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Original Articles

Randomized Comparison of Coronary Bifurcation Stenting With the Crush Versus the Culotte Technique Using Sirolimus Eluting Stents

The Nordic Stent Technique Study

Andrejs Erglis, MD; Indulis Kumsars, MD; Matti Niemelä, MD; Kari Kervinen, MD; Michael Maeng, MD; Jens F. Lassen, MD; Pål Gunnes, MD; Sindre Stavnes, MD; Jan S. Jensen, MD; Anders Galløe, MD; Inga Narbute, MD; Dace Sondore, MD; Timo Mäkikallio, MD; Kari Ylitalo, MD; Evald H. Christiansen, MD; Jan Ravkilde, MD; Terje K. Steigen, MD; Jan Mannsverk, MD; Per Thayssen, MD; Knud Nørregaard Hansen, MD; Mikko Syvänne, MD; Steffen Helqvist, MD; Nikus Kjell, MD; Rune Wiseth, MD; Jens Aarøe, MD; Mikko Puhakka, MD; Leif Thuesen, MD for the Nordic PCI Study Group

From the Latvian Centre of Cardiology (A.E., I.K., I.N., D.S.), Paul Stradins Clinical University Hospital, Riga, Latvia; Division of Cardiology (M.N., M.S., T.M., K.Y.), Department of Internal Medicine, University of Oulu, Finland; Department of Cardiology (M.M., J.F.L., E.H.C., J.R., L.T.), Aarhus University Hospital, Skejby, Aarhus Denmark; Department of Cardiology (P.G., S.S.), The Feiring Clinic, Feiring, Norway; Department of Cardiology (J.S.J., A.G.), Gentofte University Hospital, Gentofte, Denmark; Department of Cardiology (T.K.S., J.M.), University Hospital of Tromsoe, Tromsoe, Norway; Department of Cardiology (P.T., K.N.H.), Odense University Hospital, Denmark; Division of Cardiology (N.K.), Helsinki University Central Hospital, Helsinki, Finland; Department of Cardiology (S.H.), Rigshospitalet, Copenhagen, Denmark; Department of Cardiology (S.V.), Tampere University Hospital, Tampere, Finland; Department of Cardiology (R.W.), Trondheim University Hospital, Trondheim, Norway; Department of Cardiology (J.A.), Aalborg University Hospital, Aalborg, Denmark; and Division of Cardiology (M.P.), Kuopio University Central Hospital, Kuopio, Finland.

Correspondence to Andrejs Erglis, Latvian Centre of Cardiology, Pauls Stradins Clinical University Hospital, Pilsonu 13, Riga, Latvia LV1002. E-mail a.a.erglis{at}stradini.lv and Leif Thuesen, Department of Cardiology, Aarhus University Hospital, Skejby, 8200 Aarhus N, Denmark. E-mail leif.thuesen@ki.au.dk

Received July 4, 2008; accepted November 18, 2008.

Background— In a number of coronary bifurcation lesions, both the main vessel and the side branch need stent coverage. Using sirolimus eluting stents, we compared 2 dedicated bifurcation stent techniques, the crush and the culotte techniques in a randomized trial with separate clinical and angiographic end-points.

Methods and Results— A total of 424 patients with a bifurcation lesion were randomized to crush (n=209) and culotte (n=215) stenting. The primary end point was major adverse cardiac events; cardiac death, myocardial infarction, target vessel revascularization, or stent thrombosis after 6 months. At 6 months there were no significant differences in major adverse cardiac event rates between the groups; crush 4.3%, culotte 3.7% (P=0.87). Procedure and fluoroscopy times and contrast volumes were similar in the 2 groups. The rates of procedure-related increase in biomarkers of myocardial injury were 15.5% in crush versus 8.8% in culotte group (P=0.08). A total of 324 patients had a quantitative coronary assessment at the index procedure and after 8 months. The angiographic end-points of in-segment and in-stent restenosis of main vessel and/or side branch after 8 months were found in 12.1% versus 6.6% (P=0.10) and in 10.5% versus 4.5% (P=0.046) in the crush and culotte groups, respectively.

Conclusions— Both the crush and the culotte bifurcation stenting techniques were associated with similar and excellent clinical and angiographic results. Angiographically, there was a trend toward less in-segment restenosis and significantly reduced in-stent restenosis following culotte stenting.

Key Words: stents • drugs • sirolimus • restenosis • bifurcation

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