anton J. Prassl4, PhD; Luigi Di Serafino3, MD, PhD; Jaryl C.K. Ng5, PhD; Gyula Szanto2, MD, PhD; Laura Schneller1, RN; Hui Ying Ang5,6, PhD; Gernot Plank4, PhD; William Wijns7, MD, PhD; Emanuele Barbato3, MD, PhD
1. University Heart Center Graz, Department of Cardiology, Medical University of Graz, Graz, Austria; 2. 2nd Department of Internal Medicine, Division of Invasive Cardiology, University of Szeged, Szeged, Hungary; 3. Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy; 4. Gottfried Schatz Research Center: Biophysics, Medical University of Graz, Graz, Austria; 5. National Heart Research Institute of Singapore, National Heart Centre Singapore, Singapore; 6. Department of Biomedical Engineering, National University of Singapore, Singapore; 7. The Lambe Institute for Translational Medicine and Curam, Saolta University Healthcare Group, Galway, Ireland

Aims: The aim of this study was to assess whether the culotte technique could be improved by an additional kissing dilation prior to main branch (MB) stenting.

Methods and results: Double-kissing (DK) culotte was compared to the culotte and DK-crush techniques in a bench model (n=24). Results were evaluated for stent apposition, luminal opening and flow dynamics. The total procedure duration of DK-culotte was 18.3±3.4 minutes, significantly lower than for DK-crush (24.3±5.7 min; p=0.015), but similar to culotte (21.6±5.9 min, p=0.104). In DK-culotte the overall rate of moderate (200-500 µm) and significant (>500 µm) malapposition was 2.1±1.9% and 0.4±0.2%, similar as compared to culotte (3.7±3.8%, p=0.459 and 1.0±1.0%, p=0.517, respectively), and lower as compared to DK-crush (8.1±2.5%, p<0.001 and 3.7±5.3%, p=0.002, respectively). The lower malapposition rate of DK-culotte as compared to DK-crush was due to less moderate and significant malapposition in the proximal MB (0.0±0.0% vs 14.0±7.6%, p<0.001 and 0.0±0.0% vs 4.2±9.1%, p=0.026, respectively). Micro-computed tomography did not show a difference in luminal opening at the proximal MB, distal MB or SB. There was no difference either in the maximum shear rate or in areas of high shear or recirculation.

Conclusions: Bench test data suggest that the DK approach facilitates the culotte technique. The clinical validity and relevance remain to be confirmed in a larger in vivo population.

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