Percutaneous therapy of bifurcation lesions with drug‐eluting stent implantation: the Culotte technique revisited

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Abstract
INTRODUCTION: The most effective strategy for bifurcation stenting is currently undefined. The Culotte technique was developed as a method that ensures complete bifurcation lesion coverage. However, it went out of favour due to a high rate of restenosis when utilizing bare metal stents. Drug‐eluting stents reduce the rate of restenosis and need for repeat lesion revascularization compared with bare metal stents; we re‐evaluated this technique with drug‐eluting stent implantation. METHODS: Between April 2002 and October 2003, 207 patients were treated for at least one bifurcation lesion with drug‐eluting stent implantation to both the main vessel and side branch. Of these, 23 were treated with the Culotte technique (11.1%) for 24 lesions. Sirolimus‐eluting stents were used in 8.3%, and paclitaxel‐eluting stents in the remaining 92.7%. RESULTS: Clinical follow‐up was obtained in 100%. One patient had a myocardial infarction at 14 days (maximum rise in creatine kinase 872IU/L) related to thrombosis occurring in another lesion, and underwent repeat revascularization. There were no episodes of stent thrombosis in the Culotte lesions. At eight months follow‐up, there were no deaths and no further myocardial infarction. One patient required target lesion revascularization (TLR), and a second underwent target vessel revascularization. The cumulative rates of survival‐free of TLR and major adverse cardiac events were 94.7% and 84.6% respectively. Angiographic follow‐up was obtained in 16 patients (69.6%) at a mean period of 8.3±4.3months. The late lumen loss for the main vessel and side branch were 0.48±0.56 mm and 0.53±0.33 mm respectively, with binary restenosis rates of 18.8% and 12.5%. CONCLUSIONS: In this small study of bifurcation stenting utilizing the Culotte technique with drug‐eluting stent implantation, there was a low rate of major adverse events and need for target lesion revascularization at eight months, when compared with historical data of bifurcation stenting with bare metal stents. Further re‐evaluation of this technique utilizing drug‐eluting stents, is warranted in the setting of larger randomized studies.